Associations between cognition and employment outcomes after epilepsy surgery.

OBJECTIVES: Previous studies have shown that younger age, higher education, and seizure freedom after epilepsy surgery are associated with employment. However, very few studies have investigated associations with cognition and employment status in epilepsy surgery patients. METHODS: This retrospective study consists of 46 adult patients, who underwent resective epilepsy surgery in the Helsinki University Hospital between 2010 and 2018 and who had been assessed by a neuropsychologist prior to surgery and 6 months after surgery using a systematic test battery. In addition to neuropsychological evaluation, neurologists assessed the patients prior to surgery and followed up the patients up to 24 months after the surgery and evaluated work status of the patients. Logistic regression models were used to assess the effects of cognition on changes in employment status, while controlling for age and education. RESULTS: Out of the 46 patients 38 (82.6%) were seizure free and 7 (15.2%) had their seizures reduced 2 years postsurgically. From prior to surgery to 2 years postsurgery, use of antiseizure medication was reduced in most of the patients, mean reduction of the dosage being 26.9%. Employment status improved in 10 (21.7%) patients, remained unchanged in 27 (58.7%) and worsened in 3 (6.5%). An additional 6 patients were already not working prior to surgery. Subsequent analyses are based on the subsample of 37 patients whose employment status improved or remained unchanged. Mistakes in executive function tasks (p = 0.048) and working memory performance (p = 0.020) differentiated between the group whose employment status remained similar and those who were able to improve their employment status. Epilepsy surgery outcome or changes in antiseizure medication (ASM) use were not associated with changes in employment status. CONCLUSIONS: In the subsample of 37 patients, errors in executive function tasks and poorer working memory differentiated patients whose employment status did not change from those patients who could improve their employment status. Problems in executive function and working memory tasks might hinder performance in a complex work environment. When assessing the risks and opportunities in returning to work after surgery, difficulties in working memory and executive function performance should be taken into consideration as they may predispose the patient to challenges at work.

Perceived Injustice After Mild Traumatic Brain Injury.

OBJECTIVE: To examine perceived injustice and its associations with self-reported symptoms and return to work at 3 months after injury in a prospectively recruited sample of patients with mild traumatic brain injury (mTBI). DESIGN: Observational study. SETTING: TBI outpatient unit. PARTICIPANTS: Adult patients aged 18 to 68 years with mTBI (n = 100) or orthopedic injury ([OI]; n = 34). MAIN MEASURES: The Injustice Experience Questionnaire (IEQ) and its associations with the Rivermead Post Concussion Questionnaire (RPQ), Beck Depression Inventory-Second Edition (BDI-II), PTSD Checklist-Civilian Version (PCL-C), and Pain Visual Analog Scale (PVAS). Information on injury-related characteristics, compensation seeking and litigation, and return-to-work status was also collected. RESULTS: Median IEQ total score was 3 (range, 0-23) in the mTBI group and 2.5 (range, 0-25) in the OI group. In the mTBI group, IEQ was significantly correlated with RPQ (rs = 0.638, P < .01), BDI-II (rs = 0.612, P < .01), PCL-C (rs = 0.679, P < .01), and PVAS (rs = 0.232, P < .05). The association between IEQ and PCL-C (rs =0.797, P < .01) and BDI-II (rs = 0.395, P < .05) was also found in the OI group. In both groups, patients who were still on sick leave at 3 months after injury tended to report higher perceived injustice (IEQ total score) than patients who had returned to work or studies. However, this difference did not reach statistical significance. CONCLUSIONS: Perceived injustice is associated with self-reported symptoms in patients with mTBI. Our results suggest that perceived injustice could be a relevant construct to consider in clinical management of patients with mTBI. Also, perceived injustice could be a potential target for psychological interventions promoting recovery after mTBI.

Return to work after mild traumatic brain injury: association with positive CT and MRI findings.

BACKGROUND: Return to work (RTW) might be delayed in patients with complicated mild traumatic brain injury (MTBI), i.e., MTBI patients with associated traumatic intracranial lesions. However, the effect of different types of lesions on RTW has not studied before. We investigated whether traumatic intracranial lesions detected by CT and MRI are associated with return to work and post-concussion symptoms in patients with MTBI. METHODS: We prospectively followed up 113 adult patients with MTBI that underwent a brain MRI within 3-17 days after injury. Return to work was assessed with one-day accuracy up to one year after injury. Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and Glasgow Outcome Scale Extended (GOS-E) were conducted one month after injury. A Kaplan-Meier log-rank analysis was performed to analyze the differences in RTW. RESULTS: Full RTW-% one year after injury was 98%. There were 38 patients with complicated MTBI, who had delayed median RTW compared to uncomplicated MTBI group (17 vs. 6 days), and more post-concussion symptoms (median RPQ 12.0 vs. 6.5). Further, RTW was more delayed in patients with multiple types of traumatic intracranial lesions visible in MRI (31 days, n = 19) and when lesions were detected in the primary CT (31 days, n = 24). There were no significant differences in GOS-E. CONCLUSIONS: The imaging results that were most clearly associated with delayed RTW were positive primary CT and multiple types of lesions in MRI. RTW-% of patients with MTBI was excellent and a single intracranial lesion does not seem to be a predictive factor of disability to work.

Post-traumatic headache after mild traumatic brain injury in a one-year follow up study - risk factors and return to work.

BACKGROUND: Post-traumatic headache (PTH) is a common symptom following mild traumatic brain injury (mTBI). Patients at risk to develop acute PTH (aPTH) and further persistent PTH (pPTH) need to be recognized. METHODS: This is a one-year follow-up of 127 patients with mTBI, aged 18 to 68, referred to outpatient clinic in the Helsinki University Hospital. Symptoms were assessed at the emergency department (ED), with structured interview at outpatient clinic visit and with Rivermead post-concussion symptom questionnaire at one, three, and 12 months after injury. Psychiatric disorders were assessed with Structured Clinical Interview for DSM-IV Axis I disorders at 3-4 months and return to work (RTW) from patient records. RESULTS: At one month, 77/127 patients (61%) had aPTH. According to multiple logistic regression analysis, risk factors for aPTH were headache at the emergency department (ED) (OR 5.43), other pain (OR 3.19), insomnia (OR 3.23), and vertigo (OR 5.98). At three months, 17 patients (22% of aPTH patients) had developed pPTH, and at one year, 4 patients (24% of pPTH patients) still presented with pPTH. Risk factors for pPTH at three months were older age (OR 1.06) and current insomnia (OR 12.3). The frequency of psychiatric disorders did not differ between the groups. pPTH patients performed worse on their RTW. CONCLUSIONS: Risk factors for aPTH were insomnia, headache at ED, other pain, and vertigo and for pPTH, insomnia and older age. RTW rate was lower among pPTH patients.

Prenatal exposure to antiepileptic drugs and early processing of emotionally relevant sounds.

INTRODUCTION: Prenatal exposure to antiepileptic drugs (AEDs) is associated with developmental compromises in verbal intelligence and social skills in childhood. Our aim was to evaluate whether a multifeature Mismatch Negativity (MMN) paradigm assessing semantic and emotional components of linguistic and emotional processing would be useful to detect possible alterations in early auditory processing of newborns with prenatal AED exposure. MATERIAL AND METHODS: Data on AED exposure, pregnancy outcome, neuropsychological evaluation of the mothers, information on maternal epilepsy type, and a structured neurological examination of the newborn were collected prospectively. Blinded to AED exposure, we compared a cohort of 36 AED-exposed with 46 control newborns at the age of two weeks by measuring MMN with a multifeature paradigm with six linguistically relevant deviant sounds and three emotionally uttered sounds. RESULTS: Frontal responses for the emotionally uttered stimulus Happy differed significantly in the exposed newborns compared with the control newborns. In addition, responses to sounds with or without emotional component differed in newborns exposed to multiple AEDs compared with control newborns or to newborns exposed to only one AED. CONCLUSIONS: These preliminary findings suggest that prenatal AED exposure may alter early processing of emotionally and linguistically relevant sound information.

Evidence for spared attention to faces in 7-month-old infants after prenatal exposure to antiepileptic drugs.

INTRODUCTION: Prenatal antiepileptic drug (AED) exposure is associated with an increased risk of cognitive impairment and autism spectrum disorders detected mainly at the age of two to six years. We examined whether the developmental aberrations associated with prenatal AED exposure could be detected already in infancy and whether effects on visual attention can be observed at this early age. MATERIAL AND METHODS: We compared a prospective cohort of infants with in utero exposure to AED (n=56) with infants without drug exposures (n=62). The assessments performed at the age of seven months included standardized neurodevelopmental scores (Griffiths Mental Developmental Scale and Hammersmith Infant Neurological Examination) as well as a novel eye-tracking-based test for visual attention and orienting to faces. Background information included prospective collection of AED exposure data, pregnancy outcome, neuropsychological evaluation of the mothers, and information on maternal epilepsy type. RESULTS: Carbamazepine, oxcarbazepine, and valproate, but not lamotrigine or levetiracetam, were associated with impaired early language abilities at the age of seven months. The general speed of visuospatial orienting or attentional bias for faces measured by eye-tracker-based tests did not differ between AED-exposed and control infants. DISCUSSION: Our findings support the idea that prenatal AED exposure may impair verbal abilities, and this effect may be detected already in infancy. In contrast, the early development of attention to faces was spared after in utero AED exposure.

Stressful life events are associated with self-reported fatigue and depressive symptoms in patients with mild traumatic brain injury.

OBJECTIVE: To examine the associations between recent stressful life events and self-reported fatigue and depressive symptoms in patients with mild traumatic brain injury. DESIGN: Observational cohort study. PARTICIPANTS: Patients (aged 18-68 years) with mild traumatic brain injury (n = 99) or lower extremity orthopaedic injury (n = 34). METHODS: Data on stressful life events and self-reported symptoms were collected 3 months post-injury. Stressful life events in the last 12 months were assessed as part of a structured interview using a checklist of 11 common life events, self-reported fatigue with Barrow Neurological Institute Fatigue Scale, and depressive symptoms with Beck Depression Inventory - Fast Screen. RESULTS: Median number of stressful life events was 1 (range 0-7) in the mild traumatic brain injury group and 1.5 (range 0-6) in the orthopaedic injury group. The groups did not differ significantly in terms of fatigue or depressive symptoms. In the mild traumatic brain injury group, the total number of recent stressful life events correlated significantly with self-reported fatigue (rs = 0.270, p = 0.007) and depressive symptoms (rs = 0.271, p = 0.007). CONCLUSION: Stressful life events are associated with self-reported fatigue and depressive symptoms in patients with mild traumatic brain injury. Clinicians should consider stressful life events when managing patients who experience these symptoms, as this may help identifying potential targets for intervention.

Status of Clinical Neuropsychology Training in Finland.

This paper provides information on different training models within clinical neuropsychology in Finland. Systematic specialization training program began in Finland in 1983. It was first organized mainly by the Finnish Neuropsychological Society and since 1997 by the Finnish universities. At present, close to 400 clinical neuropsychologists have completed the training. The number of professionals still does not cover the needs of the country (population 5.5 million, area 338,440 km2), and geographical disparities are a constant concern. The training models in Finland have changed over the years and will continue to evolve. Specialization training can be organized by national societies or by universities. It can lead to an academic degree or a diploma. It can be linked to doctoral studies or form a parallel track. Financial model can involve student fees or be governed by ministries (such as the Ministry of Education or Ministry of Health). This paper describes and compares different strategies in education that have impact on the output of professionals. One model does not fit all, or even one country at all times. The strategies of the stakeholder ministries can change over time. The experiences from Finland can be useful for other countries that are developing their models. The estimated need of practitioners and the educational resources including the available financial models for training differ between countries. The guiding principles in specialist training should focus on the advanced competencies expected from the neuropsychologist when entering the profession.

Traumatic Microbleeds in Mild Traumatic Brain Injury Are Not Associated with Delayed Return to Work or Persisting Post-Concussion Symptoms.

The main objective of this prospective cohort study was to evaluate whether traumatic microbleeds (TMBs) are a significant prognostic factor of return to work (RTW), post-traumatic symptoms, and overall recovery in patients with mild traumatic brain injury (mTBI). One hundred and thirteen patients with mTBI were recruited from the Helsinki University Hospital emergency units. All patients underwent multi-contrast 3T magnetic resonance imaging (MRI) 3-17 days after mTBI. Patients were evaluated in the Traumatic Brain Injury Outpatient Clinic of Helsinki University Hospital 1 month after injury. Post-concussion symptoms were assessed with the Post-Concussion Symptom Questionnaire (RPQ) and overall recovery was assessed with the Glasgow Outcome Scale Extended (GOS-E). Their time to RTW was continuously measured up to 1 year after TBI. Median RTW was 9 days (interquartile range [IQR] 4-30) after mTBI and full RTW rate after 1 year was 98%. Patients with TMBs (n = 22) did not have more post-concussion symptoms (median RPQ 10.0 vs. 7.0, p = 0.217) or worse overall recovery (58% vs. 56% with GOS-E = 8, p = 0.853) than patients without TMBs (n = 91). There was no significant difference in time to RTW (13.5 vs. 7.0 days, p = 0.063). In this study, patients with TMBs did not have delayed RTW or more post-concussion symptoms than other patients with mTBI. TMBs in mTBI do not seem to be a significant prognostic factor of RTW.

Prognosis after Mild Traumatic Brain Injury: Influence of Psychiatric Disorders.

BACKGROUND: We evaluated the prevalence of psychiatric disorders in mild traumatic brain injury (MTBI) patients and investigated psychiatric comorbidity in relation to subjective symptoms and return to work (RTW). METHODS: We recruited 103 MTBI patients (mean age 40.8 years, SD 3.1) prospectively from University Hospital. The patients were followed up for one year. The Rivermead Post-Concussion Symptom Questionnaire (RPQ) and Extended Glasgow Outcome Scale (GOSE) were administered one month after MTBI. Three months after MTBI, any psychiatric disorders were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders. RESULTS: Psychiatric disorders were diagnosed in 26 patients (25.2%). The most common disorders were previous/current depression. At three months, there was no difference between patients with psychiatric disorders versus those without them in RTW (95.7% vs. 87.3%, p = 0.260) or at least in part-time work (100% vs. 94.4%, p = 0.245). In Kaplan-Meier analysis, the median time to RTW was 10 days for both groups. The median RPQ score was 13.0 (Interquartile range (IQR) 6.5-19.0) in patients with a psychiatric disorder compared to 8.5 (IQR 2.3-14.0) in those without one (p = 0.021); respectively, the median GOSE was 7.0 (IQR 7.0-8.0) compared to 8.0 (IQR 7.0-8.0, p = 0.003). CONCLUSIONS: Approximately every fourth patient with MTBI had a psychiatric disorder. These patients reported more symptoms, and their functional outcome measured with GOSE at one month after MTBI was worse. However, presence of any psychiatric disorder did not affect RTW. Early contact and adequate follow-up are important when supporting the patient's return to work.

Neuropsychology in Finland - over 30 years of systematically trained clinical practice.

OBJECTIVE: The aim of this invited paper for a special issue of international practice in The Clinical Neuropsychologist is to provide information on training models, clinical practice, and professional issues within neuropsychology in Finland. METHOD: Relevant information was gathered via literature searches, a survey by the Neuropsychology Working Group of the Finnish Psychological Association, archives of the Finnish Neuropsychological Society, and personal communication with professionals in Finland. RESULTS: The roots of Finnish neuropsychology are linked to the early German tradition of experimental psychology. Since the 1970s, it has been strongly influenced by both the psychometric approach in the U.S. and the qualitative approach by Luria. Systematic specialization training program began in Finland in 1983. It was first organized by the Finnish Neuropsychological Society and since 1997 by Finnish universities. At present, around 260 neuropsychologists have completed this training. According to the survey by the Finnish Psychological Association in 2014, 67% of Finnish neuropsychologists work in the public sector, 36% in the private sector, and 28% reported that they had private practice. Work includes assessments for 90% of the respondents, rehabilitation for 74%, and many are involved in teaching and research. Of the respondents, 20% worked both with adults and children, 44% with adults only and 36% with children only. Within test development, pediatric neuropsychology is an especially prominent field. CONCLUSIONS: A unique blend of approaches and a solid systematic training tradition has led to a strong position of neuropsychologists as distinguished experts in the Finnish health care system.

Following international trends while subject to past traditions: neuropsychological test use in the Nordic countries.

OBJECTIVE: Historically, the neuropsychological test traditions of the four Nordic countries have spanned from the flexible and qualitative tradition of Luria-Christensen to the quantitative large battery approach of Halstead and Kløve-Matthews. This study reports current test use and discusses whether these traditions still influence attitudes toward test use and choice of tests. METHOD: The study is based on survey data from 702 Nordic neuropsychologists. RESULTS: The average participant used 9 tests in a standard assessment, and 25 tests overall in their practice. Test use was moderated by nationality, competence level, practice profile, and by attitude toward test selection. Participants who chose their tests flexibly used fewer tests than those adhering to the flexible battery approach, but had fewer tests from which to choose. Testing patients with psychiatric disorders was associated with using more tests. IQ, memory, attention, and executive function were the domains with the largest utilization rate, while tests of motor, visual/spatial, and language were used by few. There is a lack of academic achievement tests. Screening tests played a minor role in specialized assessments, and symptom validity tests were seldom applied on a standard basis. Most tests were of Anglo-American origin. CONCLUSIONS: New test methods are implemented rapidly in the Nordic countries, but test selection is also characterized by the dominating position of established and much researched tests. The Halstead-Reitan and Luria traditions are currently weak, but national differences in size of test batteries seem to be influenced by these longstanding traditions.

Stability of vocational outcome in adulthood after moderate to severe preschool brain injury.

We studied how moderate to severe childhood traumatic brain injury (TBI) affects vocational outcome with time. This is the second follow-up of patients who were injured as preschoolers in traffic accidents. In the first follow-up the mean age was 23 years and in the present study the average age of the 27-patient cohort was 40 years. Twenty-two patients were assessed clinically by a neuropsychologist, neurologist and a social worker. Five patients, although not able or willing to participate in the clinical study, were contacted by telephone and interviewed on their vocational outcome. Compared to the first follow-up, 20/27 patients in total had no change in their vocational status. Nine out of the 27 patients were working full-time, two had subsidized jobs and 16 were not working. Twenty-four of 27 patients were independent in daily living. In the neuropsychological tests of executive functions, preserved flexibility associated with full-time work status. In conclusion, 1/3 of the patients were still employed full-time over 30 years after the TBI. This suggests that favorable vocational outcome, reached by young adulthood, is maintained at least until middle age.