Acute treatment with the 5-HT(1A) receptor agonist 8-OH-DPAT and chronic environmental enrichment confer neurobehavioral benefit after experimental brain trauma

Acute treatment with the 5-HT(1A) receptor agonist 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT) or chronic environmental enrichment (EE) hasten behavioral recovery after experimental traumatic brain injury (TBI). The aim of this study was to determine if combining these interventions would confer additional benefit. Anesthetized adult male rats received either a cortical impact or sham injury followed 15min later by a single intraperitoneal injection of 8-OH-DPAT (0.5mg/kg) or saline vehicle (1.0mL/kg) and then randomly assigned to either enriched or standard (STD) housing. Behavioral assessments were conducted utilizing established motor and cognitive tests on post-injury days 1-5 and 14-18, respectively. Hippocampal CA(1)/CA(3) neurons were quantified at 3 weeks. Both 8-OH-DPAT and EE attenuated CA(3) cell loss. 8-OH-DPAT enhanced spatial learning in a Morris water maze (MWM) as revealed by differences between the TBI+8-OH-DPAT+STD and TBI+VEHICLE+STD groups (P=0.0014). EE improved motor function as demonstrated by reduced time to traverse an elevated narrow beam in both the TBI+8-OH-DPAT+EE and TBI+VEHICLE+EE groups versus the TBI+VEHICLE+STD group (P=0.0007 and 0.0016, respectively). EE also facilitated MWM learning as evidenced by both the TBI+8-OH-DPAT+EE and TBI+VEHICLE+EE groups locating the escape platform quicker than the TBI+VEHICLE+STD group (P's<0.0001). MWM differences were also observed between the TBI+8-OH-DPAT+EE and TBI+8-OH-DPAT+STD groups (P=0.0004) suggesting that EE enhanced the effect of 8-OH-DPAT. However, there was no difference between the TBI+8-OH-DPAT+EE and TBI+VEHICLE+EE groups. These data replicate previous results from our laboratory showing that both a single systemic administration of 8-OH-DPAT and EE improve recovery after TBI and extend those findings by elucidating that the combination of treatments in this particular paradigm did not confer additional benefit. One explanation for the lack of an additive effect is that EE is a very effective treatment and thus there is very little room for 8-OH-DPAT to confer additional statistically significant improvement.

Measuring rehabilitation research capacity: report from the AAPM&R Research Advisory Committee

There is considerable concern regarding the paucity of individuals pursuing biomedical research in general and rehabilitation research in particular. The Research Advisory Committee (RAC) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) accepted the task to explore the barriers to biomedical research careers for physicians and rehabilitation scientists and, in particular, those factors pertaining to successfully conducting rehabilitation research. Concurrently, the Foundation for PM&R was also exploring the related issue of building capacity for rehabilitation research and planning a Rehabilitation Research Summit to address this issue for the spring of 2005. The goals of the Research Summit included the identification of barriers to rehabilitation research and development of an active agenda to enhance research capacity. As such, AAPM&R and the Foundation for PM&R worked through the RAC survey to provide some key information that would help the summit leaders achieve their goals. This report presents portions of the survey related to research capacity and outlines the methodology of the data collection and analysis within the context of the capacity taxonomy framework as presented at the Research Summit, "Building Research Capacity," held in the spring of 2005. This survey report provides quantitative information about researchers and academicians, their research environment, as well as their barriers and incentives for conducting rehabilitation research. Observations here provide a platform for future work in understanding the adequacy of the rehabilitation research enterprise, its appropriateness, and ability to meet societal needs for those with disabilities.

Gender and environmental effects on regional brain-derived neurotrophic factor expression after experimental traumatic brain injury

Alterations in brain-derived neurotrophic factor expression have been reported in multiple brain regions acutely after traumatic brain injury, however neither injury nor post-injury environmental enrichment has been shown to affect hippocampal brain-derived neurotrophic factor gene expression in male rats chronically post-injury. Studies have demonstrated hormone-related neuroprotection for female rats after traumatic brain injury, and estrogen and exercise both influence brain-derived neurotrophic factor levels. Despite recent studies suggesting that exposure post-traumatic brain injury to environmental enrichment improves cognitive recovery in male rats, we have shown that environmental enrichment mediated improvements with spatial learning are gender specific and only positively affect males. Therefore the purpose of this study was to evaluate the effect of gender and environmental enrichment on chronic post-injury cortical and hippocampal brain-derived neurotrophic factor protein expression. Sprague-Dawley male and cycling female rats were placed into environmental enrichment or standard housing after controlled cortical impact or sham surgery. Four weeks post-surgery, hippocampal and frontal cortex brain-derived neurotrophic factor expression were examined using Western blot. Results revealed significant increases in brain-derived neurotrophic factor expression in the frontal cortex ipsilateral to injury for males (P=0.03). Environmental enrichment did not augment this effect. Neither environmental enrichment nor injury significantly affected cortical brain-derived neurotrophic factor expression for females. In the hippocampus ipsilateral to injury brain-derived neurotrophic factor expression for both males and females was half (49% and 51% respectively) of that observed in shams housed in the standard environment. For injured males, there was a trend in this region for environmental enrichment to restore brain-derived neurotrophic factor levels to sham values. However, there were robust increases in hippocampal brain-derived neurotrophic factor expression ipsilateral to the injury for injured females in environmental enrichment compared with both sham and injured females placed in standard housing (P<or=0.005). In the hippocampus contralateral to injury, there were also significant injury-related increases in brain-derived neurotrophic factor expression for females (P<or=0.05) that were not further augmented by environmental enrichment. These results show significant, region-specific gender differences in brain-derived neurotrophic factor expression with both injury and environmental enrichment that may be important for recovery. However, these data do not support a critical role for brain-derived neurotrophic factor in environmental enrichment mediated improvements with spatial learning.

Gender and environmental enrichment impact dopamine transporter expression after experimental traumatic brain injury

Dopamine (DA) systems are implicated in cognitive deficits following traumatic brain injury (TBI). Rodent studies have demonstrated that both environmental enrichment (EE) and sex hormones can influence DA systems. The dopamine transporter (DAT) plays a crucial role in regulating DA transmission, and previous work shows that DAT is decreased after TBI in males. Therefore, the purpose of this study was to examine the effects of gender and EE on frontal cortex and striatal DAT expression after TBI. Sprague-Dawley male (n = 24) and cycling female rats (n = 24) were placed into EE or standard housing after controlled cortical impact (2.7 mm, 4.0 m/s) injury or sham surgery (eight groups, n = 6/group). Four weeks post-surgery, bilateral frontal cortex and striatal DAT expression was examined via Western blot. Results demonstrated that there was a significant effect of injury, EE, and region on DAT expression (P < 0.05 all comparisons) on female groups. There were no significant DAT decreases in any region as a result of injury, however, EE did promote significant post-injury DAT decreases in the striatum and ipsilateral frontal cortex (P < 0.05 all comparisons) compared to female shams housed in the standard environment. For males, there was a significant effect of injury, EE, and region for male groups (P < 0.05 all comparisons). There were decreases in DAT expression in three regions studied for injured males housed in the standard environment compared to sham males in the standard environment (P < 0.05 all comparisons), however, EE did not add significantly to post-injury DAT decreases in these regions. These results suggest that CCI causes larger relative decreases in DAT expression for males compared to females and that treatment with EE has larger effects on post-injury DAT expression for females than males. These findings may have some relevance to treatment paradigms using dopaminergic neurostimulants after TBI.

Controlled cortical impact injury affects dopaminergic transmission in the rat striatum

The therapeutic benefits of dopamine (DA) agonists after traumatic brain injury (TBI) imply a role for DA systems in mediating functional deficits post-TBI. We investigated how experimental TBI affects striatal dopamine systems using fast scan cyclic voltammetry (FSCV), western blot, and d-amphetamine-induced rotational behavior. Adult male Sprague-Dawley rats were injured by a controlled cortical impact (CCI) delivered unilaterally to the parietal cortex, or were naïve controls. Amphetamine-induced rotational behavior was assessed 10 days post-CCI. Fourteen days post-CCI, animals were anesthetized and underwent FSCV with bilateral striatal carbon fiber microelectrode placement and stimulating electrode placement in the medial forebrain bundle (MFB). Evoked DA overflow was assessed in the striatum as the MFB was electrically stimulated at 60 Hz for 10 s. In 23% of injured animals, but no naïve animals, rotation was observed with amphetamine administration. Compared with naïves, striatal evoked DA overflow was lower for injured animals in the striatum ipsilateral to injury (p < 0.05). Injured animals exhibited a decrease in V(max) (52% of naïve, p < 0.05) for DA clearance in the hemisphere ipsilateral to injury compared with naïves. Dopamine transporter (DAT) expression was proportionally decreased in the striatum ipsilateral to injury compared with naïve animals (60% of naïve, p < 0.05), despite no injury-related changes in vesicular monoamine transporter or D2 receptor expression (DRD2) in this region. Collectively, these data appear to confirm that the clinical efficacy of dopamine agonists in the treatment of TBI may be related to disruptions in the activity of subcortical dopamine systems.

Synaptosomal dopamine uptake in rat striatum following controlled cortical impact

Functional deficits following traumatic brain injury (TBI) are associated with alterations in markers of dopaminergic neurotransmission. To assess the effects of TBI on the expression and functional integrity of dopamine transporters, we measured transporter protein levels and investigated synaptosomal dopamine uptake in the rat striatum. Two or four weeks after lateral controlled cortical impact or sham injury, Western blotting revealed a decrease in transporter protein in the ipsilateral striatum of injured rats relative to shams (P < 0.05). However, no significant difference in synaptosomal uptake (K(m), V(max)) was found between injured and sham-injured animals. Our data suggest that striatal dopamine transporters are capable of normal function at 2 weeks and 4 weeks after injury. However, it is unclear whether neurons in the injured striatum can properly regulate the activity of dopamine transporters in vivo.

Gender associations with cerebrospinal fluid glutamate and lactate/pyruvate levels after severe traumatic brain injury

OBJECTIVE

Female sex hormones appear to be neuroprotective after traumatic brain injury by attenuating multiple mechanisms of secondary insult, including excitotoxicity and ischemia. The purpose of this study was to evaluate associations between gender and cerebrospinal fluid glutamate and lactate/pyruvate production and the role of hypothermia with gender in attenuating these markers.

DESIGN

Prospectively collected data were analyzed for adult patients with severe traumatic brain injury. Gender comparisons for cerebrospinal fluid glutamate and lactate/pyruvate production were determined using ventricular samples obtained over the first 48 hrs postinjury.

SETTING

University-based level I trauma center.

PATIENTS

There were 123 patients, male n = 93 and female n = 30 (n = 686 cerebrospinal fluid samples), with severe traumatic brain injury (Glasgow Coma Scale score < or =8).

INTERVENTIONS

A portion of these patients were part of a randomized controlled trial evaluating the effect of (48 hrs) therapeutic hypothermia after severe traumatic brain injury. The remainder received hypothermia (24 hrs) if they met clinical care criteria. Patients were cooled to 32-33 degrees C (within approximately 8 hrs) for either 24 or 48 hrs and then were rewarmed or remained normothermic.

MEASUREMENTS AND MAIN RESULTS

Regression analyses using generalized estimating equations for repeated measures showed significant increases in cerebrospinal fluid glutamate production for males compared with females (p = .0023) and a significant interaction between glutamate concentration, gender, and time (p = .0035) by 24 hrs postinjury. Females had lower lactate/pyruvate ratios than males (p = .0006), and there was a significant interaction between lactate/pyruvate, gender, and time (p = .0045) throughout the first 48 hrs postinjury. Hypothermia attenuated glutamate levels, particularly for males, over the time course studied.

CONCLUSIONS

These data suggest significant gender differences with glutamate and lactate/pyruvate production after severe traumatic brain injury. Gender- and hormone-mediated differences in central nervous system pathophysiology should be considered with clinical trials in traumatic brain injury.

Relationships between cerebrospinal fluid markers of excitotoxicity, ischemia, and oxidative damage after severe TBI: the impact of gender, age, and hypothermia

Excitotoxicity and ischemia can result in oxidative stress after TBI. Female sex hormones are hypothesized to be neuroprotective after TBI by affecting multiple mechanisms of secondary injury, including oxidative damage, excitotoxicity and ischemia. Ca2+ mediated oxidative stress increases with age, and hypothermia is known to attenuate secondary injury. The purpose of this study was to determine if the relationship between cerebral spinal fluid (CSF) markers of excitotoxicity, ischemia, and oxidative damage are gender and age specific and the role of hypothermia in affecting these relationships. F2-isoprostane, glutamate, and lactate/pyruvate, were assessed in CSF from adults (n = 68) with severe TBI (Glasgow coma scale [GCS] score </= 8) using ventricular CSF samples (n = 207) collected on days 1, 2, and 3 post-injury. F2-isoprostane/glutamate and F2-isoprostane/lactate/pyruvate ratios were determined for patients at each time point. Six-month Glasgow Outcome Scores (GOS) were also obtained. Repeated measures multivariate analysis showed a significant gender effect (p < 0.002) and gender*time interaction (p = 0.012) on F2-isoprostane/glutamate ratios. A significant gender effect (p = 0.050) and gender*time interaction (p = 0.049) was also seen with F2-isoprostane/lactate/pyruvate. Hypothermia (p = 0.001) and age (p = 0.026) significantly increased F2-isoprostane/glutamate ratios. Females had a significant inverse relationship between day 1 F2-isoprostane/glutamate ratios and GOS scores (r =- 0.43; p = 0.05) as well as day 1 F2-isoprostane/lactate/pyruvate ratio (r =- 0.46; p = 0.04) and GOS scores. These results indicate that females have smaller oxidative damage loads than males for a given excitotoxic or ischemic insult and female gonadal hormones may play a role in mediating this neuroprotective effect. These results also suggest that susceptibility to glutamate mediated oxidative damage increases with age and that hypothermia differentially attenuates CSF glutamate versus F2-isoprostane production. Gender and age differences in TBI pathophysiology should be considered when conducting clinical trials in TBI.

Evaluation of estrous cycle stage and gender on behavioral outcome after experimental traumatic brain injury

Female sex hormones are acutely neuroprotective in experimental models of traumatic brain injury (TBI). Because hormonal profiles are known to vary with estrous cycle stage, the purpose of this study was to evaluate how pre-injury estrous stage affects motor and cognitive performance after experimental TBI. We also sought to compare post-injury behavioral performance in males vs. females. Under anesthesia, male (n=18) and female (n=35) Sprague-Dawley rats underwent either controlled cortical impact (CCI) injury (2.7 mm; 4 m/s) or sham operations. Females were grouped according to estrous stage (proestrous or non-proestrous) at the time of surgery. Motor function was assessed pre-injury and for the first 5 days after surgery using beam balance and walking tasks. Spatial memory was assessed beginning 14 days post-injury utilizing the Morris water maze (MWM) task. No significant differences were found on any task between injured females regardless of estrous cycle stage. Females performed significantly better than males on both motor tasks, but gender did not influence MWM performance. Mixed effects multivariate analysis corroborated these results by showing that pre-injury serum hormone levels had little affect on behavioral performance. The results suggest that the presence of endogenous circulating hormones, rather than hormonal status at time of injury, may confer early neuroprotection in females after TBI. The impact of early neuroprotection on later behavioral outcome and the anatomic structural specificity of hormonal neuroprotection require further study.

Peer Review

Peer review, although the standard for evaluating scientific research, is not without flaws. Peer reviewers have been shown to be inconsistent and to miss major strengths and deficiencies in studies. Both reviewer and author biases, including conflicts of interest and positive outcome publication biases, are frequent topics of study and debate. Additional concerns have been raised regarding inappropriate authorship and adequate reporting of the ethical process involving human and animal experimentation. Despite these issues, a good peer review can provide positive feedback to authors and improve the quality of research reported in medical journals. This article reviews some issues and points of concern regarding the peer-review process, and it suggests guidelines for new (and established) reviewers in the area of physical medicine and rehabilitation. It also provides suggestions for editorial considerations and improvements in the peer-review process for physical medicine and rehabilitation research journals.

Physical medicine and rehabilitation consultation: relationships with acute functional outcome, length of stay, and discharge planning after traumatic brain injury

OBJECTIVE

Patients hospitalized with traumatic brain injury comprise a large portion of the population treated at trauma centers, and physiatry consultants evaluate many traumatic brain injury patients in this setting. The purpose of this study was to delineate relationships between physical medicine and rehabilitation consultation in this population and acute functional outcome, length of stay, and discharge planning.

DESIGN

Data were obtained for 1866 adult patients hospitalized with nonfatal traumatic brain injury. Functional outcome was determined using a modification of the FIM trade mark. Descriptive and regression analyses were used to determine the relationship of physical medicine and rehabilitation consultation to acute discharge FIM score, length of stay, and discharge disposition.

RESULTS

Patients receiving physical medicine and rehabilitation consultation had more severe injuries, lower acute discharge FIM scores, and longer length of stay. However, multivariate analysis showed that earlier (<48 hr after admission) physical medicine and rehabilitation consultation resulted in significantly better FIM scores with transfers (odds ratio, 2.61; 95% confidence interval, 1.06-6.40) and locomotion (odds ratio, 3.54; 95% confidence interval, 1.34-9.32) and a significantly shorter acute length of stay (P = 0.001).

CONCLUSIONS

Early physical medicine and rehabilitation consultation may positively impact functional status and length of stay for patients with traumatic brain injury during acute hospitalization. Additional work is needed to determine how physical medicine and rehabilitation consultation impacts rehabilitation-specific medical issues, long-term functional outcome, and healthcare costs.

Intervention with environmental enrichment after experimental brain trauma enhances cognitive recovery in male but not female rats

Environmental enrichment (EE) has been repeatedly shown to affect multiple aspects of brain function, and is known to enhance cognitive recovery after experimental traumatic brain injury (TBI) in males. However, the impact of gender on how EE affects behavioral performance after experimental TBI have not been studied. Male and normally cycling female Sprague-Dawley rats underwent controlled cortical impact injury or sham surgery and then were placed in either a standard or enriched housing environment. Motor function was assessed both pre-injury and for the first 5 days after injury. Spatial memory was assessed beginning 14 days after injury. Placement in an EE after TBI enhanced spatial memory performance in male but not female rats. EE did not impact motor performance in this setting. These findings have gender specific implications for how to approach and evaluate treatments and interventions after TBI.

Segmented regression analysis of interrupted time series studies in medication use research

Interrupted time series design is the strongest, quasi-experimental approach for evaluating longitudinal effects of interventions. Segmented regression analysis is a powerful statistical method for estimating intervention effects in interrupted time series studies. In this paper, we show how segmented regression analysis can be used to evaluate policy and educational interventions intended to improve the quality of medication use and/or contain costs.

Return to productive activity after traumatic brain injury: relationship with measures of disability, handicap, and community integration

OBJECTIVES

To identify which factors are associated with successful return to productive activity (RTPA) 1 year after hospitalization with traumatic brain injury (TBI) and to examine the relations between successful RTPA and other measures of impairment, disability, handicap, and integration into the community.

DESIGN

Prospective study with 1-year follow-up.

SETTING

Level I trauma center.

PARTICIPANTS

One hundred five respondents from a cohort of 378 adults hospitalized with TBI admitted between September 1997 and May 1998.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Return to productive work 1 year after injury; Disability Rating Scale (DRS); and Community Integration Scale (CIQ).

RESULTS

Of the 105 participants, 72% achieved RTPA. Logistic regression showed an association between RPTA and the following factors: premorbid educational level, premorbid psychiatric history, violent mechanism of injury, discharge status after acute hospitalization, prior alcohol and drug use, and injury severity. Handicap and community integration at 1-year postinjury, as measured by subscales of the DRS and the CIQ, were also associated with RTPA.

CONCLUSION

Premorbid and injury-related variables and measures of handicap and community integration were associated with RTPA at 1 year. To understand and effectively support vocational pursuits in the TBI population, future studies are needed to define further causality and origin of these relationships.

An internship for college students in physical medicine and rehabilitation: effects on awareness, career choice, and disability perceptions

OBJECTIVE

To show the impact that an internship program in Physical Medicine and Rehabilitation (PM&R) for college students has on their knowledge about the field, career choice, and perceptions about people with disabilities.

DESIGN

Twelve students were selected to participate in the study. Students observed patient therapies and followed faculty and physiatry resident physicians. Students also participated in research studies in rehabilitation research. Group discussions regarding specific projects, research methods, career choice, and perceptions about disability were part of a didactic curriculum. Surveys about PM&R knowledge, attitudes toward people with disabilities, demographics, and course evaluations were administered.

RESULTS

Results showed that the program increased knowledge about PM&R (P < 0.008). Premedical students missed significantly fewer questions (8.2 vs. 11.7; P = 0.04) on this survey than did other participants. Results also showed that this program affected their attitudes toward people with disabilities and student choice to pursue a career in health care.

CONCLUSIONS

This type of internship experience provides an educational environment for college students to become acquainted with PM&R, interact positively with people with disabilities, and influence career choice in the allied health professions.

A history and review of quantitative electroencephalography in traumatic brain injury

The electroencephalogram (EEG) is a physiologic measure of cerebral function that has been used by some to assess coma and prognosticate survival and global outcome after traumatic brain injury (TBI). Surface recordings of the brain's electrical activity reveal distinct patterns that indicate injury severity, depth of unconsciousness, and patient survival. The data produced with traditional qualitative studies, however, does not allow resolution and quantification of the wave frequency spectrum present in the brain. As a result, conventional EEG typically has only been used for gross and qualitative analyses and is not practical for use in long-term patient monitoring or as a sophisticated prognostic tool. One area of investigation that is working to address the limitations of conventional EEG has been the development and implementation of Fourier Transform (FT) EEG which resolves and quantifies frequency bands present in the brain. When FT analysis is applied to EEG, it provides concurrent and continuous monitoring, resolution, and quantification of all frequencies emitted. This review discusses the history and significance of conventional EEG and provides a review of how FT-EEG, commonly referred to as Quantitative EEG (QEEG), is being used in the clinical setting. The specific applications and significance of QEEG methods regarding treatment of patients with TBI are discussed in detail. The advantages, disadvantages, and future directions of QEEG in TBI are also discussed.

Use of injury severity variables in determining disability and community integration after traumatic brain injury

BACKGROUND

Long-term outcome is important in managing traumatic brain injury (TBI), an epidemic in the United States. Many injury severity variables have been shown to predict major morbidity and mortality. Less is known about their relationship with specific long-term outcomes.

METHODS

Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score, along with other demographic and premorbid values, were obtained for 378 consecutive patients hospitalized after TBI at a Level I trauma center between September 1997 and May 1998. Of this cohort, 120 patients were contacted for 1-year follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data.

RESULTS

Univariate analyses showed these to be significant single predictors of 1-year outcome. Multivariate analyses revealed that the Revised Trauma Score and Glasgow Coma Scale had significant additive value in predicting injury variables Disability Rating Scale scores when combined with other demographic and premorbid variables studied. Predictive models of 1-year outcome were developed.

CONCLUSION

Injury severity variables are significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term disability and community integration for individuals hospitalized with TBI.

Intentional traumatic brain injury: epidemiology, risk factors, and associations with injury severity and mortality

BACKGROUND

Intentional injury is associated with significant morbidity and mortality and has been associated with certain demographic and socioeconomic groups. Less is known about the relationship of intentional traumatic brain injury (TBI) to injury severity, mortality, and demographic and socioeconomic profile. The objective of this study was to delineate demographic and event-related factors associated with intentional TBI and to evaluate the predictive value of intentional TBI on injury severity and mortality.

METHODS

Prospective data were obtained for 2,637 adults sustaining TBIs between January 1994 and September 1998. Descriptive, univariate, and multivariate analyses were conducted to determine the predictive value of intentional TBI on injury severity and mortality.

RESULTS

Gender, minority status, age, substance abuse, and residence in a zipcode with low average income were associated with intentional TBI. Multivariate analysis found minority status and substance abuse to be predictive of intentional injury after adjusting for other demographic variables studied. Intentional TBI was predictive of mortality and anatomic severity of injury to the head. Penetrating intentional TBI was predictive of injury severity with all injury severity markers studied.

CONCLUSION

Many demographic variables are risk factors for intentional TBI, and such injury is a risk factor for both injury severity and mortality. Future studies are needed to definitively link intentional TBI to disability and functional outcome.

The value of trauma scores: predicting discharge after traumatic brain injury

OBJECTIVE

To determine the association of acute variables with disposition after acute hospitalization.

DESIGN

Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Combined Trauma Score Injury Severity Score (TRISS(RTS)) were compared with discharge disposition after acute hospitalization of 378 consecutive patients who sustained a traumatic brain injury (TBI) and were treated at a level 1 trauma center between September 1997 and May 1998.

RESULTS

Logistic regression modeling found TRISS(RTS) to predict discharge to home with or without home health assistance or inpatient rehabilitation vs. nursing home placement or death. Subsequent modeling, excluding patients who died or went to nursing homes, identified RTS and ISS as predictors of discharge to home with or without home health vs. inpatient rehabilitation. A sensitivity of 97.78% and 93.91% were achieved with these two models when tested on a population of 4,625 patients with TBI treated during the last 10 yr at the same facility.

CONCLUSIONS

The results suggest that RTS, ISS, and TRISS(RTS) are predictors of discharge disposition after acute hospitalization with TBI and may be useful measures of rehabilitation services resource planning early in the course of TBI management.

The impact of a single seizure on health status and health care utilization

PURPOSE

To assess the health status of patients after a single seizure.

METHODS

We compared single-seizure patients (SS) with patients who had well-controlled epilepsy (WC), and uncomplicated hypertension (HT). Patients were adults screened from emergency and outpatient units of two urban teaching hospitals using predefined criteria. The 83 patients (SS, 30; WC, 29; HT, 24) were interviewed by phone about functional status (SF-36), comorbid illness, cause of illness, number of visits to health providers, and drug side effects.

RESULTS

No significant differences were found among groups for health status, SF-36 domain, or occurrence of drug side effects. SS patients had significantly lower scores on vitality (p < 0.03) and a trend toward lower role physical function (p < 0.07) compared with age-adjusted population norms. SS reported more visits to health providers than WC or HT, and the number of visits remained high at interview 1 year later. Patient knowledge of the "reason" for the seizure was not associated with health status or number of visits.

CONCLUSIONS

Health status of patients within 1 year of a single seizure is similar to that of patients with well-controlled epilepsy or hypertension, but SS patients have greater health care utilization.

A Kiswahili version of the SF-36 Health Survey for use in Tanzania: translation and tests of scaling assumptions

The objective of the study was to translate and adapt the SF-36 Health Survey for use in Tanzania and to test the psychometric properties of the Kiswahili SF-36. A cross-sectional study was conducted as part of a household survey of a representative sample of the adult population of Dar es Salaam, Tanzania. The IQOLA method of forward and backward translation was used to translate the SF-36 into Kiswahili. The translated questionnaire was administered by trained interviewers to 3,802 adults (50% women, mean (SD) age 31 (13) years, 50% married and 60% with primary education). Data quality and psychometric assumptions underlying the scoring of the eight SF-36 scales were evaluated for the entire sample and separately for the least educated subgroup (n = 402), using multitrait scaling analysis. Forward and backward translation procedures resulted in a Kiswahili SF-36 that was considered conceptually equivalent to the US English SF-36. Data quality was excellent: only 1.2% of respondents were excluded because they answered less than half of the items for one or more scales; ninety percent of respondents answered mutually exclusive items consistently. Median item-scale correlations across the eight scales ranged from 0.47 to 0.81 for the entire sample. Median scaling success rates were 100% (range 87.5-100.0). The median internal consistency reliability of the eight scales for the entire sample was 0.81 (range 0.70-0.92). Floor effects were low and ceiling effects were high on five of the eight scales. Results for n = 402 people without formal education did not differ substantially from those of the entire sample. The results of data quality and psychometric tests support the scoring of the eight scales using standard scoring algorithms. The Kiswahili translation of the SF-36 may be useful in estimating the health of people in Dar es Salaam. Evidence for the validity of the SF-36 for use in Tanzania needs to be accumulated.

Validation of the Kiswahili version of the SF-36 Health Survey in a representative sample of an urban population in Tanzania

The objective of this study was to assess the validity of a Kiswahili translation of the SF-36 Health Survey (SF-36) among an urban population in Tanzania, using the method of known-groups validation. People were randomly selected from a demographic surveillance system in Dar es Salaam. The representative sample consisted of 3,802 adults (15 years and older). Health status differences were hypothesized among groups, who differed in sex, age, socioeconomic status and self-reported morbidity. Mean SF-36 scale scores were calculated and compared using t-test and ANOVA. Women had significantly lower mean SF-36 scale scores (indicating worse health status) than men on all scales and scores were lower for older people than younger on all domains, as hypothesized. On five of the eight SF-36 scales, means were higher for people of higher socioeconomic status compared to those of lower socioeconomic status. People who reported an illness within the previous 2 weeks scored significantly lower on all scales compared to those who were healthy, as did people who said they had a disability or a chronic condition.

Evaluation of ENCOREplus. A community-based breast and cervical cancer screening program

BACKGROUND

Minority women and women with low income levels are significantly less likely to practice appropriate mammography and Pap test screening. ENCOREplus is a health promotion program that provides outreach, education, referral, and other service that facilitate breast and cervical cancer screening for medically underserved women. The program is delivered through a network of community-based nonprofit organizations (YWCA of the U.S.A). The purpose of this study was to assess the effectiveness of ENCOREplus in promoting mammography and Pap test screening among women who were nonadherent to screening guidelines.

METHODS

Baseline data were collected from women participating in the program. Follow-up occurred within six months of baseline to assess whether or not enrollees received recommended screenings. Screening-completion rates were compared to rates from other published intervention studies.

RESULTS

Data from the program's second implementation year show that 27,494 women participated in the ENCOREplus program. Over half the women were racial/ethnic minorities, over 75% reported annual incomes under $15,000, and 49% reported no insurance. Among women 40 and over, 69.7% were nonadherent to ACS mammography screening guidelines at baseline. Among participants 18 and older, 68.9% were nonadherent to Pap test screening guidelines. Of nonadherent participants, 57.8% received mammograms and 36.5% received Pap tests. Both mammography and Pap test screening-completion rates compared favorably with other programs.

CONCLUSION

This study demonstrates that programs implemented through community-based organizations can be successful in increasing mammography and Pap test screening among low-income and minority women.