Faculty Bibliography

OBJECTIVES/OBJECTIVE:In this study, we describe unmet service needs of children hospitalized for traumatic brain injury (TBI) during the first 2 years after injury and examine associations between child, family, and injury-related characteristics and unmet needs in 6 domains (physical therapy, occupational therapy, speech therapy, mental health services, educational services, and physiatry). METHODS:Prospective cohort study of children age 8 to 18 years old admitted to 6 hospitals with complicated mild or moderate to severe TBI. Service need was based on dysfunction identified via parent-report compared with retrospective baseline at 6, 12, and 24 months. Needs were considered unmet if the child had no therapy services in the previous 4 weeks, no physiatry services since the previous assessment, or no educational services since injury. Analyses were used to compare met and unmet needs for each domain and time point. Generalized multinomial logit models with robust SEs were used to assess factors associated with change in need from pre-injury baseline to each study time point. RESULTS:Unmet need varied by injury severity, time since injury, and service domain. Unmet need was highest for physiatry, educational services, and speech therapy. Among children with service needs, increased time after TBI and complicated mild TBI were associated with a higher likelihood of unmet rather than met service needs. CONCLUSIONS:Children hospitalized for TBI have persistent dysfunction with unmet needs across multiple domains. After initial hospitalization, children with TBI should be monitored for functional impairments to improve identification and fulfillment of service needs.

OBJECTIVE: To characterize and compare subgroups of survivors with assault-related versus self-inflicted traumatic brain injuries (TBI) via firearms at time of inpatient rehabilitation, 1, 2, and 5 year follow-up. DESIGN: Secondary analysis of data from the Traumatic Brain Injury Model Systems National Database (TBIMS NDB), a multicenter longitudinal cohort study. SETTING: Retrospective analyses of a subset of individuals enrolled in the TBIMS NDB. PARTICIPANTS: Individuals 16 years and older (N=399; 310 via assault and 89 via self-inflicted injury) with a primary diagnosis of TBI due to firearm injury enrolled in the TBIMS NDB. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS), Glasgow Outcome Scale-Extended (GOS-E), socio-demographic variables (sex, age, race, marital status), injury-related/acute care information (posttraumatic amnesia, loss of consciousness, time from injury to acute hospital discharge) and mental health variables (i.e., substance use history, psychiatric hospitalizations, suicide history, incarcerations). RESULTS: Individuals who survived TBI secondary to a firearm injury differed by injury mechanism (assault versus self-inflicted) on critical demographic, injury-related/acute care, and mental health variables at inpatient rehabilitation and across long-term recovery. Groups differed in terms of geographic area, age, ethnicity, education, marital status, admission GCS, and alcohol abuse, suicide attempts, and psychiatric hospitalizations at various time points. CONCLUSION: These findings have implications for prevention, for example mental health programming and access to firearms in targeted areas, and for rehabilitation planning, for instance by incorporating training with coping strategies and implementation of addictions-related services for firearm-related TBI, based upon subtype of injury.

PURPOSE: The primary objective is to provide evidence of convergent and discriminant validity for the pediatric and parent-proxy versions of the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, Depression, Anger, Peer Relations, Mobility, Pain Interference, and Fatigue item banks, the Neurology Quality of Life measurement system (Neuro-QOL) Cognition-General Concerns and Stigma item banks, and the Traumatic Brain Injury Quality of Life (TBI-QOL) Executive Function and Headache item banks in a pediatric traumatic brain injury (TBI) sample. METHODS: Participants were 134 parent-child (ages 8-18 years) days. Children all sustained TBI and the dyads completed outcome ratings 6 months after injury at one of six medical centers across the United States. Ratings included PROMIS, Neuro-QOL, and TBI-QOL item banks, as well as the Pediatric Quality of Life inventory (PedsQL), the Health Behavior Inventory (HBI), and the Strengths and Difficulties Questionnaire (SDQ) as legacy criterion measures against which these item banks were validated. RESULTS: The PROMIS, Neuro-QOL, and TBI-QOL item banks demonstrated good convergent validity, as evidenced by moderate to strong correlations with comparable scales on the legacy measures. PROMIS, Neuro-QOL, and TBI-QOL item banks showed weaker correlations with ratings of unrelated constructs on legacy measures, providing evidence of discriminant validity. CONCLUSION: Our results indicate that the constructs measured by the PROMIS, Neuro-QOL, and TBI-QOL item banks are valid in our pediatric TBI sample and that it is appropriate to use these standardized scores for our primary study analyses.

Research Objectives: Processing speed (PS) deficits are among the most common neuropsychological (NP) deficits following traumatic brain injury (TBI). These objective deficits may lead to subjective feelings of being flooded and overwhelmed or that things happen too quickly that one can no longer keep up with cognitive demands made by external events. This subjective experience of slowed PS has been proposed to underlie symptoms of emotional reactivity (ER), such as, tension, frustration, and irritability, which in turn may exacerbate cognitive complaints. The aim of this study was to evaluate the role of objective PS deficits in ER and cognitive/somatic postconcussive symptoms (PCS) following mild TBI (mTBI). Design: Correlational/regression analyses examining objective PS measures, ER, and somatic/cognitive PCS. Setting: Large academic medical center. Participants: Adults with mTBI (n = 31), 52% female, primarily White (74%), average age of 35.8, with 16.1 years of education. Interventions: N/A. Main Outcome Measure(s): Standard TBI outcome battery, 6,7 addressing (a) objective NP impairments, (b) psychological status, and (c) PCS. ER was assessed using z-score composite of relevant self-report items. Results: Objective PS measures were significantly related to ER. ER explained a significant 33% of variance in somatic/cognitive PCS, Beta = -.62, t (29) = -3.15, p =.004, over and above variance explained directly by PS, Beta = -.07, t (29) = -.38, ns. Conclusions: ER is directly related to objective PS deficits. In addition, ER is a significant predictor of somatic/cognitive PCS, whereas objective PS measures are not directly related to PCS. Emotional reactions to the experience of objective cognitive slowing warrant further investigation as a predictor of those at risk for prolonged PCS. Further examination of ER as a predictor of PCS may lead to more accurate assessment/prognosis following mTBI

OBJECTIVE: To determine whether severities of head and extra-cranial injuries (ECI) were associated with suicidal ideation (SI) or suicide attempt (SA) after traumatic brain injury (TBI). DESIGN: Factors associated with SI and SA were assessed in this inception cohort study using data collected 1, 2, and 5 years post-TBI from the National Trauma Databank (NTDB) and TBI model system (TBI-MS) databases. SETTING: Level I Trauma, Inpatient Rehabilitation Centers, the community PARTICIPANTS: 3,575 participants with TBI from 15 TBI-MS Centers with linked NTDB trauma data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES(S): SI was measured via the Patient Health Questionnaire 9 (PHQ-9, question #9). SA in the past year was assessed via interview. ECI was measured by Injury Severity Scale (non-head) and categorized as none, mild, moderate, and severe. RESULTS: 293 (8.2%) participants had SI without SA and 109 (3.0%) had SA at least once in the first 5 years post-injury. Random effects logit modeling showed a higher likelihood of SI when ECI was severe (OR: 2.730; 95%CI: 1.55-4.82, p=0.001). Drug use at time of injury was also associated with SI (OR: 1.69; 95%CI: 1.11-2.86; p=0.015). Severity of ECI was not associated with SA. CONCLUSIONS: Severe ECI carried a nearly 3-fold increase in the odds of SI after TBI, but was not related to SA. Head injury severity and less severe ECI were not associated with SI or SA. These findings warrant additional work to identify factors associated with severe ECI that make individuals more susceptible to SI after TBI.

OBJECTIVE: Cortical structural and functional anomalies have been found to associate with language impairments in both schizophrenia patients and genetic high risk individuals for developing schizophrenia. However, subcortical structures that contribute to language processing haven't been well studied in this population, and thus became the main objective of this study. METHOD: We examined structural MRI data from 20 patients with schizophrenia, 21 individuals at genetic high risk, and 48 controls. Surface shape and volume differences of 6 subcortical structures that are involved in language processing, including nuclei pallidum, putamen, caudate, amygdala, thalamus, and hippocampus from both hemispheres, were compared between groups. Performance scores of language-associated cognitive tests were obtained to identify relationships of subcortical structures to language-related behaviors. RESULTS: Significantly reduced volumes of both the left and right side caudate nuclei, thalami and right side amygdala were shown in patients when compared with controls. Very interestingly, the high risk group demonstrated significantly increased correlations between volumes of left side pallidum nucleus and bilateral thalami and language-related cognitive test scores when compared to controls. CONCLUSIONS: This study furthers our understanding of subcortical structural alterations in schizophrenia and high risk individuals, and suggests the contribution of subcortical structures to the language impairments that may serve as an early sign for impending development of schizophrenia.

Objective To develop an item response theory (IRT)-calibrated spinal cord injury (SCI)-specific Positive Affect and Well-being (PAWB) item bank with flexible options for administration. Design Qualitative feedback from patient and provider focus groups was used to expand on the Neurological Disorders and Quality of Life (Neuro-QOL) positive affect & well-being item bank for use in SCI. New items were created and revised based on expert review and patient feedback and were then field tested. Analyses included confirmatory factor analysis, graded response IRT modeling and evaluation of differential item functioning (DIF). Setting We tested a 32-item pool at several rehabilitation centers across the United States, including the University of Michigan, Kessler Foundation, Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital and the James J. Peters/Bronx Department of Veterans Affairs hospital. Participants A total of 717 individuals with SCI answered the PAWB questions. Results A unidimensional model was observed (Confirmatory Fit Index = 0.947; Root Mean Square Error of Approximation = 0.094) and measurement precision was good (reliability in theta of -2.9 to 1.2 is roughly equivalent to classical reliability of 0.95 or above). Twelve items were flagged for DIF, however, after examination of effect sizes, the DIF was determined to be negligible and would have little practical impact on score estimates. The final calibrated item bank resulted in 28 retained items Conclusions This study indicates that the Spinal Cord Injury - Quality of Life PAWB bank represents a psychometrically robust measurement tool. Short form items are also suggested and a computer adaptive test is available.