Rasch Analysis of the Mayo-Portland Adaptability Inventory for Posthospital Brain Injury Rehabilitation.

OBJECTIVES: (1) Reexamine the item structure and reliability of the Mayo-Portland Adaptability Inventory (4th ed; MPAI-4) through Rasch analysis of admission and discharge scores for a large sample of adults with acquired brain injury (ABI) who participated in various types of posthospital brain injury rehabilitation (PHBIR) programs; (2) compare differential item functioning (DIF) for traumatic brain injury (TBI), stroke and other ABI; and (3) explore the viability of more specific subscales in addition to the established indices. SETTING: Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community, Day Treatment, and Outpatient rehabilitation programs serving individuals with ABI. PARTICIPANTS: A total of 2154 individuals with TBI, stroke, or other ABI. DESIGN: Retrospective analysis of de-identified admission and discharge data from the Foundation to Advance Brain Rehabilitation (FABR) consortium database. MAIN MEASURE: MPAI-4. RESULTS: After adjusting 4 misfitting items and eliminating 20 misfitting persons, the MPAI-4 demonstrated real person reliability/separation = 0.93/3.52 and real item reliability/separation = 1.00/24.02. Independent Rasch analyses by diagnostic category found similar reliabilities and separations. Residual item correlations and principal component analysis of residuals (PCAR) indicated areas of local dependence arranged hierarchically reflecting the full-scale item hierarchy and providing the basis for 3 new subscales of Physical Abilities, Cognitive Abilities, and Autonomy. DIF across diagnostic categories revealed differences in item elevations characteristic of typical patients in each category. Measure means and SDs were very similar across categories. CONCLUSIONS: MPAI-4 items demonstrate very good person and item reliabilities for individuals with TBI, stroke, and other ABI at a level that supports individual evaluation. Variations in item calibrations across diagnostic categories reflect the differential characteristics of typical patients within categories. The entire measure provides an overall assessment of common sequalae of ABI, and standard indices used in combination with newly derived subscales provide more specific assessments of rehabilitation needs for treatment planning.

Distinguishing Characteristics of Admissions to Various Types of Posthospital Brain Injury Rehabilitation Programs.

OBJECTIVE: Describe and compare the demographic characteristics and disability profiles of individuals admitted to 6 types of posthospital brain injury rehabilitation (PHBIR) programs. SETTING: Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and Supported Living programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: Two thousand twenty-eight individuals with traumatic brain injury (TBI), stroke, or other ABI. MAIN MEASURES: Sex, age, time since injury, and Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4). DESIGN: Retrospective analyses of demographic variables and MPAI-4 Total, Index, and subscale Rasch-derived T-scores on admission comparing diagnostic categories and program types within diagnostic categories. RESULTS: Participants with TBI were predominantly male, and those with stroke were generally older. Admissions to more intensive and supervised programs (residential neurobehavioral and residential neurorehabilitation) generally showed greater disability than admissions to home and community programs who were more disabled than participants in day treatment and outpatient programs. Residential neurobehavioral and supported living program participants generally were male and had TBI. Home and community admissions tended to be more delayed than residential neurorehabilitation admissions. The majority of those with other ABI were admitted to outpatient rather than more intensive programs. Additional analyses demonstrated significant differences in MPAI-4 profiles among the various program types. CONCLUSIONS: Admissions with TBI, stroke, and other ABI to PHBIR differ in demographic factors and disability profiles. When examined within each diagnostic category, demographic features and disability profiles also distinguish among admissions to the various program types. Results provide insights about decision-making in referral patterns to various types of PHBIR programs, although other factors not available for analysis (eg, participant/family preference, program, and funding availability) likely also contribute to admission patterns.

Outcomes of Six Specific Types of Post-Hospital Brain Injury Rehabilitation Programs.

OBJECTIVE: Evaluate outcomes of intensive posthospital brain injury rehabilitation programs compared to supported living (SL) programs; explore variations in outcome by diagnostic category (traumatic brain injury, stroke, and other acquired brain injury [ABI]) and specific program type. SETTING: Data were obtained from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and SL programs serving individuals with ABI. PARTICIPANTS: A total of 2120 individuals with traumatic brain injury, stroke, or other ABI participated in this study. MAIN MEASURES: The main measures are sex, age, time since injury, and Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). DESIGN: Retrospective analyses of demographic variables and MPAI-4 Total, index, and subscale Rasch-derived T-scores on admission and discharge. RESULTS: Gains on MPAI-4  Total T-scores were significantly greater for the intensive rehabilitation (IR) group in comparison to stable functioning in the SL group (F = 236.69, P < .001, partial η2 = .101) while controlling for admission/time 1 scores; similar results were found for MPAI-4 indices and subscales. For the IR cohort, discharge scores differed by diagnostic category after controlling for admission scores for the Total MPAI-4 T-score (F = 22.65, P < .001, partial η2 = .025), as well as all indices and subscales. A statistically significant interaction between program type and diagnostic group on discharge MPAI-4 Total T-scores (F = 2.55, P = .018, partial η2 = .01) after controlling for admission scores indicated that differing outcomes across diagnoses also varied by program type. Varying significant main effects and interactions were apparent for MPAI-4 indices and subscales with generally small effect sizes. CONCLUSIONS: Significant gains on MPAI-4 variables across IR program types compared to no change over a comparable period of time for SL programs supports the effectiveness of posthospital brain injury rehabilitation. This finding in the presence of small effect sizes on outcome variables for program type and for significant interactions between program type and diagnostic category suggests that participants generally were appropriately matched to program type and benefited from interventions provided through specific program types.

Evaluation of Posthospital Brain Injury Rehabilitation Outcomes With Quasi-Experimental Controls.

OBJECTIVE: To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study (n = 2120). SETTING: Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating. MAIN MEASURES: Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating. DESIGN: Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category. RESULTS: Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score (F = 77.21, P < .001; partial η2 = 0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group. CONCLUSIONS: These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

Role and Outcomes of Supported Community Living Programs in Post-Hospital Brain Injury Rehabilitation Programs.

OBJECTIVES: (1) To determine the proportion of participants admitted to supported community living (SCL) programs over the course of 5 years who improve, decline, or maintain functioning and community integration and (2) to examine the associations of time since injury, time in program, and age to their functional trajectory. SETTING: Data from SCL programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: 104 individuals with traumatic brain injury (TBI), stroke, or other ABI. MAIN MEASURES: Sex, age, time since injury, Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). DESIGN: Retrospective analyses of MPAI-4 total and MPAI-4 indices using Linear Mixed Models (LMM) of Rasch-derived T-scores from admission to 5 years into service delivery. RESULTS: MPAI-4 total, index, and subscale scores for yearly intervals of SCL services from admission to 5 years showed a high degree of stability in function (defined using the standard error of measurement (SEM) for the MPAI-4, defined as change ≥3 T-score points) with all intervals showing at least 89% of patients with improved scores or no change. The rate of change over time did not significantly vary by time since injury, time in the program, or age. CONCLUSIONS: The expectations for services in the SCL portion of the care continuum for ABI are unique. Unlike intensive rehabilitation programs which focus on improvement often earlier in the course of recovery, the goal of SCL services is sustained functioning over the long term. Analyses reported here indicate this can be achieved for at least 5 years, potentially mitigating the increased risk for rehospitalization and increased care needs in the ABI population. This study highlights a key finding of MPAI-4 stability within these understudied brain injury service lines. Additional exploration of comorbidities and more nuanced delineation of diagnostic information could further clarify factors influencing outcome stability over time.

Unexpected Non-Maternally Derived Anti-PP1Pk in an 11-Week-Old Patient.

Alloantibody formation at less than 4 months of age is rare. Most antibodies identified in these patients are maternally derived. Anti-PP1Pk was detected in an 11-week-old infant that was not maternally derived. A multidisciplinary team approach led to appropriate testing, diagnosis, and transfusion management in this critically ill infant.

Levels-of-processing effect on word recognition in schizophrenia.

BACKGROUND: Individuals with schizophrenia have difficulty organizing words semantically to facilitate encoding. This is commonly attributed to organizational rather than semantic processing limitations. By requiring participants to classify and encode words on either a shallow (e.g., uppercase/lowercase) or deep level (e.g., concrete/abstract), the levels-of-processing paradigm eliminates the need to generate organizational strategies. METHODS: This paradigm was administered to 30 patients with schizophrenia and 30 healthy comparison subjects to test whether providing a strategy would improve patient performance. RESULTS: Word classification during shallow and deep encoding was slower and less accurate in patients. Patients also responded slowly during recognition testing and maintained a more conservative response bias following deep encoding; however, both groups showed a robust levels-of-processing effect on recognition accuracy, with unimpaired patient performance following both shallow and deep encoding. CONCLUSIONS: This normal levels-of-processing effect in the patient sample suggests that semantic processing is sufficiently intact for patients to benefit from organizational cues. Memory remediation efforts may therefore be most successful if they focus on teaching patients to form organizational strategies during initial encoding.

An fMRI study of facial emotion processing in patients with schizophrenia.

OBJECTIVE: Emotion processing deficits are notable in schizophrenia. The authors evaluated cerebral blood flow response in schizophrenia patients during facial emotion processing to test the hypothesis of diminished limbic activation related to emotional relevance of facial stimuli. METHOD: Fourteen patients with schizophrenia and 14 matched comparison subjects viewed facial displays of happiness, sadness, anger, fear, and disgust as well as neutral faces. Functional magnetic resonance imaging was used to measure blood-oxygen-level-dependent signal changes as the subjects alternated between tasks of discriminating emotional valence (positive versus negative) and age (over 30 versus under 30) of the faces with an interleaved crosshair reference condition. RESULTS: The groups did not differ in performance on either task. For both tasks, healthy participants showed activation in the fusiform gyrus, occipital lobe, and inferior frontal cortex relative to the resting baseline condition. The increase was greater in the amygdala and hippocampus during the emotional valence discrimination task than during the age discrimination task. In the patients with schizophrenia, minimal focal response was observed for all tasks relative to the resting baseline condition. Contrasting patients and comparison subjects on the emotional valence discrimination task revealed voxels in the left amygdala and bilateral hippocampus in which the comparison subjects had significantly greater activation. CONCLUSIONS: Failure to activate limbic regions during emotional valence discrimination may explain emotion processing deficits in patients with schizophrenia. While the lack of limbic recruitment did not significantly impair simple valence discrimination performance in this clinically stable group, it may impact performance of more demanding tasks.

Acute hemolytic transfusion reaction in a pediatric patient following transfusion of apheresis platelets.

The practice of transfusing ABO-incompatible platelets, driven primarily by concerns about inventory management, has been considered generally safe because the accompanying plasma is usually diluted in the recipient's total blood volume. However, if the platelet product contains a large volume of plasma or a high concentration of incompatible isoagglutinin, there may be hemolysis of the recipient's red cells. Patients with a small blood volume, such as babies and children, are considered to be at particular risk for such a complication. We describe the case of a baby who suffered massive hemolysis of her group A red cells after transfusion of group O Apheresis Platelets containing a high-titered anti-A isoagglutinin. We also offer a review of the literature on this subject and recommendations to avoid acute hemolytic reactions as a result of platelet transfusion.

Brain activation during facial emotion processing.

Functional neuroimaging studies have helped identify neural systems involved in cognitive processing and more recently have indicated limbic activation to emotional stimuli. Some functional magnetic resonance imaging (fMRI) studies have reported increased amygdala response during exposure to emotional stimuli while others have not shown such activation. The present study was designed to test the hypothesis that activation of the amygdala is related to the relevance of the emotional valence of stimuli. Healthy young participants (7 men, 7 women) were studied in a high-field (4 tesla) scanner using blood oxygenation-level dependent (BOLD) signal changes in a blocked "box car" design. They viewed facial displays of happiness, sadness, anger, fear, and disgust as well as neutral faces obtained from professional actors and actresses of diverse ethnicity and age. Their task alternated between emotion discrimination (indicating whether the emotion was positive or negative) and age discrimination (indicating whether the poser was older or younger than 30). Blocks contained the same proportion of emotional and neutral faces. Limbic response was greater during the emotion than during the age discrimination conditions. The response was most pronounced in the amygdala, but was also present in the hippocampus and circumscribed voxels in other limbic regions. These results support the central role of the amygdala in emotion processing, and indicate its sensitivity to the task relevance of the emotional display.