Spontaneous intracerebral hemorrhage - patients retrospectively consent to fibrinolytic surgery despite poor neurological outcome and reduced health-related quality of life.

Spontaneous intracerebral hemorrhage (ICH) might lead to devastating consequences. Nonetheless, subjective interpretation of life circumstances might vary. Recent data from ischemic stroke patients show that there might be a paradox between clinically rated neurological outcome and self-reported satisfaction with quality of life. Our hypothesis was that minimally invasive surgically treated ICH patients would still give their consent to stereotactic fibrinolysis despite experiencing relatively poor neurological outcome. In order to better understand the patients' perspective and to enhance insight beyond functional outcome, this is the first study assessing disease-specific health-related quality of life (hrQoL) in ICH after fibrinolytic therapy. We conducted a retrospective analysis of patients with spontaneous ICH treated minimally invasive by stereotactic fibrinolysis. Subsequently, using standardized telephone interviews, we evaluated functional outcome with the modified Rankin Scale (mRS), health-related Quality of Life with the Quality of life after Brain Injury Overall scale (QOLIBRI-OS), and assessed retrospectively if the patients would have given their consent to the treatment. To verify the primary hypothesis that fibrinolytic treated ICH patients would still retrospectively consent to fibrinolytic therapy despite a relatively poor neurological outcome, we conducted a chi-square test to compare good versus poor outcome (mRS) between consenters and non-consenters. To investigate the association between hrQoL (QOLIBRI-OS) and consent, we conducted a Mann-Whitney U-test. Moreover, we did a Spearman correlation to investigate the correlation between functional outcome (mRS) and hrQoL (QOLIBRI-OS). The analysis comprised 63 data sets (35 men, mean age: 66.9 ± 11.8 years, median Hemphill score: 3 [2-3]). Good neurological outcome (mRS 0-3) was achieved in 52% (33/63) of the patients. Patients would have given their consent to surgery retrospectively in 89.7% (52/58). These 52 consenting patients comprised all 33 patients (100%) who achieved good functional outcome and 19 of the 25 patients (76%) who achieved poor neurological outcome (mRS 4-6). The mean QOLIBRI-OS value was 49.55 ± 27.75. A significant association between hrQoL and retrospective consent was found (p = 0.004). This study supports fibrinolytic treatment of ICH even in cases when poor neurological outcome would have to be assumed since subjective perception of deficits could be in contrast with the objectively measured neurological outcome. HrQoL serves as a criterion for success of rtPa lysis therapy in ICH.

Quality of life after brain injury-overall scale, Japanese version: assessment of reliability and validity.

This study analyzed the linguistic and psychometric validation of the Japanese version of the Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS) consisting of six items which cover several TBI-relevant domains. We hypothesized that the Japanese version has good reliability, convergent validity, and divergent validity, compared with its long version, the 37-item QOLIBRI. The QOLIBRI-OS Japanese version was forward and back-translated from the English version. In total, 129 individuals participated in this study after experiencing a traumatic brain injury and attending clinics, rehabilitation centers, and support centers in Japan. The structure of the QOLIBRI-OS was investigated by confirmatory factor analyses and compared with the QOLIBRI. Only one factor was extracted, and a model with one underlying factor had a good fit. The QOLIBRI-OS showed good-to-excellent internal consistency and test-retest reliability. The QOLIBRI-OS was positively correlated with the QOLIBRI, Short Form Health Survey-36 version 2, and Glasgow Outcome Scale Extended, and negatively correlated with the Hospital Anxiety and Depression Scale. The results suggest that the QOLIBRI-OS Japanese version is a reliable and valid tool for assessing disease-specific health-related QOL in individuals after traumatic brain injury in Japan.

Frequency and predictors of headache in the first 12 months after traumatic brain injury: results from CENTER-TBI.

BACKGROUND: Headache is a prevalent and debilitating symptom following traumatic brain injury (TBI). Large-scale, prospective cohort studies are needed to establish long-term headache prevalence and associated factors after TBI. This study aimed to assess the frequency and severity of headache after TBI and determine whether sociodemographic factors, injury severity characteristics, and pre- and post-injury comorbidities predicted changes in headache frequency and severity during the first 12 months after injury. METHODS: A large patient sample from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study was used. Patients were stratified based on their clinical care pathway: admitted to an emergency room (ER), a ward (ADM) or an intensive care unit (ICU) in the acute phase. Headache was assessed using a single item from the Rivermead Post-Concussion Symptoms Questionnaire measured at baseline, 3, 6 and 12 months after injury. Mixed-effect logistic regression analyses were applied to investigate changes in headache frequency and associated predictors. RESULTS: A total of 2,291 patients responded to the headache item at baseline. At study enrolment, 59.3% of patients reported acute headache, with similar frequencies across all strata. Female patients and those aged up to 40 years reported a higher frequency of headache at baseline compared to males and older adults. The frequency of severe headache was highest in patients admitted to the ICU. The frequency of headache in the ER stratum decreased substantially from baseline to 3 months and remained from 3 to 6 months. Similar trajectory trends were observed in the ICU and ADM strata across 12 months. Younger age, more severe TBI, fatigue, neck pain and vision problems were among the predictors of more severe headache over time. More than 25% of patients experienced headache at 12 months after injury. CONCLUSIONS: Headache is a common symptom after TBI, especially in female and younger patients. It typically decreases in the first 3 months before stabilising. However, more than a quarter of patients still experienced headache at 12 months after injury. Translational research is needed to advance the clinical decision-making process and improve targeted medical treatment for headache. TRIAL REGISTRATION: ClinicalTrials.gov NCT02210221.

Cerebrolysin after moderate to severe traumatic brain injury: prospective meta-analysis of the CAPTAIN trial series.

INTRODUCTION: This prospective meta-analysis summarizes results from the CAPTAIN trial series, evaluating the effects of Cerebrolysin for moderate-severe traumatic brain injury, as an add-on to usual care. MATERIALS AND METHODS: The study included two phase IIIb/IV prospective, randomized, double-blind, placebo-controlled clinical trials. Eligible patients with a Glasgow Coma Score (GCS) between 6 and 12 received study medication (50 mL of Cerebrolysin or physiological saline solution per day for ten days, followed by two additional treatment cycles with 10 mL per day for 10 days) in addition to usual care. The meta-analysis comprises the primary ensembles of efficacy criteria for 90, 30, and 10 days after TBI with a priori ordered hypotheses based on multivariate, directional tests. RESULTS: A total 185 patients underwent meta-analysis (mean admission GCS = 10.3, mean age = 45.3, and mean Baseline Prognostic Risk Score = 2.8). The primary endpoint, a multidimensional ensemble of functional and neuropsychological outcome scales indicated a "small-to-medium" sized effect in favor of Cerebrolysin, statistically significant at Day 30 and at Day 90 (Day 30: MWcombined = 0.60, 95%CI 0.52 to 0.66, p = 0.0156; SMD = 0.31; OR = 1.69; Day 90: MWcombined = 0.60, 95%CI 0.52 to 0.68, p = 0.0146; SMD = 0.34, OR = 1.77). Treatment groups showed comparable safety and tolerability profiles. DISCUSSION: The meta-analysis of the CAPTAIN trials confirms the safety and efficacy of Cerebrolysin after moderate-severe TBI, opening a new horizon for neurorecovery in this field. Integration of Cerebrolysin into existing guidelines should be considered after careful review of internationally applicable criteria.

Prehospital Management of Traumatic Brain Injury across Europe: A CENTER-TBI Study.

BACKGROUND: Prehospital care for traumatic brain injury (TBI) is important to prevent secondary brain injury. We aim to compare prehospital care systems within Europe and investigate the association of system characteristics with the stability of patients at hospital arrival. METHODS: We studied TBI patients who were transported to CENTER-TBI centers, a pan-European, prospective TBI cohort study, by emergency medical services between 2014 and 2017. The association of demographic factors, injury severity, situational factors, and interventions associated with on-scene time was assessed using linear regression. We used mixed effects models to investigate the case mix adjusted variation between countries in prehospital times and interventions. The case mix adjusted impact of on-scene time and interventions on hypoxia (oxygen saturation <90%) and hypotension (systolic blood pressure <100mmHg) at hospital arrival was analyzed with logistic regression. RESULTS: Among 3878 patients, the greatest driver of longer on-scene time was intubation (+8.3 min, 95% CI: 5.6-11.1). Secondary referral was associated with shorter on-scene time (-5.0 min 95% CI: -6.2- -3.8). Between countries, there was a large variation in response (range: 12-25 min), on-scene (range: 16-36 min) and travel time (range: 15-32 min) and in prehospital interventions. These variations were not explained by patient factors such as conscious level or severity of injury (expected OR between countries: 1.8 for intubation, 1.8 for IV fluids, 2.0 for helicopter). On-scene time was not associated with the regional EMS policy (p= 0.58). Hypotension and/or hypoxia were seen in 180 (6%) and 97 (3%) patients in the overall cohort and in 13% and 7% of patients with severe TBI (GCS <8). The largest association with secondary insults at hospital arrival was with major extracranial injury: the OR was 3.6 (95% CI: 2.6-5.0) for hypotension and 4.4 (95% CI: 2.9-6.7) for hypoxia. DISCUSSION: Hypoxia and hypotension continue to occur in patients who suffer a TBI, and remain relatively common in severe TBI. Substantial variation in prehospital care exists for patients after TBI in Europe, which is only partially explained by patient factors.

Efficacy and safety of cerebrolysin in neurorecovery after moderate-severe traumatic brain injury: results from the CAPTAIN II trial.

INTRODUCTION: The objective of this trial was to evaluate the efficacy and safety of Cerebrolysin in treating patients after moderate to severe traumatic brain injury (TBI) as an adjunct to standard care protocols. The trial was designed to investigate the clinical effects of Cerebrolysin in the acute (neuroprotective) stage and during early and long-term recovery as part of a neurorestorative strategy. MATERIALS AND METHODS: The study was a phase IIIb/IV single-center, prospective, randomized, double-blind, placebo-controlled clinical trial. Eligible patients with a Glasgow Coma Score (GCS) between 7 and 12 received study medication (50 ml of Cerebrolysin or physiological saline solution per day for 10 days, followed by two additional treatment cycles with 10 ml per day for 10 days) in addition to standard care. We tested ensembles of efficacy criteria for 90, 30, and 10 days after TBI with a priori ordered hypotheses using a multivariate, directional test, to reflect the global status of patients after TBI. RESULTS: The study enrolled 142 patients, of which 139 underwent formal analysis (mean age = 47.4, mean admission GCS = 10.4, and mean Baseline Prognostic Risk Score = 2.6). The primary endpoint, a multidimensional ensemble of 13 outcome scales, indicated a "small-to-medium"-sized effect in favor of Cerebrolysin, statistically significant at day 90 (MWcombined = 0.59, 95% CI 0.52 to 0.66, P = 0.0119). Safety and tolerability observations were comparable between treatment groups. CONCLUSION: Our trial confirms previous beneficial effects of the multimodal, biological agent Cerebrolysin for overall outcome after moderate to severe TBI, as measured by a multidimensional approach. Study findings must be appraised and aggregated in conjunction with existing literature, as to improve the overall level of insight regarding therapeutic options for TBI patients. The widely used pharmacologic intervention may benefit from a large-scale observational study to map its use and to establish comparative effectiveness in real-world clinical settings.

Emotion Recognition in Kindergarten Children.

BACKGROUND/AIMS: Recognition and understanding of emotions are essential skills in nonverbal communication and in everyday social functioning. These are already evident in infancy. We aimed to compare how young children recognize facial emotional expressions from static faces versus vocal emotional expressions from speech prosody. METHODS: Participants were 313 kindergarten children (162 girls, mean age = 51.01, SD 9.65 months; range 36-72). The design consisted of a visual and an auditory block (with 45 randomized trials each). Children were seated in front of a 14-inch laptop monitor and received visual stimuli (photos of faces) or auditory stimuli (spoken sentences) via loudspeakers. RESULTS: Recognizing emotions from looking at static faces was found to be easier compared to interpreting emotions transmitted by speech prosody alone. The ability to interpret emotions from both faces and speech prosody increased with age. It was easier to identify a "happy" emotion from a facial expression than an "angry" or "sad" one, whereas a "sad" emotion could be more easily recognized from speech prosody alone than facial imagery alone. Girls were significantly better than boys in identifying "sad" facial expressions. CONCLUSION: The results of the study are discussed in terms of educational implications for nonverbal communication.

Validation of the QOLIBRI - Quality of Life after Brain Injury questionnaire in patients after TBI in Israel.

BACKGROUND: The QOLIBRI - Quality of Life after Brain Injury questionnaire was developed by the QOLIBRI Task Force (QTF). Our goal was to investigate the applicability, validity and reliability of the QOLIBRI in Israel. METHODS: Validation of the Hebrew questionnaire was performed after it had been administered to 128 adults with traumatic brain injury (TBI), who were between 3 months' and 15 years' post-discharge from rehabilitation. RESULTS: The internal consistency of the QOLIBRI subscales with the QOLIBRI Total scale was high (Cronbach's α = 0.92); the same was true regarding the correlations between each QOLIBRI subscale and its own items (α = 0.92-0.95). Significant and high Pearson's and Spearman's correlations of the QOLIBRI subscales with demographic and clinical characteristics of the GOSE, ADL, HADS, SF-36, and various aspects of self-reported health status were found. Factor analyses (FA) were applied to confirm the validity of the Hebrew version, using the maximum likelihood method. The six subscales explained 100% of the variance. CONCLUSION: The Hebrew version of the QOLIBRI was found to be useful, meaningful and meeting psychometric criteria in persons after TBI in Israel. The findings support the cross-cultural applicability of the QOLIBRI, regardless of cultural and social differences.

The Norwegian version of the QOLIBRI - a study of metric properties based on a 12 month follow-up of persons with traumatic brain injury.

BACKGROUND: Consequences after Traumatic brain injury (TBI) affect the injured person's self-image and quality of life. The purpose was to assess the health related quality of life (HRQoL) at 12 months after a TBI in patients admitted to regional trauma centres, and to evaluate the metric properties of the Norwegian version of the Quality of Life After Brain Injury (QOLIBRI) questionnaire. METHODS: Two hundred four patients with TBI of all severities were included. HRQoL at 12 months post-injury was measured by the QOLIBRI. It has a total scale and 6 subscales (satisfied with Cognition, Self, Daily Life and Autonomy and Social Relationships, and bothered by Emotions and Physical Problems). Demographic and injury related data were registered. Disability was registered by Glasgow Outcome Scale Extended (GOSE) and Rivermead Post-Concussion Questionnaire, and mental health by Hospital Anxiety and Depression Scale. Descriptive statistics, internal consistency by Cronbach's alpha and Corrected Item-Total Correlations were calculated. Rasch analysis, Principal Component Analysis (PCA) and Structural Equation Modelling (SEM) were applied. RESULTS: Mean age was 37.6 (SD 15.4) years; 72% were men, and 41% had higher education. Over 60% were severely injured. Mean Glasgow Coma Scale score was 9.3 (SD 4.5). According to the GOSE 5.9% had severe disability, 45.5% had moderate disability, and 48.5% had good recovery at 12 months post-injury. The QOLIBRI scales had a high internal consistency (α = 0.75-0.96), and only Physical Problems had an α < 0.85. In the Rasch analysis all subscales and their items fit the Rasch model, except for the depression item in the Emotion subscale. PCA and SEM analyses supported a six-factor structure in a second-order latent model. The QOLIBRI supports an underlying unidimensional HRQoL model. The SEM model fit statistics of the second-order model indicated a moderate fit to the observed data (CFI = 0.86, TLI = 0.85, RMSEA = 0.076, SRMR = 0.061, χ2 = 1315.76, df = 623, p-value < 0.001). CONCLUSION: The Norwegian QOLIBRI has favourable psychometric properties, but there were some weaknesses related to its measurement properties of the total score when tested on a TBI population where many had severe TBI, and many had good recovery.

Quality of life in persons after traumatic brain injury as self-perceived and as perceived by the caregivers.

The primary aim of the study was to adopt QOLIBRI (quality of life after brain injury) questionnaire in a proxy version (Q-Pro), i.e., to use caregivers for comparison and to evaluate whether TBI patients' judgment corresponds to that of their caregivers since the possible self-awareness deficit of the persons with TBI. A preliminary sample of 19 outpatients with TBI and their proxies was first evaluated with the Patient Competency Rating Scale to assess patients' self-awareness; then they were evaluated with the QOLIBRI Patient version (Q-Pt) and a patient-centered version of the Q-Pro. Subsequently, 55 patients and their caregivers were evaluated using the patient-centered and the caregiver-centered Q-Pro versions. Q-Pt for assessing Quality of Life (QoL) after TBI, as patients' subjective perspective and Q-Pro to assess the QoL of patients as perceived by the caregivers. The majority of patients (62.2%) showed better self-perception of QoL than their proxies; however, patients with low self-awareness were less satisfied than patients with adequate self-awareness. Low self-awareness does not impair the ability of patients with TBI to report on satisfaction with QoL as self-perceived.

Evaluation in undergraduate medical education: Conceptualizing and validating a novel questionnaire for assessing the quality of bedside teaching.

BACKGROUND: Evaluation is an integral part of curriculum development in medical education. Given the peculiarities of bedside teaching, specific evaluation tools for this instructional format are needed. Development of these tools should be informed by appropriate frameworks. The purpose of this study was to develop a specific evaluation tool for bedside teaching based on the Stanford Faculty Development Program's clinical teaching framework. METHODS: Based on a literature review yielding 47 evaluation items, an 18-item questionnaire was compiled and subsequently completed by undergraduate medical students at two German universities. Reliability and validity were assessed in an exploratory full information item factor analysis (study one) and a confirmatory factor analysis as well as a measurement invariance analysis (study two). RESULTS: The exploratory analysis involving 824 students revealed a three-factor structure. Reliability estimates of the subscales were satisfactory (α = 0.71-0.84). The model yielded satisfactory fit indices in the confirmatory factor analysis involving 1043 students. DISCUSSION: The new questionnaire is short and yet based on a widely-used framework for clinical teaching. The analyses presented here indicate good reliability and validity of the instrument. Future research needs to investigate whether feedback generated from this tool helps to improve teaching quality and student learning outcome.

Evaluation of large-group lectures in medicine - development of the SETMED-L (Student Evaluation of Teaching in MEDical Lectures) questionnaire.

BACKGROUND: The seven categories of the Stanford Faculty Development Program (SFDP) represent a framework for planning and assessing medical teaching. Nevertheless, so far there is no specific evaluation tool for large-group lectures that is based on these categories. This paper reports the development and psychometric validation of a short German evaluation tool for large-group lectures in medical education (SETMED-L: 'Student Evaluation of Teaching in MEDical Lectures') based on the SFDP-categories. METHODS: Data were collected at two German medical schools. In Study 1, a full information factor analysis of the new 14-item questionnaire was performed. In Study 2, following cognitive debriefings and adjustments, a confirmatory factor analysis was performed. The model was tested for invariance across medical schools and student gender. Convergent validity was assessed by comparison with results of the FEVOR questionnaire. RESULTS: Study 1 (n = 922) yielded a three-factor solution with one major (10 items) and two minor factors (2 items each). In Study 2 (n = 2740), this factor structure was confirmed. Scale reliability ranged between α = 0.71 and α = 0.88. Measurement invariance was given across student gender but not across medical schools. Convergent validity in the subsample tested (n = 246) yielded acceptable results. CONCLUSION: The SETMED-L showed satisfactory to very good psychometric characteristics. The main advantages are its short yet comprehensive form, the integration of SFDP-categories and its focus on medical education.

[Indicators for Speech Comprehension in Migrant Children. A comparison of Extreme Groups]. / Indikatoren für Sprachverständnis bei Kindern mit Migrationshintergrund. Ein Extremgruppenvergleich.

Objective Children with migrant background learning German as second language are frequently considered having problems in speech comprehension and speaking; nevertheless, it is very difficult to objectify that for young children. For this purpose risk-factors should be determined empirically. Material and Methods The study comprised 126 children from a developmental longitudinal study in 7 day-care centers in Frankfurt/M and Darmstadt. The sample was sorted into two extreme groups by their achievement in oral German language comprehension: criterion T-score ≥46=age appropriate (N=61) vs. T-score ≤32=poor (N=65). The study used an assumed best-subtests variable-selection (intelligence; grammatical based comprehension; verbal conceptualization; recognition of semantic and grammatical inconsistencies) to examine risk-factors for the quality of development in German as second language. Results Intelligence was average in both groups, however, significantly different (T-score=54.1; SD 6.7 vs. T-score=42.2; SD 8.8; p<0,001). Risk-factors for a separation between rather convenient and less convenient conditions for the development of German as second language could be identified by applying discriminant analyses (in order of descending magnitude): intelligence; recognition of verbal inconsistencies; mother's level of education; grammatical based comprehension. Regarding the group affiliation, 88% of the children with poor and 84% of those with age appropriate oral comprehension could be correctly classified within the selected samples. Conclusions The results provide an acceptable standard to distinguish migrant children with an age appropriate oral comprehension in German as the second language from such with a poorer one.

[Assessment of Social-Communicative Behaviour Problems and Expression of Emotions in Three- to Six-Year Old Children in Nursery School and Kindergarten]. / Beurteilung von sozial-kommunikativem Problemverhalten und Emotionsausdruck Drei- bis Sechsjähriger in einer Kindertageseinrichtung.

Developmental support and promotion of children with behavioural disorders received little attention in nursery school and kindergarten in the last years. Parents expect that their children exhibiting psychosocial deficits or problems in social-communicative competence will also get support by the said educational institutions. This requires a preliminary, but reliable and economic monitoring, estimation and evaluation of selected behaviour patterns. Therefore, we developed and validated a scale to rate social-communicative behaviour problems and expression of emotions. Factor analysis suggested two factors which corresponded to the intended measurement object and the defined taxonomy of behavioural problems (scale 1: mainly internalized behaviour; scale 2: externalized behaviour). Both internal consistency and split-half reliability proved to be good. High convergent criterion validity was found for scale 1 and still substantial, although lower, for scale 2. The rating is simple and can be performed within ten and scored within five minutes. The result is a reliable indicator for a step-by-step approach to recommend an expanded specific psycho-diagnostics, so that therapeutic interventions as well as prevention programmes for vulnerable children and appropriate social training programmes can start timely.

Neurocognitive functions and brain atrophy after proven neuroborreliosis: a case-control study.

BACKGROUND: Patients often report neurocognitive difficulties after neuroborreliosis (NB). The frequency and extent of cognitive problems in European patients have been studied incompletely. METHODS: Sixty patients received a neurological and neuropsychological work-up 6 months or longer after treatment for proven NB. Quality of life, psychiatric symptom load, and brain atrophy were measured. All results were compared with a group of 30 healthy control persons adapted for age, gender and education being serologically negative for Borrelia burgdorferi senso latu. A cognitive sum score and a global sum score including cognitive, psychological results and quality of life data was calculated for both groups. RESULTS: Patients after NB showed a lower (i.e. more impaired) score on the Scripps Neurological rating scale (SNRS), but the observed neurological deficits were generally mild (mean ± SD: 97.1 ± 4.7 vs. 99.1 ± 2.4, p = 0.02). The mean neuropsychological domain results of the NB group were all within the normal range. However, a lower performance was found for the frontal executive function z-values (mean ± SD -0.29 ± 0.60 vs. 0.09 ± 0.60; p = 0.0059) of NB patients. Comparing the global sum score (mean ± SD 11.3 ± 4.2 NB vs. 14.3 ± 2.9 control , p = 0.001) and the cognitive sum score of the NB group with those of the control group (mean ± SD -0.15 ± 0.42 NB vs. 0.08 ± 0.31 control , p = 0.0079), both differences were statistically different. The frequencies of impaired global sum scores and those of the pathological cognitive sum scores (p = 0.07) did not differ statistically. No significant differences were found for health-related quality of life (hrQoL), sleep, psychiatric symptom load, or brain atrophy. CONCLUSION: The mean cognitive functions of patients after proven NB were in the normal range. However, we were able to demonstrate a lower performance for the domain of frontal executive functions, for the mean cognitive sum score and the global sum score as a sign of subtle but measurable sequelae of neuroborreliosis. Brain atrophy is not a common consequence of neuroborreliosis.

Health related quality of life of immigrant children: towards a new pattern in Germany?

BACKGROUND: To study Health related quality of life (HRQoL) of a sample of kindergarten children with migration background. METHODS: Five kindergartens in Frankfurt/Main and Darmstadt (Germany) participated. HRQoL was measured with the Kiddy-KINDL (KK) in 3 to 5 year old children. We examined the associations of HRQoL with socio-demographic variables, positive development and resilience, socio-emotional and motor development. Linear regression models were applied to examine differences in HRQoL between migrant and native-born German children. RESULTS: The response rate was 90.5% (N = 283). The children had predominantly migrant background (81.35%). Perceived health was slightly higher in migrants (69.85, SD 17.00) compared to native-born German children (68.33, SD 17.31, p > 0.05), even though migrant children were characterized by a lower socio-economic status (p < 0.01). CONCLUSIONS: Results suggest that HRQoL at early ages in our study exhibits a different pattern than reported previously in studies among older individuals. We attribute the discrepancy partly to a possible changing pattern of migration in Europe with more migrants capable to migrate with healthy profiles, and to the age of our population. Our findings underscore the need to study the life course trajectory of HRQoL among young immigrants and replication in representative samples.

Self-awareness and health-related quality of life after traumatic brain injury.

OBJECTIVE: To investigate the relations among self-awareness (SA), impaired SA, and health-related quality of life (HRQOL) after traumatic brain injury (TBI). PARTICIPANTS: One hundred forty-one adults hospitalized with TBI and their significant others from a cross-sectional multicenter study. Using Glasgow Coma Scale classification, 32 participants had severe injuries, 29 moderate, 44 mild, and 25 complicated mild TBI. MEASURES: Patient Competency Rating Scale for Neurorehabilitation; Short Form-36 Health Survey; Cognitive Quality of Life; Quality Of Life after Brain Injury; Hospital Anxiety and Depression Scale; Profile of Mood States; Glasgow Outcome Scale Extended. METHOD: Patient Competency Rating Scale for Neurorehabilitation ratings made by participants and their significant others were used to assess SA and discrepancies between the 2 ratings were used to define impaired SA. RESULTS: Significant associations were identified between SA and HRQOL, anxiety, depression, and severity of injury. Participants with and without impaired SA differed in cognitive HRQOL and leisure activities. Using multiple regression, no direct predictors of SA were identified, although interaction effects were observed. CONCLUSION: After TBI, lower SA is associated with higher estimates of HRQOL, particularly in the cognitive domain. Although the associations are modest, the assessment of SA should play a role in the interpretation of reported HRQOL after TBI.

Reference Values of the Quality of Life after Brain Injury (QOLIBRI) from a General Population Sample in Italy.

Traumatic brain injury (TBI) may affect the lives of the individuals concerned and their relatives negatively in many dimensions. Health-related quality of life (HRQoL) is a comprehensive and complex concept that can assess one's satisfaction with a broad range of areas of life and health. The Quality of Life after Traumatic Brain Injury (QOLIBRI) questionnaire is a TBI-specific measure for HRQoL which is used in research and health services worldwide. When evaluating self-reported HRQoL after TBI, reference values from a general population are helpful to perform clinically relevant evaluations and decisions about the condition of an affected person by comparing the patient scores with reference values. Despite the widespread use of the QOLIBRI, reference values have until now only been available for the Netherlands and the United Kingdom. The aim of this study was to validate the QOLIBRI for the general population in Italy and to provide reference values. An adapted form of the QOLIBRI was administered to 3298 Italians from a healthy general population using an online survey. Their scores were compared with those of 298 individuals post-TBI recruited within the international longitudinal observational cohort CENTER-TBI study in Italian hospitals, who completed the original questionnaire. The psychometric characteristics and the measurement invariance of the QOLIBRI were assessed. A regression analysis was performed to identify predictors relevant for HRQoL in the general population. Reference values were provided using percentiles. Measurement invariance analysis showed that the QOLIBRI captures the same HRQoL constructs in an Italian general population and Italian TBI sample from the observational Center-TBI study. Higher age, higher education and the absence of a chronic health condition were associated with higher QOLIBRI scores, suggesting better HRQoL. Reference values were provided for a general Italian population adjusted for age, sex, education and presence of chronic health conditions. We recommend using these for a better interpretation of the QOLIBRI score in clinical practice and research in Italy.

Effectiveness of a minimal virtual motivational interviewing training for first years medical students: differentiating between pre-test and then-test.

BACKGROUND: Shifting towards patient-centeredness, medical doctors need patient-centered communication skills. Motivational Interviewing (MI) is an evidence-based, collaborative, goal-oriented communication technique to strengthen a person's own motivation and commitment to change. The purpose of this study is to evaluate the effectiveness of a brief virtual role-play MI-training program on MI-knowledge and skills in first-year undergraduate medical students, making use of both a pre-test and a then-test (retrospective pre-test) to check for response shift in evaluating the educational intervention. METHODS: Four 10-15 min MI-game-based training conversations embedded in the Kognito Conversation Platform™ were offered to the students using a single-group Interrupted Time Series design. RESULTS: Participants included 339 undergraduate medical students (RR= 83.1%). The one-hour MI virtual training proved effective in two ways: participants gained knowledge and skills, and increased awareness of the existing intrinsic knowledge and skill they already possess to communicate with future patients in a patient-centered way. CONCLUSION: A brief one-hour MI-training simulation can be effective even if offered at an early stage during medical education. Furthermore, response shift varied and was not present in all students. PRACTICE IMPLICATION: The addition of a then-test to the study design reveals results that otherwise would not have been found.

Health-Related Quality of Life after Pediatric Traumatic Brain Injury: A Qualitative Comparison of Perspectives of Children and Adolescents after TBI and a Comparison Group without a History of TBI.

BACKGROUND: The assessment of the impact of pediatric traumatic brain injury (TBI) on the health-related quality of life (HRQoL) of the children and adolescents affected can be ameliorated by a disease-specific instrument. Such an instrument does not yet exist. This qualitative study investigates how children and adolescents after TBI subjectively perceive their HRQoL and whether and how this differs from the perspective of individuals without a history of TBI. METHODS: Eight problem-centered interviews were conducted with 11 children and adolescents around four years after mild TBI and with eight children and adolescents around three years after moderate to severe TBI. Nine problem-centered interviews were conducted with 25 participants without a history of TBI. The interviews were recorded and transcribed verbatim. The statements were assigned to inductively and deductively derived categories relevant to the HRQoL of children and adolescents after TBI and compared with those of individuals without a history of TBI. RESULTS: The HRQoL of children and adolescents after TBI tended to display both structural and content-related differences, independently of TBI severity, on several HRQoL dimensions, in contrast to the comparison group. For example, participants after TBI reported a broader range of negative emotions (such as worry, sadness, shame, and guilt), permanent physical impairments, felt that they were treated differently from others, and perceived cognitive limitations. CONCLUSIONS: The results of this qualitative study identified HRQoL dimensions that are relevant to children and adolescents after TBI and underlined the need for the development of a disease-specific instrument.