Faculty Bibliography

PURPOSE: Research suggests that there are reciprocal relationships between mental health (MH) disorders and epilepsy risk. However, MH relationships to post-traumatic epilepsy (PTE) have not been explored. Thus, the objective of this study was to assess associations between PTE and frequency of depression and/or anxiety in a cohort of individuals with moderate-to-severe TBI who received acute inpatient rehabilitation. METHODS: Multivariate regression models were developed using a recent (2010-2012) cohort (n=867 unique participants) from the TBI Model Systems (TBIMS) National Database, a time frame during which self-reported seizures, depression [Patient Health Questionnaire (PHQ)-9], and anxiety [Generalized Anxiety Disorder (GAD-7)] follow-up measures were concurrently collected at year-1 and year-2 after injury. RESULTS: PTE did not significantly contribute to depression status in either the year-1 or year-2 cohort, nor did it contribute significantly to anxiety status in the year-1 cohort, after controlling for other known depression and anxiety predictors. However, those with PTE in year-2 had 3.34 times the odds (p=.002) of having clinically significant anxiety, even after accounting for other relevant predictors. In this model, participants who self-identified as Black were also more likely to report clinical symptoms of anxiety than those who identified as White. PTE was the only significant predictor of comorbid depression and anxiety at year-2 (Odds Ratio 2.71; p=0.049). CONCLUSIONS: Our data suggest that PTE is associated with MH outcomes 2years after TBI, findings whose significance may reflect reciprocal, biological, psychological, and/or experiential factors contributing to and resulting from both PTE and MH status post-TBI. Future work should consider temporal and reciprocal relationships between PTE and MH as well as if/how treatment of each condition influences biosusceptibility to the other condition.

BACKGROUND: Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. In addition, Speech-Language Pathology rehabilitation was added to the early mobilization program. OBJECTIVE: 1. To assess the efficacy of early mobilization of patients with and without mechanical ventilation in the intensive care units (ICUs) on length of stay (LOS) and patient outcomes. 2. To determine the financial viability of the program. DESIGN: PIP. Prospective data collection in 2014 (PIP) compared to a historical patient population in 2012 (pre-PIP). SETTING: Medical and surgical ICUs of a Level 2 trauma hospital. PATIENTS: 160 in the PIP and 123 in the pre-PIP. INTERVENTIONS: Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the MICU and SICU for medically appropriate patients. MEASUREMENTS: Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; average cost per day. MAIN RESULTS: Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by more than 20% from 4.6 days (pre-PIP) to 3.8 days (PIP) (p=.05). A decrease of 30% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (p<.01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared to 18.2% in the pre-PIP phase (p<.01). Average cost per day in the ICU and floor bed decreased in the PIP group resulting in an annualized net cost savings of $1.5 million. CONCLUSIONS: The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs and decreased need for post-acute care services.

Research Objectives: This analysis examines barriers affecting participant follow-up in longitudinal studies, specifically the Rusk Rehabilitation Traumatic Brain Injury Model System (TBIMS). While longitudinal designs allow researchers to study clinically-meaningful outcomes, high rates of participant loss to follow-up (LTFU) are a common problem. This study examines possible factors associated with LTFU. Design: Utilized data collected through TBIMS Form I interviews and abstraction from acute and rehabilitation medical records. Setting: Two urban New York City TBIMS hospitals. Participants: Participants (N=135) enrolled in TBIMS between April 2013 and June 2016, primarily male (79.3%), White (40%) or Hispanic (28.9%), English-speaking (67.4%), an average of 48.2 years old (SD = 19.0) and had an average of 14 years of education (SD = 9). Interventions: N/A. Main Outcome Measure(s): Variables from TBIMS Form I (pre-injury, medical record abstraction). Results: Descriptive and inferential statistics were used to analyze the demographics, psychosocial variables, injury-related variables, and other jeopardizing factors one year post- injury. The attrition rate was 15.5%. Participants lost to follow-up were more likely to report binge drinking (p< .01) and substance abuse (p< .01). Race was not associated with loss to follow-up (p > .05). Conclusions: Unlike previous studies, results did not demonstrate an association between LTFU and race. This may be due to the homogeneous, less diverse samples commonly found in the literature, leading to biased results. Results also identify substance abuse and binge drinking as risk factors for LTFU. Therefore, physicians should encourage patients to utilize hospital offered substance abuse-related resources. Data collection will be continued to further examine selection bias

OBJECTIVE: Determine incidence of posttraumatic seizure (PTS) following traumatic brain injury (TBI) among individuals with moderate-to-severe TBI requiring rehabilitation and surviving at least 5 years. METHODS: Using the prospective TBI Model Systems National Database, we calculated PTS incidence during acute hospitalization, and at years 1, 2, and 5 postinjury in a continuously followed cohort enrolled from 1989 to 2000 (n = 795). Incidence rates were stratified by risk factors, and adjusted relative risk (RR) was calculated. Late PTS associations with immediate (<24 h), early (24 h-7 day), or late seizures (>7 day) versus no seizure prior to discharge from acute hospitalization was also examined. RESULTS: PTS incidence during acute hospitalization was highest immediately (<24 h) post-TBI (8.9%). New onset PTS incidence was greatest between discharge from inpatient rehabilitation and year 1 (9.2%). Late PTS cumulative incidence from injury to year 1 was 11.9%, and reached 20.5% by year 5. Immediate/early PTS RR (2.04) was increased for those undergoing surgical evacuation procedures. Late PTS RR was significantly greater for individuals who self-identified as a race other than black/white (year 1 RR = 2.22), and for black individuals (year 5 RR = 3.02) versus white individuals. Late PTS was greater for individuals with subarachnoid hemorrhage (year 1 RR = 2.06) and individuals age 23-32 (year 5 RR = 2.43) and 33-44 (year 5 RR = 3.02). Late PTS RR years 1 and 5 was significantly higher for those undergoing surgical evacuation procedures (RR: 3.05 and 2.72, respectively). SIGNIFICANCE: In this prospective, longitudinal, observational study, PTS incidence was similar to that in studies published previously. Individuals with immediate/late seizures during acute hospitalization have increased late PTS risk. Race, intracranial pathologies, and neurosurgical procedures also influenced PTS RR. Further studies are needed to examine the impact of seizure prophylaxis in high-risk subgroups and to delineate contributors to race/age associations on long-term seizure outcomes.

Research Objectives: This study analysis examines the underlying barriers and facilitators to research recruitment within the protocol-eligible vulnerable population of the Traumatic Brain Injury Model Systems (TBIMS) research study. The difficulties behind TBI research lies in its more complicated, difficult to consent, yet eligible participants, such as those of multiple vulnerable group memberships (i.e., non-domicile, minority), those with cognitive impairments, and those lacking social support. This study seeks not only to address the question of research possible selection bias, but also identify possible risk and support factors influencing study enrollment. Design: Utilized data collected through TBI Model Systems (TBIMS) Form I & II interviews and additional interview at first year post-injury follow up. Setting: Data collected through in-person and telephone interviews and medical record abstractions from acute and rehabilitation medical records from two urban New York City TBIMS hospitals. Participants: Participants included over 300+ individuals who were admitted to two TBIMS hospitals from March 2013 through 2016. As of November 2015, participants were primarily male (80%), White (39%) or Hispanic (27%), spoke English (68%), and were an average of 52.3 years old (SD = 19.3). Interventions: Not Applicable. Main Outcome Measure(s): Demographic, psychosocial, and injury-related variables taken from TBIMS Form I (pre-injury, medical record abstraction) and Form II (year one follow-up). Preliminary results showed, slightly above half (56%) of the recruited protocol-eligible TBIMS patients agreed to participate is the study. Results: Descriptive and inferential statistics will be utilized to identify risk and support factors for protocol-eligible non-enrollment, such as demographics, degree of social support, and other jeopardizing factors, such as history of homelessness. Conclusions: Implications for clinical interventions and suggestions for decreasing refusal rates within a TBI population will be discussed

Research Objectives: Outpatient rehabilitation is a critical piece of the traumatic brain injury (TBI) care continuum to optimize physical or cognitive recovery gains after discharge from inpatient rehabilitation. The purpose of this study is to investigate post-inpatient discharge awareness of, attitude toward, and attendance in outpatient rehabilitation. Design: Utilized data collected through TBI Model Systems (TBIMS) Form I & II interviews and additional interview at first year post-injury follow up. Setting: A large, public, urban hospital. Participants: Respondents with TBI (Mage = 48.8, SD = 18.2) were primarily male (82%), White (44%) or Hispanic (22%), single (46%), and with a college education (53%). Interventions: Not Applicable Main Outcome Measure(s): Post-discharge care interview, psychosocial and functional variables from TBIMS Form I (pre-injury, medical record abstraction) and Form II (year one follow-up). Results: Analyses were carried out on the 34 patients who were discharged to a private residence. Out of these respondents, 36.4% did not return for their outpatient follow-up appointments. Figures and tables with descriptive statistics regarding patient attitudes toward and attendance in follow-up care at 1 year post-injury will be presented across demographic and psychosocial variables (age, race, social support), functional outcomes (Functional Independence Measure [FIM], length of stay (LOS), and patient attitudes toward participating in followup care. Conclusions: These results provide insight into the risk factors, circumstances, and beliefs that hinder patient attendance in recommended outpatient follow-up. Implications for clinical care include early identification of these patients (i.e., age, level of social support) to ensure adequate education about the importance of continued therapy in order to improve long-term outcomes