Discriminating Mild Traumatic Brain Injury and Posttraumatic Stress Disorder Using Latent Neuroimaging and Neuropsychological Profiles in Active-Duty Military Service Members

OBJECTIVE

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) commonly occur among military Service Members and Veterans and have heterogenous, but also overlapping symptom presentations, which often complicate the diagnoses of underlying impairments and development of effective treatment plans. Thus, we sought to examine whether the combination of whole brain gray matter (GM) and white matter (WM) structural measures with neuropsychological performance can aid in the classification of military personnel with mTBI and PTSD.

METHODS

Active-Duty US Service Members ( n = 156; 87.8% male) with a history of mTBI, PTSD, combined mTBI+PTSD, or orthopedic injury completed a neuropsychological battery and T1- and diffusion-weighted structural neuroimaging. Cortical, subcortical, ventricular, and WM volumes and whole brain fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated. Latent profile analyses were performed to determine how the GM and WM indicators, together with neuropsychological indicators, classified individuals.

RESULTS

For both GM and WM, respectively, a 4-profile model was the best fit. The GM model identified greater ventricular volumes in Service Members with cognitive symptoms, including those with a diagnosis of mTBI, either alone or with PTSD. The WM model identified reduced FA and elevated RD in those with psychological symptoms, including those with PTSD or mTBI and comorbid PTSD. However, contrary to expectation, a global neural signature unique to those with comorbid mTBI and PTSD was not identified.

CONCLUSIONS

The findings demonstrate that neuropsychological performance alone is more robust in differentiating Active-Duty Service Members with mTBI and PTSD, whereas global neuroimaging measures do not reliably differentiate between these groups.

Associations between Dentition Status and Nutritional Status in Community-Dwelling Older Adults

BACKGROUND/OBJECTIVE

Older adults are at higher risk of malnutrition. The aim of this study was to explore associations between nutritional status and dentition status among older adults seeking care in a dental clinic.

METHODS

This was a cross-sectional study of data from older adults (65-89 y) who received care at a northeastern US urban dental school clinic between June 2015 and June 2020 (N = 305). Clinical and demographic data were obtained from the electronic health record; nutritional status was determined using the Self-Mini Nutritional Assessment (Self-MNA), and odontograms and digital radiography were used to determine dental data. Adjusted multivariable models were used to explore associations between variables.

RESULTS

The sample was 53.8% female with a median age of 72.0 y. The median Self-MNA score was 13, reflective of normal nutritional status; 29.5% were at risk of or had malnutrition. Median numbers of teeth and posterior and anterior occluding pairs of teeth (POP, AOP) were 18.0, 2.0, and 5.0, respectively. Those with normal nutritional status had significantly more teeth, POPs, and AOPs than those at risk of or with malnutrition (P = 0.015, P = 0.015, and P = 0.039, respectively). Every additional unit increase in the number of natural or restored teeth or POP was associated with significantly lower odds of being at risk of or with malnutrition (3% and 13%, respectively). Having functional dentition was associated with 46% lower odds of being at risk of or with malnutrition.

CONCLUSION

This study demonstrated that older adults who had more teeth, better occlusion, and functional dentition were more likely to be of normal nutritional status than those who had less teeth, had poorer occlusion, and lacked functional dentition. Further research with larger, more diverse samples and varied measures of dentition are needed to better understand the associations between nutritional status and dentition status.

KNOWLEDGE TRANSFER STATEMENT

The findings from this study suggest that older adults with fewer teeth and therefore less efficient occlusion are at higher risk for malnutrition than those with more teeth and better occlusion. Health care professionals should include screening for dentition and malnutrition as part of their routine practice to identify patients who may have tooth loss and be at risk of malnutrition and refer them accordingly for interventions to optimize oral health and nutritional status.

A knowledge broker facilitated intervention to improve the use of standardized assessment tools by physical therapists: A cluster randomized trial

OBJECTIVE

To compare two methods of knowledge broker support to improve standardized assessment use.

DESIGN

Two-site cluster randomized trial.

SETTING

Acute rehabilitation hospital.

PARTICIPANTS

18 physical therapists.

INTERVENTION

A 10-month intervention was collaboratively designed with an external knowledge broker and physical therapists to compare full and partial implementation support. The knowledge broker provided education and strategies for implementation to the fully supported group and recommended strategies to the partially supported group that they self-implemented.

MEASUREMENT

Chart audit data documenting frequency of use was extracted at four timepoints. Ten focus groups were conducted to describe factors that influenced use. Focus group data were coded using the Consolidated Framework for Implementation Research and rated as barriers and facilitators for standardized assessment use.

RESULTS

For the fully supported group, standardized assessment use at initial examination increased from 0% to 58.3% at month 2 and decreased to 17.6% and 11.8% at months 4 and 8-10. For the partially supported group, standardized assessment use increased from 0% to 46% and 50% at month 2 and 4 and decreased to 2.8% at months 8-10. For both groups, early use was seen multiple facilitators. At month 10, barriers included organizational changes that impacted intervention fit. In addition, the fully supported group didn't value the selected standardized assessment and the partially supported group lacked space.

CONCLUSIONS

Knowledge broker support improved both groups standardized assessment use early on, but it was not sustained. The amount of support could not be isolated as factors that influenced use varied by groups.

Tooth Loss and Nutritional Status in Older Adults: A Systematic Review and Meta-analysis

BACKGROUND/OBJECTIVE

Older adults are at risk for tooth loss and compromised nutritional status. Our objective was to conduct a systematic review and meta-analysis to answer the following question: Among adults aged ≥60 y living in developed countries, what are the associations between tooth loss and nutritional status as assessed by a validated nutrition screening or assessment tool?

METHODS

PRISMA guidelines were followed. PubMed, Scopus, CINAHL, Web of Science, and MEDLINE were searched for studies published in English between 2009 and 2019 that met inclusion criteria. Data extracted included study and participant characteristics, dentition, and nutritional status. Risk of bias was assessed with a modified Newcastle-Ottawa Scale. Random effects meta-analysis was used.

RESULTS

Of the 588 unduplicated articles identified, 78 were reviewed in full text, and 7 met inclusion criteria. Six studies were combined for a meta-analysis, which revealed that individuals who were completely edentulous or who lacked functional dentition had a 21% increased likelihood of being at risk of malnutrition or being malnourished, as compared with those who were dentulous or had functionally adequate dentition (risk ratio, 1.21; 95% CI, 1.11 to 1.32; I² = 70%). Whether the article statistically adjusted for medical history explained most of the heterogeneity in the pooled effect.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition. Use of validated tools to assess risk of malnutrition in older adults with tooth loss is important to promote early intervention and referral to optimize nutrition and oral health status. Findings were limited by heterogeneity, risk of bias, and overall quality of the studies reviewed. Cohort studies that adjust for known confounders and use consistent approaches to assess tooth loss and nutritional status are needed.

KNOWLEDGE TRANSFER STATEMENT

The results of this study suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition. Screening of this population for malnutrition by health care professionals, including dentists and dietitians, may result in corresponding referrals to optimize nutrition and oral health status. Further research is needed with consistent approaches to assess tooth loss and nutritional status.

Using risk of bias domains to identify opportunities for improvement in food- and nutrition-related research: An evaluation of research type and design, year of publication, and source of funding

PURPOSE

This retrospective cross-sectional study aimed to identify opportunities for improvement in food and nutrition research by examining risk of bias (ROB) domains.

METHODS

Ratings were extracted from critical appraisal records for 5675 studies used in systematic reviews conducted by three organizations. Variables were as follows: ROB domains defined by the Cochrane Collaboration (Selection, Performance, Detection, Attrition, and Reporting), publication year, research type (intervention or observation) and specific design, funder, and overall quality rating (positive, neutral, or negative). Appraisal instrument questions were mapped to ROB domains. The kappa statistic was used to determine consistency when multiple ROB ratings were available. Binary logistic regression and multinomial logistic regression were used to predict overall quality and ROB domains.

FINDINGS

Studies represented a wide variety of research topics (clinical nutrition, food safety, dietary patterns, and dietary supplements) among 15 different research designs with a balance of intervention (49%) and observation (51%) types, published between 1930 and 2015 (64% between 2000-2009). Duplicate ratings (10%) were consistent (κ = 0.86-0.94). Selection and Performance domain criteria were least likely to be met (57.9% to 60.1%). Selection, Detection, and Performance ROB ratings predicted neutral or negative quality compared to positive quality (p<0.001). Funder, year, and research design were significant predictors of ROB. Some sources of funding predicted increased ROB (p<0.001) for Selection (interventional: industry only and none/not reported; observational: other only and none/not reported) and Reporting (observational: university only and other only). Reduced ROB was predicted by combined and other-only funding for intervention research (p<0.005). Performance ROB domain ratings started significantly improving in 2000; others improved after 1990 (p<0.001). Research designs with higher ROB were nonrandomized intervention and time series designs compared to RCT and prospective cohort designs respectively (p<0.001).

CONCLUSIONS

Opportunities for improvement in food and nutrition research are in the Selection, Performance, and Detection ROB domains.

Proactive management in the managed care era

Preparing for the future impact of managed care on clinical laboratories remains a complex challenge as the corporate strategies of health maintenance organizations (HMOs) and managed care contracting continue to evolve. Employers often fail to use data or quality measures to select an HMO, preventing a clinical laboratory from competing on patient care issues. Developing analysis skills and knowledge concerning physician ordering data, HMO information, costs, and capitation rate corridors prepares the enterprise and managers for a successful future.