Assessing menopause symptoms in women with traumatic brain injury: the development and initial testing of a new scale.

With greater survival rates after catastrophic injury, more women with traumatic brain injury (TBI) are living longer than ever. However, knowledge about this transition in these women is largely unexamined and there are no scales that have been developed to assess the experience of symptoms. To address this gap, we developed and tested a new scale of menopause symptoms in midlife women with TBI. We selected candidate items from two existing measures based on feedback from focus group discussions with seven women with TBI. Twenty candidate items were tested in cognitive interviews with six women with TBI/1 non-TBI. Then, these were field tested with 221 participants (TBI, n = 68; non-TBI, n = 153) recruited from registries. Rasch analysis and convergent validity testing were used to evaluate the new scale. Results of the Rasch analysis indicate that overall, the scale fits well the Rasch model with evidence for unidimensionality. Differential item functioning indicated that the scale performed equally well for women with and without TBI and distinguished pre- and post-menopausal states. Convergent validity was found in the expected directions. These findings support further development of the new scale to understand the experience of menopause symptoms among women with TBI.

Predicting seizure clustering in the epilepsy monitoring unit: A multivariable analysis.

INTRODUCTION: Seizure clustering, is the most frequently reported adverse event in epilepsy monitoring unit (EMU) safety studies which, can also potentiate other adverse events, such as falls, status epilepticus, and increased length of stay. The purpose of this study is to determine variables associated with increased risk of seizure clustering among patients admitted to the EMU. METHODS: A retrospective review of patients admitted to the EMU over a two-year period was completed. Data collected included patient demographics, types of epilepsy, seizure frequency, anti-seizure medications (ASMs) and hospital and EMU course including incidence of seizure clustering. RESULTS: Two hundred seven patients were included in our study; of these, ninety patients experienced two or more seizures in a 24-hour period (24SC), and 68 patients experienced two or more seizures in a 4-hour period (4SC). Logistic regression analysis associated the absence of long-acting ASM with increased clustering within the 4SC group (p = 0.038). For every additional ASM taken by a patient at home, the odds of seizure clustering increased by 81% in the 4SC group (p = 0.009) and by 61% in the 24SC group (p = 0.022). In addition, patients with a diagnosis of temporal lobe epilepsy had some association with clustering in the 24SC group (p = 0.061). CONCLUSION: Our data showed that long-acting ASMs can be protective against seizure clustering. Furthermore, patients with temporal lobe epilepsy, and those on increased numbers of ASMs, were more likely to experience seizure clustering when undergoing medication withdrawal during an EMU evaluation.

Impact of ambulatory pharmacist on hospital visits in older adults with epilepsy: A case-control study.

OBJECTIVE: Older adults have the highest prevalence of epilepsy of any age group. Care in this group is complex because of comorbidities, polypharmacy, and cognitive impairment. We aimed to assess the impact of an ambulatory pharmacist in decreasing hospital visits in this group. METHODS: We performed a case-control study at a tertiary care center. The study group was seen in a multi-disciplinary older adult epilepsy clinic with the services of an ambulatory pharmacist to help with medication reconciliation, assessment, and adherence. The control clinic also cared for older adults with epilepsy but lacked a pharmacist. The occurrence and factors related to hospital visits were compared three months post-clinic visit. Demographic data were reported using descriptive statistics. A multinomial regression analysis was conducted to assess how well hospital visits could be predicted by pharmacist presence and other relevant variables. RESULTS: Over 19 months, 58 and 74 patients were seen in the study and control groups, respectively. 26.6% and 18.4% of study and control group clinic visits were associated with a hospital visit, respectively (nonsignificant difference). The study group had significantly more patients with cognitive impairment (53.4% vs. 16.2%; p < 0.001), a higher burden of comorbidities as measured by Charlson comorbidity index (CCI) (mean 3.5 vs. 2.9; p = 0.02), and a greater number of patients with >1 seizure per month (17.2% vs. 6.8%) as compared to the control group. Hospital visits unrelated to epilepsy were associated with a higher CCI. Hospital visits related to epilepsy were associated with >1/month seizure frequency (>3 times risk). CONCLUSIONS: This study demonstrates the multifactorial complexity of older adults with epilepsy. While the presence of a pharmacist resulted in similar hospital visits as the control group, the study group had a much more complex patient population. More studies are required to assess the best use of a pharmacist in older adults with epilepsy outpatient care.

Psychiatric changes after stereotactic laser amygdalohippocampotomy for medial temporal lobe epilepsy.

PURPOSE: Stereotactic laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for drug-resistant temporal lobe epilepsy (TLE) that has comparable rates of seizure freedom to traditional open resective TLE surgery. The objective of this study was to determine psychiatric outcome (i.e., depression and anxiety changes, psychosis) after SLAH, to explore possible contributory factors to these changes, and to determine the prevalence of de novo psychopathology. METHODS: We explored mood and anxiety in 37 adult patients with TLE undergoing SLAH using the Beck psychiatric symptoms scales (i.e., Beck Depression Inventory-II [BDI-II] and Beck Anxiety Inventory [BAI]) preoperatively and 6 months following surgery. Multivariable regression analysis was conducted to identify predictors of worse depression or anxiety symptoms following SLAH. The prevalence of de novo psychopathology following SLAH was also determined. RESULTS: We found a significant decrease in BDI-II (mean decline from 16.3 to 10.9, p = 0.004) and BAI (mean decline from 13.3 to 9.0, p = 0.045) scores following SLAH at the group level. While the rate of resolution of depression (from 62% to 49%) did not achieve statistical significance (p = 0.13, McNemar's), the rate of resolution of anxiety (from 57% to 35%) was statistically significant (p = 0.03, McNemar's). The de novo rate of psychopathology (i.e., new onset depression or anxiety) following SLAH was 1 of 7 (14%). Using a metric of meaningful change rather than complete symptom resolution, 16 of 37 (43%) patients experienced improvement in depression and 6 of 37 (16%) experienced worsening. For anxiety, 14 of 37 (38%) experienced meaningful improvement and 8 of 37 (22%) experienced worsening. Baseline performance on the Beck Scales was the only factor contributing to outcome status. DISCUSSION: In one of the first studies to evaluate psychiatric outcomes after SLAH, we found promising overall trends toward stability or significant improvement in symptom burden at the group level for both depression and anxiety. There was also a significant improvement in clinical anxiety, though the decrease in clinical depression was not significant, likely owing to the limitations of sample size. SLAH may improve overall psychiatric symptoms, similarly to traditional resective TLE surgery, but de novo psychopathology and postoperative psychiatric morbidity remain significant issues, and larger samples are necessary to determine causal contributory factors.

Factors Associated with Refractory Status Epilepticus Termination Following Ketamine Initiation: A Multivariable Analysis Model.

BACKGROUND: In this study, we identify factors associated with ketamine success in the treatment of refractory status epilepticus (SE). We also evaluate for adverse events including systemic and cerebral hemodynamic stability and fluid volume overload. METHODS: In this retrospective, large, single-center, observational study over a 10-year period, 879 consecutive patients receiving intravenous (IV) ketamine were reviewed, and 81 patients were identified as receiving IV ketamine for the treatment of SE. Descriptive analysis was done to determine treatment response and adverse events in patients receiving IV ketamine for SE. Multivariable logistic regression analyses were fitted to determine prediction models for seizure cessation. RESULTS: Permanent cessation of SE was achieved in 49 of 81 (60.5%) of patients for whom ketamine was part of the treatment plan. Of those, 36 (44.4%) were attributed to ketamine as the last drug used (ketamine-associated cessation [AC]). Prior history of epilepsy had an odds ratio of 3.19 (confidence interval 0.83-12.67, p = 0.09) associated with efficacious medication response. Increased latency to ketamine was associated with cessation of SE specifically in patients in the AC group (p = 0.077). Longer SE duration (p = 0.04), administration of ketamine loading dose (bolus; p = 0.03), and anoxia (p = 0.007) were negatively associated with AC. Administration of ketamine loading dose (p = 0.02) and anoxia (p = 0.009) were negatively associated with overall SE cessation. There was no significant impact of ketamine on cerebral hemodynamics, but evidence of fluid volume overload was seen (28.4% of patients). CONCLUSIONS: Our cohort is a large observational study showing a high success rate of permanent cessation of SE after the addition of ketamine. Using multivariable analysis, we demonstrate a significant association with seizure cessation in patients with prior history of epilepsy and those with prolonged latency to ketamine initiation. Furthermore, we describe the impact of fluid volume overload as an anticipated complication with ketamine use.

Rasch analysis of fatigue severity scale in patients with epilepsy.

OBJECTIVE: To utilize the Rasch model to validate and assess the psychometric properties of the Fatigue Severity Scale (FSS) in patients with epilepsy. METHODS: A total of 307 patients (age > 18 years) with a confirmed diagnosis of epilepsy were consented to participate. Exclusion criteria included patients with psychogenic nonepileptic events, cognitive disabilities, and patients who did not speak/understand English. The nine-step FSS was programmed into software administered to patients on electronic tablets, and patient responses were auto-scored. The Rasch rating scale model (RSM) was used to evaluate the unidimensionality, reliability, and targeting of the FSS. To assess unidimensionality, we examined infit and outfit mean squares. We also assessed unidimensionality of the FSS using a principal component analysis of Rasch residuals, where residuals are understood as the difference between observed and expected data values. We evaluated the internal consistency of person and item performance by examining separation reliability estimates and separation ratio. Differential Item Functioning (DIF) was calculated for gender. RESULTS: There was mixed evidence regarding the extent to which the FSS fit the Rasch model. Outfit values ranged from 0.52 to 2.72 and infit values were 0.60 to 2.18, strongly suggesting the presence of misfitting items: Item 1 ("My motivation is lower when I am fatigued") and Item 2 ("Exercise brings on my fatigue"). SIGNIFICANCE: The nine-item FSS showed fair psychometric properties in this sample of patients with epilepsy. Our study provides unique, supportive information for the use of a modified version of the FSS, omitting the first two items, in patients with epilepsy. Given the prevalence of fatigue and other neuropsychiatric comorbidities of epilepsy, having a validated fatigue scale can aid healthcare providers to identify moderate-to-severe fatigue levels in patients with epilepsy and address the plausible risk factors.

Lacosamide serum concentrations during pregnancy.

Still considered a new ASD, teratogenicity from lacosamide (LCM) exposure during pregnancy is unknown. LCM metabolism through several cytochrome P450 enzymes and minor glucuronidation metabolism in the liver may increase during pregnancy and theoretically lead to lower LCM levels during pregnancy and the risk of increased seizures. Our objective was to determine the impact of pregnancy on serum LCM levels in a series of women with epilepsy (WWE). We identified seven pregnancies with exposure to LCM with at least one level drawn during pregnancy. Patient ages ranged from 18 to 38 years (mean 26.4 years) and total daily doses of LCM ranged from 200 to 600 mg/day. Two patients had increased dose adjustments in response to breakthrough seizures. Dose normalized concentrations (DNC) showed an overall decrease over time through each trimester (p = 0.002) and significantly lower during trimester 2 and 3 (p = 0.001 and p = 0.004, respectively) compared to pre-pregnancy levels. There were no significant changes in seizure frequency and none of the neonates had teratogenic findings at time of birth. We are the first to report a case series on the changes in LCM levels during pregnancy with significant decreased LCM DNC levels during the second and third trimesters in comparison to pre-pregnancy values.

The relation between cognitive dysfunction and diffusion tensor imaging parameters in traumatic brain injury.

PURPOSE OF THE STUDY: To investigate the association among global and regional white matter fractional anisotropy (FA) values following traumatic brain injury (TBI) and cognitive functioning. MATERIALS AND METHODS: This research was conducted in an urban rehabilitation hospital. Participants included adults who were healthy controls (n = 18) or who had a TBI (n = 27). Diffusion tensor imaging using a Siemens VERIO 3T scanner and calculation of global and regional FA values were undertaken. FA values were correlated with neuropsychological test scores and injury severity variables. Logistic regression and receiver operating characteristic (ROC) curve analysis were used to investigate discriminative ability of the FA values. Neuropsychological measures, including the Symbol Digit Modalities Test (SDMT), Trail Making Test, Wechsler Test of Adult Reading, California Verbal Learning Test 2nd Edition, Digit Vigilance Test, and Wisconsin Card Sorting Test, comprised the cognitive measures. RESULTS: Within the TBI group, regional FA values were significantly lower across regions compared with controls; global FA and five brain regions were associated with SDMT scores. The FA value within the body of the corpus callosum (CC) yielded excellent discrimination between groups. CONCLUSIONS: Convergent findings support the discriminability and potential clinical utility of the CC body FA value in the context of TBI.

Social Competence Treatment After Traumatic Brain Injury: A Multicenter, Randomized Controlled Trial of Interactive Group Treatment Versus Noninteractive Treatment.

OBJECTIVE: To evaluate the effectiveness of a replicable group treatment program for improving social competence after traumatic brain injury (TBI). DESIGN: Multicenter randomized controlled trial comparing 2 methods of conducting a social competency skills program, an interactive group format versus a classroom lecture. SETTING: Community and veteran rehabilitation centers. PARTICIPANTS: Civilian, military, and veteran adults with TBI and social competence difficulties (N=179), at least 6 months postinjury. INTERVENTIONS: The experimental intervention consisted of 13 weekly group interactive sessions (1.5h) with structured and facilitated group interactions to improve social competence, and the control consisted of 13 traditional classroom sessions using the same curriculum with brief supplemental individual sessions but without structured group interaction. MAIN OUTCOME MEASURES: Profile of Pragmatic Impairment in Communication (PPIC), an objective behavioral rating of social communication impairments after TBI. LaTrobe Communication Questionnaire (LCQ), Goal Attainment Scale (GAS), Satisfaction with Life Scale, Posttraumatic Stress Disorder Checklist-C (PCL) civilian version, Brief Symptom Inventory 18 (BSI-18), Scale of Perceived Social Self-Efficacy (PSSE). RESULTS: Social competence goals (GAS) were achieved and maintained for most participants regardless of treatment method. Significant improvements in the primary outcome (PPIC) and 2 of the secondary outcomes (LCQ and BSI) were seen immediately posttreatment and at 3 months posttreatment in the alternative treatment arm only; however, these improvements were not significantly different between the group interactive structured treatment and alternative treatment arms. Similar trends were observed for PSSE and PCL-C. CONCLUSIONS: Social competence skills improved for persons with TBI in both treatment conditions. The group interactive format was not found to be a superior method of treatment delivery in this study.

Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization.

OBJECTIVES: To identify health beliefs of emergency department (ED) patients with low acuity conditions and how these affect ambulance (AMB) utilization. METHODS: We performed a prospective, observational study on a convenience sample of patients 18years or older, who presented to the ED of an urban, academic hospital with an Emergency Severity Index (ESI) triage level of 4 or 5. Demographics, treatment, and disposition data were obtained along with self-administered surveys. Characteristics of patients with low acuity conditions who presented to the ED by AMB were compared to the patients who came to the ED by private transportation (PT). Data were analyzed with the chi-square test, t-test, and Mann-Whitney test. RESULTS: A total of 197 patients (97 AMB and 100 PT) were enrolled. Compared to PT, AMB patients were more likely to: be insured (82% vs. 56%; p=0.000), have a primary care provider (62% vs. 44%; p=0.048), and lack a regular means of transportation (53% vs. 33%; p=0.005). Three surveys were used the SF-8, Short Test of Functional Health Literacy in Adults [STOFHLA], and Health Belief Model [HBM]. Answers to HBM showed patients perceive that their illness required care within one hour of arrival (38% vs. 21%; p=0.04), have used an ambulance in the past year (76% vs. 33%; p=0.001) and to utilize an ambulance in the future for similar concerns (53% vs. 15%; p=0.000). AMB patients were more likely to call an ambulance for any health concern (p=0.035) and felt that there were enough ambulances for all patients in the city (p=0.01). There were no differences in age, employment, level of income and education, nor hospital admission rate between groups. CONCLUSIONS: Ambulance use in low-acuity ED patients is associated with misperceptions regarding severity of illness and resource allocation as well as limited access to private transportation. Understanding patient perceptions of illness and other barriers to receiving care is imperative for the development of interventions aimed at enabling change in health behaviors such as the elective use of limited resources.

Blood pressure variability as an indicator of sepsis severity in adult emergency department patients.

STUDY OBJECTIVE: Quantify the correlation between blood pressure variability (BPV) and markers of illness severity: serum lactate (LAC) or Sequential Organ Failure Assessment (SOFA) scores. METHODS: We performed a secondary analysis of data from a prospective, observational study evaluating fluid resuscitation on adult, septic, ED patients. Vital signs and fluid infusion volumes were recorded every 15min during the 3h following ED arrival. BPV was assessed via average real variability (ARV): the average of the absolute differences between consecutive BP measurements. ARV was calculated for the time periods before and after 3 fluid infusion milestones: 10-, 20-, and 30-mL/kg total body weight (TBW). Spearman's rho correlation coefficient analysis was utilized. A p-value<0.05 was considered statistically significant. RESULTS: Forty patients were included. Mean fluid infusion was 33.7mL/kg TBW (SD 22.1). All patients received fluid infusion≥10mL/kg TBW, 25 patients received fluid infusion>20mL/kg TBW, and 16 patients received fluid infusion>30mL/kg TBW. Mean initial LAC was 4.0mmol/L (SD 3.2). Mean repeat LAC was 3.1mmol/L (SD 3.2), obtained an average of 6.6h (SD 5.3) later. Mean SOFA score was 7.0 (SD 4.4). BPV correlated with both follow-up LAC (r=0.564; p=0.023) and SOFA score (r=0.544; p=0.024) among the cohort that received a fluid infusion>20-mL/kg TBW. CONCLUSION: With the finding of a positive correlation between BPV and markers of illness severity (LAC and SOFA scores), this pilot study introduces BPV analysis as a real-time, non-invasive tool for continuous sepsis monitoring in the ED.

Presenting phenotypes of acute heart failure patients in the ED: Identification and implications.

BACKGROUND: There is little known about the baseline hemodynamic (HD) profiles (beyond pulse/blood pressure) of patients presenting to the Emergency department (ED) with acute heart failure (AHF). Assessing these baseline parameters could help differentiate underlying HD phenotypes which could be used to develop specific phenotypic specific approaches to patient care. METHODS: Patients with suspected AHF were enrolled in the PREMIUM (Prognostic Hemodynamic Profiling in the Acutely Ill Emergency Department Patient) multinational registry and continuous HD monitoring was initiated on ED presentation using noninvasive finger cuff technology (Nexfin, BMEYE, Edwards Lifesciences, Irvine, California). Individuals with clinically suspected and later confirmed AHF were included in this analysis and initial 15minute averages for available HD parameters were calculated. K-means clustering was performed to identify out of 23 HD variables a set that provided the greatest level of inter-cluster discrimination and intra-cluster cohesions. RESULTS: A total of 127 patients had confirmed AHF. The final model, using mean normalized patient baseline HD values was able to differentiate these individuals into 3 distinct phenotypes. Cluster 1: normal cardiac index (CCI) and systemic vascular resistance index (SVRI); cluster 2: very low CI and markedly increased SVRI: and cluster 3: low CI and an elevated SVRI. These clusters were not differentiated using clinically available ED information. CONCLUSIONS: Three distinct clusters were defined using novel noninvasive presenting HD monitoring technology in this cohort of ED AHF patients. Further studies are needed to determine whether phenotypic specific therapies based on these clusters can improve outcomes.

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.

OBJECTIVES: The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both. METHODS: We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS). RESULTS: On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P<.0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function. CONCLUSIONS: In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion.

Hemodynamic characteristics of suspected stroke in the emergency department.

BACKGROUND: Systemic hemodynamic characteristics of patients with suspected acute ischemic stroke are poorly described. The objective of this study was to identify baseline hemodynamic characteristics of emergency department (ED) patients with suspected acute stroke. METHODS: This was a planned analysis of the stroke cohort from a multicenter registry of hemodynamic profiling of ED patients. The registry prospectively collected non-invasive hemodynamic measurements of patients with suspicion for acute stroke within 12h of symptom onset. K-means cluster analysis identified hemodynamic phenotypes of all suspected stroke patients, and we performed univariate hemodynamic comparisons based on final diagnoses. RESULTS: There were 72 patients with suspected acute stroke, of whom 38 (53%) had a final diagnosis of ischemic stroke, 10 (14%) had hemorrhagic stroke, and 24 (33%) had transient ischemic attack (TIA). Analysis defined three phenotypic clusters based on low or normal cardiac index (CI) and normal or high systemic vascular resistance index (SVRI). Patients with TIA had lower mean CI (2.3L/min/m2) compared to hemorrhagic or ischemic stroke patients (p<0.01). CONCLUSIONS: The study demonstrates the feasibility of defining hemodynamic phenotypes of ED patients with suspected stroke.

Presenting hemodynamic phenotypes in ED patients with confirmed sepsis.

OBJECTIVES: To derive distinct clusters of septic emergency department (ED) patients based on their presenting noninvasive hemodynamic (HD) measurements and to determine if any clinical parameters could identify these groups. METHODS: Prospective, observational, convenience study of individuals with confirmed systemic infection. Presenting, pretreatment noninvasive HD parameters were compiled using Nexfin (Bmeye/Edwards LifeSciences) from 127 cases. Based on normalized parameters, k-means clustering was performed to identify a set of variables providing the greatest level of intercluster discrimination and intracluster cohesion. RESULTS: Our best HD clustering model used 2 parameters: the cardiac index (CI [L/min per square meter]) and systemic vascular resistance index (SVRI [dynes·s/cm5 per square meter]). Using this model, 3 different patient clusters were identified. Cluster 1 had high CI with normal SVRI (CI, 4.03 ± 0.61; SVRI, 1655.20 ± 348.08); cluster 2 low CI with increased vascular tone (CI, 2.50 ± 0.50; SVRI, 2600.83 ± 576.81); and cluster 3 very low CI with markedly elevated SVRI (CI, 1.37 ± 0.81; SVRI, 5951.49 ± 1480.16). Cluster 1 patients had the lowest 30-day overall mortality. Among clinically relevant variables available during the initial patient evaluation in the ED age, heart rate and temperature were significantly different across the 3 clusters. CONCLUSIONS: Emergency department patients with confirmed sepsis had 3 distinct cluster groupings based on their presenting noninvasively derived CI and SVRI. Further clinical studies evaluating the effect of early cluster-specific therapeutic interventions are needed to determine if there are outcome benefits of ED HD phenotyping in these patients.

Better object recognition and naming outcome with MRI-guided stereotactic laser amygdalohippocampotomy for temporal lobe epilepsy.

OBJECTIVES: Patients with temporal lobe epilepsy (TLE) experience significant deficits in category-related object recognition and naming following standard surgical approaches. These deficits may result from a decoupling of core processing modules (e.g., language, visual processing, and semantic memory), due to "collateral damage" to temporal regions outside the hippocampus following open surgical approaches. We predicted that stereotactic laser amygdalohippocampotomy (SLAH) would minimize such deficits because it preserves white matter pathways and neocortical regions that are critical for these cognitive processes. METHODS: Tests of naming and recognition of common nouns (Boston Naming Test) and famous persons were compared with nonparametric analyses using exact tests between a group of 19 patients with medically intractable mesial TLE undergoing SLAH (10 dominant, 9 nondominant), and a comparable series of TLE patients undergoing standard surgical approaches (n=39) using a prospective, nonrandomized, nonblinded, parallel-group design. RESULTS: Performance declines were significantly greater for the patients with dominant TLE who were undergoing open resection versus SLAH for naming famous faces and common nouns (F=24.3, p<0.0001, η2=0.57, and F=11.2, p<0.001, η2=0.39, respectively), and for the patients with nondominant TLE undergoing open resection versus SLAH for recognizing famous faces (F=3.9, p<0.02, η2=0.19). When examined on an individual subject basis, no SLAH patients experienced any performance declines on these measures. In contrast, 32 of the 39 patients undergoing standard surgical approaches declined on one or more measures for both object types (p<0.001, Fisher's exact test). Twenty-one of 22 left (dominant) TLE patients declined on one or both naming tasks after open resection, while 11 of 17 right (nondominant) TLE patients declined on face recognition. SIGNIFICANCE: Preliminary results suggest (1) naming and recognition functions can be spared in TLE patients undergoing SLAH, and (2) the hippocampus does not appear to be an essential component of neural networks underlying name retrieval or recognition of common objects or famous faces.

Rasch analysis of the coping inventory for stressful situations in individuals with moderate to severe traumatic brain injury.

OBJECTIVE: To evaluate psychometric properties of the Coping Inventory for Stressful Situations (CISS) in individuals with traumatic brain injury (TBI). DESIGN: Archival study using Rasch analysis. SETTING: Postacute rehabilitation hospital. PARTICIPANTS: Adults (N=331) 1 to 15 years after moderate to severe TBI, recruited consecutively. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: CISS. RESULTS: Indices of unidimensionality and model fit supported the scale's proposed multidimensional structure consisting of Task, Emotion, and Avoidant coping style; 3 unidimensional scales showed better fit than a single combined scale. The 3 scales met Rasch expectations of reliability and separation for persons and items, as well as adequate response category functioning. The scales were generally well targeted but showed some evidence of ceiling effect for Task, and floor effects for Emotion and Avoidant coping; item difficulties did not fully capture extreme ranges demonstrated by some participants, suggesting that measurement of coping after TBI on the CISS would be improved with additional items at low and high ranges of difficulty. Results were generally equivalent for cross-sectional groups representing short-term (1y), intermediate (2y), and long-term (5-15y). CONCLUSIONS: The CISS showed good psychometric properties as a measure of coping style among persons with moderate to severe TBI in acute and chronic phases of recovery, and showed evidence of multidimensionality as predicted by theory, consistent with 3 unidimensional scales. Added items tapping broader (or more accessible, less cognitively complex) ranges of coping responses would likely benefit the scale overall and improve correspondence with the response needs of people with TBI.

Comorbidity and insurance as predictors of disability after traumatic brain injury.

OBJECTIVE: To examine the unique contribution of self-reported medical comorbidity and insurance type on disability after traumatic brain injury (TBI). DESIGN: Inception cohort design at 1-year follow up. SETTING: A university affiliated rehabilitation hospital. PARTICIPANTS: Adults with mild-complicated to severe TBI (N=70). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Self-reported medical comorbidities were measured using the Modified Cumulative Illness Rating Scale, while insurance type was classified as commercial or government-funded; disability was measured using the Disability Rating Scale. RESULTS: Two models were run using multiple linear regression, and the best-fitting model was selected on the basis of Bayesian information criterion. The full model, which included self-reported medical comorbidity and insurance type, was significantly better fitting than the reduced model. Participants with a longer duration of posttraumatic amnesia, more self-reported medical comorbidities, and government insurance were more likely to have higher levels of disability. Meanwhile, individual organ systems were not predictive of disability. CONCLUSIONS: The cumulative effect of self-reported medical comorbidities and type of insurance coverage predict disability above and beyond well-known prognostic variables. Early assessment of medical complications and improving services provided by government-funded insurance may enhance quality of life and reduce long-term health care costs.

Role of character strengths in outcome after mild complicated to severe traumatic brain injury: a positive psychology study.

OBJECTIVE: To examine the effects of character strengths on psychosocial outcomes after mild complicated to severe traumatic brain injury (TBI). DESIGN: Prospective study with consecutive enrollment. SETTING: A Midwestern rehabilitation hospital. PARTICIPANTS: Persons with mild complicated to severe TBI (N=65). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community Integration Measure, Disability Rating Scale, Modified Cumulative Illness Rating Scale, Positive and Negative Affect Schedule, Satisfaction with Life Scale, Values in Action Inventory of Strengths, and Wechsler Test of Adult Reading. RESULTS: Character virtues and strengths were moderately associated with subjective outcomes, such that there were fewer and less strong associations between character virtues/strengths and objective outcomes than subjective outcomes. Specifically, positive attributes were associated with greater life satisfaction and perceived community integration. Fewer and less strong associations were observed for objective well-being; however, character strengths and virtues showed unique value in predicting physical health and disability. Positive affectivity was not meaningfully related to objective outcomes, but it was significantly related to subjective outcomes. In contrast, negative affectivity was related to objective but not subjective outcomes. CONCLUSIONS: Given the strength of the associations between positive aspects of character or ways of perceiving the world and positive feelings about one's current life situation, treatments focused on facilitating these virtues and strengths in persons who have experienced TBI may result in better perceived outcomes and potentially subsequently lower comorbidities.

Rasch analysis of the community integration measure in persons with traumatic brain injury.

OBJECTIVE: To examine the measurement properties of the Community Integration Measure (CIM) in persons with traumatic brain injury (TBI). DESIGN: Rasch analysis was used to retrospectively evaluate the CIM. SETTING: Rehabilitation hospital. PARTICIPANTS: Persons (N=279) 1 to 15 years after a TBI. INTERVENTIONS: None. MAIN OUTCOME MEASURE: CIM RESULTS: The CIM met Rasch expectations of unidimensionality and reliability (person separation ratio=2.01, item separation ratio=4.52). However, item endorsibility was poorly targeted to the participants' level of community integration. A ceiling effect was found with this sample. CONCLUSIONS: The CIM is a relatively reliable and unidimensional scale. Future iterations might benefit from the addition of items that are more difficult to endorse (ie, improved targeting).