Initial Validation of a Behavioral Phenotyping Model for Substance Use Disorder

Standard nosological systems, such as DSM-5 or ICD-10, are relied upon as the diagnostic basis when developing treatments for individuals with substance use disorder (SUD). Unfortunately, the vast heterogeneity of individuals within a given SUD diagnosis results in a variable treatment response and/or difficulties ascertaining the efficacy signal in clinical trials of drug development. Emerging precision medicine methods focusing on targeted treatments based on phenotypic subtypes rather than diagnosis are being explored as alternatives. The goal of the present study was to provide initial validation of emergent subtypes identified by an addiction-focused phenotyping battery. Secondary data collected as part of a feasibility study of the NIDA phenotyping battery were utilized. Participants completed self-report measures and behavioral tasks across six neurofunctional domains. Exploratory and confirmatory factor analysis (EFA/CFA) were conducted. A three-factor model consisting of negative emotionality, attention/concentration, and interoception and mindfulness, as well as a four-factor model adding a second negative emotion domain, emerged from the EFA as candidate models. The CFA of these models did not result in a good fit, possibly resulting from small sample sizes that hindered statistical power.

Outcomes of Emergency Department Patients With Opioid Use Disorder Utilizing a Virtual Addiction Bridge Clinic: A Case Series

OBJECTIVES

Within the last decade, there has been a dramatic increase in the rate of emergency department (ED) visits and death from opioid overdose. Those who present to the ED are at high risk for subsequent morbidity and mortality. Despite effective treatment, many patients do not get rapidly connected to outpatient care. The aim of this investigation was to describe outpatient treatment engagement after ED discharge among patients with opioid use disorder (OUD) enrolled in a virtual Addiction Bridge Clinic (ABC).

METHODS

This was a retrospective case series describing an ED-initiated referral for rapid telehealth follow-up among patients with OUD. The primary outcome was addiction treatment engagement among those who completed the initial virtual ABC visit (engaged in ABC) vs. those who did not complete an ABC visit (Not engaged in ABC) at 1 week, 1 month, and 3 and 6 months timepoint intervals after the initial ED presentation.

RESULTS

Of the N = 201 patients referred to the ABC between March and December 2021, a majority were Black (71%) and male (77%). Of the 201 referrals, 85 (42%) completed an initial ABC telehealth visit. Subsequent treatment engagement was 26% at 1 week, 26% at 1 month, 22% at 3 months, and 18% at 6 months after the index ED visit.

CONCLUSIONS

A telehealth-enabled virtual addiction bridge clinic is one potential approach to reduce barriers to rapid treatment access. Strategies are needed to improve subsequent addiction treatment engagement after a virtual addiction bridge clinic visit.

Behavioral and neurocognitive factors distinguishing post-traumatic stress comorbidity in substance use disorders

Significant trauma histories and post-traumatic stress disorder (PTSD) are common in persons with substance use disorders (SUD) and often associate with increased SUD severity and poorer response to SUD treatment. As such, this sub-population has been associated with unique risk factors and treatment needs. Understanding the distinct etiological profile of persons with co-occurring SUD and PTSD is therefore crucial for advancing our knowledge of underlying mechanisms and the development of precision treatments. To this end, we employed supervised machine learning algorithms to interrogate the responses of 160 participants with SUD on the multidimensional NIDA Phenotyping Assessment Battery. Significant PTSD symptomatology was correctly predicted in 75% of participants (sensitivity: 80%; specificity: 72.22%) using a classification-based model based on anxiety and depressive symptoms, perseverative thinking styles, and interoceptive awareness. A regression-based machine learning model also utilized similar predictors, but failed to accurately predict severity of PTSD symptoms. These data indicate that even in a population already characterized by elevated negative affect (individuals with SUD), especially severe negative affect was predictive of PTSD symptomatology. In a follow-up analysis of a subset of 102 participants who also completed neurocognitive tasks, comorbidity status was correctly predicted in 86.67% of participants (sensitivity: 91.67%; specificity: 66.67%) based on depressive symptoms and fear-related attentional bias. However, a regression-based analysis did not identify fear-related attentional bias as a splitting factor, but instead split and categorized the sample based on indices of aggression, metacognition, distress tolerance, and interoceptive awareness. These data indicate that within a population of individuals with SUD, aberrations in tolerating and regulating aversive internal experiences may also characterize those with significant trauma histories, akin to findings in persons with anxiety without SUD. The results also highlight the need for further research on PTSD-SUD comorbidity that includes additional comparison groups (i.e., persons with only PTSD), captures additional comorbid diagnoses that may influence the PTSD-SUD relationship, examines additional types of SUDs (e.g., alcohol use disorder), and differentiates between subtypes of PTSD.

New approaches to deep phenotyping in addictions

OBJECTIVE

The causes of substance use disorders (SUDs) are largely unknown and the effectiveness of their treatments is limited. One crucial impediment to research and treatment progress surrounds how SUDs are classified and diagnosed. Given the substantial heterogeneity among individuals diagnosed with a given SUD (e.g., alcohol use disorder [AUD]), identifying novel research and treatment targets and developing new study designs is daunting.

METHOD

In this article, we review and integrate two recently developed frameworks, the National Institute on Drug Abuse's Phenotyping Assessment Battery (NIDA PhAB) and the Hierarchical Taxonomy of Psychopathology (HiTOP), that hope to accelerate progress in understanding the causes and consequences of psychopathology by means of deep phenotyping, or finer-grained analysis of phenotypes.

RESULTS AND CONCLUSIONS

NIDA PhAB focuses on addiction-related processes across multiple units of analysis, whereas HiTOP focuses on clinical phenotypes and covers a broader range of psychopathology. We highlight that NIDA PhAB and HiTOP together provide deep and broad characterizations of people diagnosed with SUDs and complement each other in their efforts to address widely known limitations of traditional classification systems and their diagnostic categories. Next, we show how NIDA PhAB and HiTOP can be integrated to facilitate optimal rich phenotyping of addiction-related phenomena. Finally, we argue that such deep phenotyping promises to advance our understanding of the neurobiology of SUD and addiction, which will guide the development of personalized medicine and interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Attentional function and inhibitory control in different substance use disorders

Attentional function in substance use disorder (SUD) is not well understood. To probe attentional function in SUD as a function of primary substance of abuse, we administered the attentional network task (ANT) to 44 individuals with Cocaine Use Disorder (CoUD), 49 individuals with Cannabis Use Disorder (CaUD), 86 individuals with Opioid Use Disorder (OUD), and 107 controls with no SUD, along with the stop-signal task (SST). The ANT quantifies the effects of (temporal) alerting cues and (spatial) orienting cues to reduce reaction time (RT) to targets, as well as probing how conflicting (target-incongruent) stimuli slow RT. The SST quantifies individuals' ability to inhibit already-initiated motor responses. After controlling for sex representation and age, OUD and CaUD participants showed blunted alerting effects compared to controls, whereas CaUD and CoUD participants showed greater stimulus conflict (flanker) effects. Finally, CoUD participants showed a trend toward increased orienting ability. In SST performance, no SUD group showed a prolonged stop-signal reaction compared to controls. However, the OUD group (and CoUD group at trend level) showed prolonged "go" RT to targets and reduced hit rates. These data indicate differences in attentional function in persons with SUD as a function of the primary substance use.

Improving Peripartum Care Engagement Among Black Women at Risk for Low Prenatal Care Attendance: A Secondary Analysis of Predictors of Attendance and Sample Representativeness

Background: The United States has unacceptably high rates of maternal and infant mortality, especially among Black women and their infants. Prenatal and postpartum care help reduce maternal and infant morbidity and mortality; however, Black women are less likely to access and utilize peripartum care largely due to structural racism. Identifying factors that buffer against the systemic barriers disproportionately impacting this community is an important step in addressing racial health disparities. Using existing data from a randomized controlled trial (RCT) targeting maternal and infant health disparities, this study aims to (1) explore predictors of peripartum care attendance and (2) examine clinical trial sample representativeness. Methods: The analyses addressing the primary aim of the study included Black women at risk for low prenatal care (PNC) engagement who consented to RCT participation and had a documented live birth (n = 123). For the secondary study aim, comparisons between women who consented to the RCT (Consenters; n = 149) and those who did not (Non-consenters; n = 122) were made using chi-square and t-tests. Results: Hierarchical linear and logistic regression identified predictors of prenatal and postpartum care attendance, respectively. After controlling for multiple comparisons, no significant differences were identified between characteristics of Consenters and Non-consenters. Older age (p = 0.038), high-risk pregnancy (p < 0.001), and no past week substance use (p = 0.033) predicted better PNC attendance. PNC attendance predicted postpartum visit attendance (p < 0.001). Conclusions: This study provides benchmark data on predictors of peripartum care and sample representativeness in RCTs. Findings have important implications for health care system changes and development of culturally informed interventions.

Sex Specific Sleep Parameters Among People With Substance Use Disorder

INTRODUCTION

Sleep can have substantial impacts in substance use disorder (SUD) pathogenesis, treatment, and recovery. Sex differences exist in both sleep and SUD, but how sleep is uniquely associated with SUD by sex is not known. The study objective was to compare, within sex, sleep parameters between individuals with SUD and non-substance misusing controls.

METHODS

Secondary analyses of a parent cross-sectional study examining the feasibility and acceptability of a novel neurocognitive phenotyping assessment battery were completed. SUD and control subjects were recruited through local advertising and an established research registry. Subjects with SUD were also recruited through a university-based outpatient SUD treatment clinic. Self-reported sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Sex-stratified t-tests compared sleep between SUD and control subjects while Crosstab analyses explored group differences in the proportion of individuals reporting poor sleep (defined as PSQI ≥ 5).

RESULTS

Data from 162 males (44 controls, 118 SUD) and 146 females (64 controls, 82 SUD) were included in the present study. For females only, a significantly lower proportion of controls reported PSQI-defined poor sleep than individuals with any SUD or specifically with opioid use disorder. Male, but not female, controls reported shorter sleep latency, longer sleep duration, and less sleep disturbance than males with each SUD type.

DISCUSSION/IMPLICATIONS

Sleep holds promise as an avenue to address SUD within a biopsychosocial model. Future work at the intersection of SUD and sleep should prioritize investigations of their interplay with sex to identify targets for tailored SUD interventions.

Clinical features and outcomes between African American and Caucasian patients with Takotsubo Syndrome

BACKGROUND

Takotsubo syndrome (TS) is an acute, reversible form of heart failure, often mimicking an acute coronary syndrome (ACS). Data regarding racial differences in TS are inconsistent. The aim is to assess clinical features associated with unfavorable in-hospital outcomes between African American (AA) and Caucasian (CAU) patients.

METHODS

A retrospective electronic health record query identified 44 AA patients and 110 CAU patients with a diagnosis of TS. Our primary outcome was a composite of death, stroke, and cardiogenic shock during hospitalization. Variables associated with an increased risk of the primary composite outcomes were included in a logistic regression model.

RESULTS

Compared to CAU patients, AA patients were a more comorbid population, and presented a higher prevalence of history of illicit drug use (27.3% vs. 13.6% P=0.044). There were no significant differences regarding in-hospital complication rates between AA and CAU patients. In the logistic regression model, infection was associated with greater risk of developing the primary outcome in AA patients (OR=7.26 [95% CI 1.22-43.17], P=0.029), whereas angina was a protective factor (OR=0.11 [95% CI 0.02-0.65], P=0.015). In CAU patients, severely depressed ejection fraction and worse peak creatinine during hospitalization increased risk of developing the primary outcome (OR=5.88 95% CI [2.01-17.17], P<0.001 and OR=1.64 [95% CI 1.15-2.58], P=0.031, respectively). Meanwhile, emotional stressors were protective (OR=0.16 [95% CI 0.03-0.88], P=0.004).

CONCLUSIONS

Despite experiencing the same rate of in-hospital complications, the clinical profiles of AA patients are distinct from CAU patients admitted for TS, and clinical variables correlated with worse in-hospital outcomes also differ by race.

Social Information Processing in Substance Use Disorders: Insights From an Emotional Go-Nogo Task

Positive social connections are crucial for recovery from Substance Use Disorder (SUD). Of interest is understanding potential social information processing (SIP) mediators of this effect. To explore whether persons with different SUD show idiosyncratic biases toward social signals, we administered an emotional go-nogo task (EGNG) to 31 individuals with Cocaine Use Disorder (CoUD), 31 with Cannabis Use Disorder (CaUD), 79 with Opioid Use Disorder (OUD), and 58 controls. Participants were instructed to respond to emotional faces (Fear/Happy) but withhold responses to expressionless faces in two task blocks, with the reverse instruction in the other two blocks. Emotional faces as non-targets elicited more "false alarm" (FA) commission errors as a main effect. Groups did not differ in overall rates of hits (correct responses to target faces), but participants with CaUD and CoUD showed reduced rates of hits (relative to controls) when expressionless faces were targets. OUD participants had worse hit rates [and slower reaction times (RT)] when fearful faces (but not happy faces) were targets. CaUD participants were most affected by instruction effects (respond/"go" vs withhold response/"no-go" to emotional face) on discriminability statistic A. Participants were faster to respond to happy face targets than to expressionless faces. However, this pattern was reversed in fearful face blocks in OUD and CoUD participants. This experiment replicated previous findings of the greater salience of expressive face images, and extends this finding to SUD, where persons with CaUD may show even greater bias toward emotional faces. Conversely, OUD participants showed idiosyncratic behavior in response to fearful faces suggestive of increased attentional disruption by fear. These data suggest a mechanism by which positive social signals may contribute to recovery.

Increasing Prenatal Care Compliance in At-Risk Black Women: Findings from a RCT of Patient Navigation and Behavioral Incentives

BACKGROUND

In the USA, infant mortality remains a major public health concern, particularly for Black women and their infants who continue to experience disproportionately high mortality rates. Prenatal care is a key determinant of infant health, with inadequate prenatal care increasing risk for prematurity, stillbirth, neonatal loss, and infant death. The aim of the present study was to determine if concurrent delivery of patient navigation and behavioral incentives to at-risk Black pregnant women could improve prenatal care attendance and associated maternal and infant outcomes.

METHODS

Participants were 150 Black pregnant women recruited at first prenatal visit and screening at risk for adverse maternal and infant outcomes. Women were randomized to either the patient navigation + behavioral incentives intervention (PNBI) or assessment + standard care control (ASC) group. All were followed throughout pregnancy and 12-week postpartum. Group comparisons were made using intention-to-treat and per-protocol sensitivity analyses.

RESULTS

While no group differences were found in prenatal care visits, the average number of visits for both groups (9.3 for PNBI and 8.9 for ASC) approached the American College of Obstetricians and Gynecologists (ACOG) recommended guidelines. There were also no group differences in maternal and infant outcomes. Both intention-to-treat and per-protocol sensitivity analyses, however, consistently found PNBI women attended more postpartum visits than ASC controls (p = 0.002).

CONCLUSIONS

Given ACOG's redefining of the postpartum period as the fourth trimester, study findings suggest PNBI may facilitate prevention and intervention efforts to more successfully reduce health disparities in outcomes for both mother and infant.

Clinical features and outcomes between African American and Caucasian patients with Takotsubo Syndrome

BACKGROUND

Takotsubo syndrome (TS) is an acute, reversible form of heart failure, often mimicking an acute coronary syndrome (ACS). Data regarding racial differences in TS are inconsistent. The aim is to assess clinical features associated with unfavorable in-hospital outcomes between African American (AA) and Caucasian (CAU) patients.

METHODS

A retrospective electronic health record query identified 44 AA patients and 110 CAU patients with a diagnosis of TS. Our primary outcome was a composite of death, stroke, and cardiogenic shock during hospitalization. Variables associated with an increased risk of the primary composite outcomes were included in a logistic regression model.

RESULTS

Compared to CAU patients, AA patients were a more comorbid population, and presented a higher prevalence of history of illicit drug use (27.3% vs 13.6% p=0.044). There were no significant differences regarding in-hospital complication rates between AA and CAU patients. In the logistic regression model, infection was associated with greater risk of developing the primary outcome in AA patients (OR=7.26 95% CI [1.22-43.17], p=0.029), whereas angina was a protective factor (OR=0.11 95% CI [0.02-0.65], p=0.015). In CAU patients, severely depressed ejection fraction and worse peak creatinine during hospitalization increased risk of developing the primary outcome (OR=5.88 95% CI [2.01-17.17], p<0.001 and OR=1.64 95% CI [1.15-2.58], p=0.031, respectively). Meanwhile, emotional stressors were protective (OR=0.16 95% CI [0.03-0.88], p=0.004).

CONCLUSIONS

Despite experiencing the same rate of in-hospital complications, the clinical profiles of AA patients are distinct from CAU patients admitted for TS, and clinical variables correlated with worse in-hospital outcomes also differ by race.

Safety and Preliminary Efficacy of Lorcaserin for Cocaine Use Disorder: A Phase I Randomized Clinical Trial

Background and Objectives: Preclinical studies show serotonin (5-HT) 5-HT_2C receptor (5-HT_2CR) agonists reduce cocaine-seeking and cocaine intake. This study examined safety of the 5-HT_2CR agonist lorcaserin administered with cocaine in participants with cocaine use disorder (CocUD). Secondarily, subjective response to cocaine and choice of cocaine vs. money were examined. Methods: A double-blind, randomized, placebo-controlled trial of 25 inpatient non-treatment seeking participants with CocUD. Participants were randomized to either lorcaserin (n = 17) or placebo (n = 8). Primary outcome measures included cardiovascular measures and plasma cocaine levels. Secondary measures of subjective response to cocaine were assessed using a visual analog scale (VAS) and cocaine vs. money progressive ratio choice sessions. Results: Thirteen randomized participants were included in the final analysis. No serious or unexpected adverse events were related to lorcaserin. There were no significant interactions between cocaine and lorcaserin on cardiovascular measures, plasma cocaine, or subjective ratings. After multiple comparisons correction, cocaine significantly increased blood pressure, heart rate, and QTc. Lorcaserin significantly decreased VAS ratings of "feel irritable," "feel hungry," and "I am craving." For the cocaine vs. money choice procedure, there was a significant interaction between choice (cocaine vs. money) and lorcaserin. Participants treated with lorcaserin were more likely to choose cocaine. Discussion and Conclusions: This study showed safety of lorcaserin administered with cocaine but lack of efficacy to reduce the reinforcing effects of cocaine. Scientific Significance: This study is the first to show a disconnect between effects of 5-HT_2CR agonists on craving and cocaine choice in human cocaine users.

Resting-State Directional Connectivity and Anxiety and Depression Symptoms in Adult Cannabis Users

BACKGROUND

Anxiety and depression symptoms are common among cannabis users and could be a risk factor for cannabis use (CU) disorder. Thus, it is critical to understand the neuronal circuits underlying the associations between CU and these symptoms. Alterations in resting-state functional connectivity within and/or between the default mode network and salience network have been reported in CU, anxiety, and depressive disorders and thus could be a mechanism underlying the associations between CU disorder and anxiety/depression symptoms.

METHODS

Using resting-state functional magnetic resonance imaging, effective connectivities (ECs) among 9 major nodes from the default mode network and salience network were measured using dynamic causal modeling in 2 datasets: the Human Connectome Project (28 CU participants and 28 matched non-drug-using control participants) and a local CU study (21 CU participants and 21 matched non-drug-using control participants) in separate and parallel analyses.

RESULTS

Relative to the control participants, right amygdala to left amygdala, anterior cingulate cortex to left amygdala, and medial prefrontal cortex to right insula ECs were greater, and left insula to left amygdala EC was smaller in the CU group. Each of these ECs showed a reliable linear relationship with at least one of the anxiety/depression measures. Most findings on the right amygdala to left amygdala EC were common to both datasets.

CONCLUSIONS

Right amygdala to left amygdala and anterior cingulate cortex to left amygdala ECs may be related to the close associations between CU and anxiety/depression symptoms. The findings on the medial prefrontal cortex to right insula and left insula to left amygdala ECs may reflect a compensatory mechanism.

Tobacco smoke exposure as a risk factor for human papillomavirus infections in women 18-26 years old in the United States

Background

Although tobacco smoke has been associated with many infections, little is known of its association with human papillomavirus (HPV) infections among young adult women. The aim of the study was to explore the association of tobacco smoke exposure on HPV infections in young adult women in the United States. It was hypothesized that tobacco smoke exposure (both active and passive) as objectively measured by cotinine levels was associated with increased HPV infection in a national sample of 18 and 26 year-old women in the United States.

Study methods and findings

The NHANES 2007–2012 dataset was used in the analyses. A national representative sample of women 18 to 26 year old (N = 1,414) was included in the study. Infection with any HPV was determined by PCR while tobacco smoke exposure was determined by measuring serum cotinine levels. Women with cotinine levels <0.05 ng/mL were considered unexposed and those with levels > = 0.05 were considered as exposed. Exposed women were further categorized as passive smokers (cotinine levels 0.05-<10 ng/mL, while active smokers were those with cotinine levels = > 10ng/mL). Data were analyzed by descriptive statistics and multiple logistic regression analysis. Exposed women (passive smokers with cotinine levels > = 0.05ng/mL-10ng/mL) were almost 2 times (64% vs 35%) more likely to be infected with any HPV type than their unexposed counterparts (cotinine levels <0.05ng/mL). Also women who were active smokers (cotinine levels > = 10 ng/mL) were more than twice more likely (75%) to be infected with the virus than the unexposed counterparts. The relationship held true even after controlling for various socio-demographics. Indeed in the multiple regression analyses controlling for the various confounders, compared to their unexposed counterparts, women exposed to second hand smoke were more than twice more likely to have HPV infections (OR: 2.45; 95% C.I = 1.34–4.48). When compared to their unexposed counterparts, actively smoking women were more than 3.5 times more likely to be infected with HPV (OR = 3.56; 95% CI 1.23–10.30).

Finally, a strong dose-response relationship was further demonstrated with increasing risk of HPV with each quartile of cotinine levels even after controlling for various confounders. The risk of HPV was lowest in the lowest quartile (Referent OR = 1) and increased steadily with each quartile of cotinine levels until the risk was highest among women with cotinine levels in the 4^th quartile (OR = 4.16; 95% C.I. = 1.36–12.67).

Conclusion

Both passive and active tobacco smoking were strongly associated with any HPV infection in 18 to 26 year old young women with a significant dose-response relationship. Future studies should explore the effect of tobacco smoke exposure among younger women less than 18 years of age.

P760Clinical profile of African-American and non-Hispanic caucasian patients with Takotsubo cardiomyopathy syndrome in a large urban hospital in the United States of America

Background

Takotsubo (stress) cardiomyopathy is an acute reversible heart failure syndrome initially described in Japanese patients, but now well characterized in Caucasians patients in Europe or of European descent. An initial observation has suggested a lower incidence of Takotsubo in non-Caucasian subjects, particularly in the African-American (AA) population in the United States of America. The purpose of this study was to assess whether epidemiologic and clinical differences were present in Takotsubo in a large urban hospital in Virginia, USA.

Methods

We used an informatics-based system to query electronic health records (TriNetX, Cambridge, MA, USA) to search for cases of Takotsubo between 2010 and 2018 and a corresponding cohort of patients with non-ST segment elevation acute myocardial infarction (NSTEMI). We then performed a chart-level review of 160 cases and obtained additional clinical information including symptoms, risk factors, co-morbidities, and in-hospital outcomes. This retrospective study was approved by the Institutional Review Board of our institution.

Results

We identified 260 cases of Takotsubo and 6,270 of NSTEMI in the same time period (1:24, 4.2%). Being AA was associated with an odds ratio of Takotsubo versus NSTEMI of 0.38 [0.29–0.50] (P=0.0001). With further evaluation of patients with Takotsubo (N=160), AA (N=44, 27.2%) and Non-Hispanic Caucasian (C) (N=110, 67.9%) had no differences in age and sex. AA patients with Takotsubo however were more likely than C patients to be affected by type II diabetes mellitus (38.6% versus 14.5%, P=0.002, OR 3.70 [1.65–8.28]), have history of drug abuse (27.3% versus 9.1%, P=0.009, OR 3.75 [1.48–9.49]) and of cocaine use in particular (9.1% versus 0.9%, P=0.024, OR 11.0 [1.19–101.4]). The pattern of wall motion abnormality was not different between the 2 groups. AA patients presented with a lower ratio of brain natriuretic peptide (BNP) to troponin I (41.9 [12.7–258] pg./ml versus 281 [42–890] pg/ml, P=0.022). There was no significant difference of in-hospital mortality between the AA and C groups (9.1% versus 25%, respectively, OR 0.40 [0.13–1.24], P=0.11).

Conclusions

The incidence and clinical characteristics of Takotsubo (stress) cardiomyopathy appear to be different between African-American and Non-Hispanic Caucasian patients. African-American patients are more likely to have diabetes and illicit drug usage, but have a lower BNP/troponin I ratio. Both AA and Non-Hispanic Caucasian patients have similar in-hospital mortality.

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions.

Fronto-striatal effective connectivity of working memory in adults with cannabis use disorder

Previous working memory (WM) studies found that relative to controls, subjects with cannabis use disorder (CUD) showed greater brain activation in some regions (e.g., left [L] and right [R] ventrolateral prefrontal cortex [VLPFC], and L dorsolateral prefrontal cortex [L-DLPFC]), and lower activation in other regions (e.g., R-DLPFC). In this study, effective connectivity (EC) analysis was applied to functional magnetic resonance imaging data acquired from 23 CUD subjects and 23 controls (two groups matched for sociodemographic factors and substance use history) while performing an n-back WM task with interleaved 2-back and 0-back periods. A 2-back minus 0-back modulator was defined to measure the modulatory changes of EC corresponding to the 2-back relative to 0-back conditions. Compared to the controls, the CUD group showed smaller modulatory change in the R-DLPFC to L-caudate pathway, and greater modulatory changes in L-DLPFC to L-caudate, R-DLPFC to R-caudate, and R-VLPFC to L-caudate pathways. Based on previous fMRI studies consistently suggesting that greater brain activations are related to a compensatory mechanism for cannabis neural effects (less regional brain activations), the smaller modulatory change in the R-DLPFC to L-caudate EC may be compensated by the larger modulatory changes in the other prefrontal-striatal ECs in the CUD individuals.

Peer Network Counseling with Urban Adolescents: A Randomized Controlled Trial with Moderate Substance Users

Close peer networks can affect adolescents' health behaviors by altering their social environments, and thus their risk for and protection against substance use involvement. We tested a 20 minute intervention named Peer Network Counseling that integrates motivational interviewing and peer network strategies with 119 urban adolescents who reported occasional or problem substance use. Adolescents presenting at primary care clinic were randomized to intervention or control conditions and followed for 6 months. Mixed-effect latent growth models were used to evaluate intervention effects on trajectories of alcohol and marijuana use, offers to use substances, and moderation models to test for interactions between intervention condition and peer network characteristics. A significant intervention effect was found for boys for offers to use alcohol from friends (p<.05), along with a trend significant effect for alcohol use (p<.08). Intervention was more effective in reducing marijuana use, vs. control, for participants with more peer social support (p<.001) and with more peer encouragement for prosocial behavior (school, clubs, sports, religious activities); however, intervention did not affect these network characteristics. Results provide support to continue this line of research to test brief interventions that activate protective peer network characteristics among at-risk adolescents, while also raising some interesting gender-based intervention questions for future research.

Altered white matter in cocaine-dependent subjects with traumatic brain injury: A diffusion tensor imaging study

BACKGROUND

Diffusion tensor imaging (DTI) is a useful technique for non-invasively investigating the microstructural organization of white matter (WM), and the most consistent DTI finding regarding cocaine-related WM alterations is in the corpus callosum (CC). WM injury has also been observed in subjects with traumatic brain injury (TBI), including in the CC.

METHODS

We used DTI to test if the WM microstructure is relatively more impaired in cocaine-dependent subjects who had suffered a mild TBI (mTBI). Fractional anisotropy (FA), which reflects the degree of alignment of cellular structures within fiber tracts and their structural integrity, was compared across cocaine-dependent subjects with mTBI (COCTBI group, n = 9), matched cocaine-dependent subjects without TBI (COC group, n = 12), and matched healthy controls (CTL group, n = 12).

RESULTS

The COCTBI group had significantly lower FA in the genu, body, and splenium of CC, than the CTL group whenever the education was controlled or not. The COC group had significantly lower FA in the left and right anterior corona radiata than the CTL group only when the education was controlled. There was no significant difference in FA between the COC and COCTBI groups.

CONCLUSION

Cocaine dependence (or mTBI) related WM impairments in the CC were not detectable in this small subject sample. The significant finding in the CC suggests that the concurrence of cocaine dependence and mTBI might result in more severe damage to the CC, which could even be detected in small sample size.

A brief analysis of suicide methods and trends in Virginia from 2003 to 2012

BACKGROUND

The objective is to analyze and compare Virginia suicide data from 2003 to 2012 to US suicide data.

METHODS

Suicide trends by method, age, gender, and race were obtained from Virginia's Office of the Chief Medical Examiner's annual reports.

RESULTS

Similar to US suicide rates, suicide rates in Virginia increased between 2003 and 2012 from 10.9/100,000 people to 12.9/100,000 people. The most common methods were firearm, asphyxia, and intentional drug overdose, respectively. The increase in asphyxia (r = 0.77, P ≤ 0.01) and decrease in CO poisoning (r = -0.89, P ≤ 0.01) were significant. Unlike national trends, intentional drug overdoses decreased (r = -0.55, P = 0.10). Handgun suicides increased (r = 0.61, P = 0.06) and are the most common method of firearm suicide. Hanging was the most common method of asphyxia. Helium suicides also increased (r = 0.75, P = 0.05). Middle age females and males comprise the largest percentage of suicide. Unlike national data, the increase in middle age male suicides occurred only in the 55-64-year-old age group (r = 0.79, P ≤ 0.01) and decreased in the 35-44-year-old age group (r = -0.60, P = 0.07) and 10-14-year-old age group (r = -0.73, P = 0.02). Suicide in all female age ranges remained stable. Caucasians represent the highest percentage of suicide.

CONCLUSION

There has been a rise in suicide in Virginia and suicide rates and trends have closely resembled the national average albeit some differences. Suicide prevention needs to be enhanced.

Trauma, gender, and mental health symptoms in individuals with substance use disorders

Individuals with substance use disorders are often plagued by psychiatric comorbidities and histories of physical and/or sexual trauma. Males and females, although different in their rates of expressed trauma and psychiatric symptomatology, experience comparable adverse consequences, including poorer substance abuse treatment outcomes, diminished psychosocial functioning, and severe employment problems. The goal of the current study was to examine the relationships between trauma history, lifetime endorsement of psychiatric symptoms, and gender in a sample of individuals participating in outpatient substance abuse treatment. Study participants (N = 625) from six psychosocial counseling and five methadone maintenance programs were recruited as part of a larger study conducted through the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN). Study measures included lifetime trauma experience (yes/no), type of trauma experienced (sexual, physical, both), lifetime depression/anxiety, and lifetime suicidal thoughts/attempts (as measured by the Addiction Severity Index-Lite [ASI-Lite]). Lifetime endorsement of psychiatric symptoms was compared between individuals with and without trauma history. The role of gender was also examined. Results indicated that the experience of trauma was associated with an increase in lifetime report of psychiatric symptoms. Experience of physical and combined physical and sexual trauma consistently predicted positive report of psychiatric symptoms in both males and females, even when controlling for demographic and treatment-related variables. Employment outcomes, however, were not predicted by self-reported history of lifetime trauma.

Development and Outcomes of a Text Messaging Tobacco Cessation Intervention With Urban Adolescents

BACKGROUND

This paper describes the development of an urban adolescent text messaging tobacco cessation intervention and preliminary findings from a randomized, controlled trial. The authors successfully adapted a face-to-face intervention into a personalized, automated, and interactive 5-day texting protocol.

METHODS

Respondent-driven sampling was used beginning at a community substance abuse facility. Seventy-two tobacco-dependent adolescents were randomized into an automated computer texting program that delivered either the experimental condition of 30 motivational interviewing- and social network counseling-based personalized messages or the attention control condition consisting of a texting program covering general (non-smoking-related) health habits. All teens were provided smartphones for the study and were assessed at baseline and at 1, 3, and 6 months post intervention. Analyses examined condition×time interactions.

RESULTS

At 6 months, the experimental condition decreased the number of cigarettes smoked in the past 30 days, increased intentions not to smoke in the future, and increased peer social support compared with controls. Effect sizes were moderate to large.

CONCLUSIONS

These findings are unique, as they target urban adolescents with a mobile health format and add to the growing literature on the efficacy of text-delivered interventions.

Least explored factors associated with prenatal smoking

Poor pregnancy and birth outcomes are major problems in the United States, and maternal smoking during pregnancy has been identified as one of the most preventable risk factors associated with these outcomes. This study examines less explored risk factors of smoking among underserved African American pregnant women. A cross-sectional survey was conducted at an outpatient obstetrics-gynecology clinic of an inner-city university hospital in Virginia from March 2009 through January 2011 in which pregnant women (N = 902) were interviewed at their first prenatal care visit. Survey questions included items related to women's sociodemographic characteristics as well as their pregnancy history; criminal history; receipt of social services; child protective services involvement; insurance status; and history of substance abuse, domestic violence, and depression. Multiple logistic regression was conducted to calculate odds ratios and 95 % confidence intervals depicting the relationship between these factors and smoking during pregnancy. The analysis reported that maternal age [OR = 1.08, 95 % CI = 1.05-1.12], less than high school education [OR = 4.30, 95 % CI = 2.27-8.14], unemployed [OR = 2.33, 95 % CI = 1.35-4.04], criminal history [OR = 1.66, 95 % CI = 1.05-2.63], receipt of social services [OR = 2.26, 95 % CI = 1.35-3.79] alcohol use [OR = 2.73, 95 % CI = 1.65-4.51] and illicit drug use [OR = 1.97, 95 % CI = 1.04-3.74] during pregnancy were statistically significant risk factors associated with smoking during pregnancy. In addition to the well known risk factors, public health professionals should be aware that criminal history and receipt of social services are important factors associated with smoking during pregnancy. Social service providers such as WIC and prisons and jails may offer a unique opportunity for education and cessation interventions during the preconception or interconception period.

The association between gender, race and marital status on functional outcome at rehabilitation discharge after thromboembolic stroke: a prospective analysis

Appropriate allocation of rehabilitation resources requires that the rehabilitation professional have a knowledge of reliable predictors of functional outcome. To determine what influence pre-morbid demographic variables have on functional outcome following thromboembolic stroke, we analyzed prospectively collected demographic and functional data from consecutive patients admitted to rehabilitation at a tertiary university medical center. Data from 117 patients were statistically analyzed for correlations between demographic factors and functional outcome as measured by the FIM scale and hospital length of stay (LOS). While no significant correlations were found between race or gender and functional outcome, Caucasians were found to stay an average of 5 days longer in acute care than African-Americans. Non-married patients were found to have significantly longer rehabilitation LOS and return home following discharge less often. It is concluded that non-married status is a significant negative prognostic factor for functional outcome after thromboembolic stroke, while gender and race have no correlation.

Perceived mental health treatment need and substance use correlates among young adults

OBJECTIVES

The relationship between perceived need for mental health treatment, reasons for not receiving care, substance use, and race and gender among young adults was examined to identify barriers to mental health care.

METHODS

Data from the 2010 National Survey on Drug Use and Health for 14,718 adults ages 18 to 23 were used. Logistic regression analysis compared substance use among young adults with perceived mental health treatment need grouped by race and gender.

RESULTS

A total of 7.6% of young adults wanted mental health treatment but did not receive care. Persons with perceived treatment need were more likely than recipients of treatment to smoke cigarettes, use marijuana, meet criteria for marijuana abuse or dependence, and engage in binge drinking, after analyses controlled for income and health insurance. White males with perceived need were 3.2 times more likely to smoke and to meet criteria for marijuana abuse or dependence and were 2.6 times more likely to engage in binge drinking. Hispanic males were 2.9 times more likely to smoke and meet criteria for marijuana abuse or dependence. White females were 1.7 times more likely than other subgroups to perceive need for mental health care.

CONCLUSIONS

Young adults with perceived mental health treatment need are at high risk of substance abuse and dependence. Results support targeting knowledge and attitudes surrounding mental health services by race-ethnicity and gender to improve willingness to receive care.

The prevalence and effects of environmental tobacco smoke exposure among inner-city children: lessons for pediatric residents

PURPOSE

To determine the prevalence of environmental tobacco smoke (ETS) exposure, to explore the relationship between ETS exposure and the use of health services, and to examine the degree to which pediatric residents document ETS exposure status and counsel parents.

METHOD

In 2006, the authors recruited dyads of children (0-12 years old) and their mothers from an inner-city pediatric group practice clinic. Mothers completed a survey, and the authors searched the children's medical charts. The authors compared ETS-exposed children with nonexposed children using chi-square, t test, and ANOVA analyses. They also ran logistic regression analyses to examine the relationship between the use of health services and selected child and maternal variables.

RESULTS

More than 60% (142/232) of children were exposed to ETS, and more than 69% (99/142) of those children had a mother who smoked. ETS exposure significantly predicted the overall number of sick visits, even after controlling for sociodemographic confounders (odds ratio = 7.44; 95% confidence internal = 1.21-44.55). About 80% (187/232) of mothers reported that their child's pediatrician had counseled them on the dangers of ETS exposure. Less than half (105/232) of the children's charts included their ETS exposure status.

CONCLUSIONS

Although pediatric residents often counsel parents on the dangers of ETS exposure, educators should teach residents to regard ETS exposure status as a fifth vital sign. By screening for and documenting ETS exposure status, residents can identify at-risk children and parents, who could benefit from counseling.

Reducing Sexual Risk Behaviors for HIV/STDs in Women with Alcohol Use Disorders

Objective: A pilot randomized clinical trial (RCT) examined effectiveness of HIV/STD Safer Sex Skills Building + Alcohol (SSB+A) intervention for women with Alcohol Use Disorders (AUDs) in a residential treatment setting. Method: After randomizing thirty-six women with AUDs and reporting having intercourse with a male partner in the past 180 days to SSB+A or HE (standard HIV/STD education) groups, rates of penetrative intercourse with and without condoms at 60 day and 180 day follow-up were compared between SSB+A or HE groups. Results: There was a significant difference in mean number of sex acts with condoms between SSB+A and HE groups over time. Specifically, SSB+A and HE groups did not differ at 60 day follow-up, but at 180 day follow-up, mean sex acts with condoms among SSB+A group was significantly higher than HE. Conclusion: Pilot study findings affirm the effectiveness of the SSB+A in reducing sexual risk behaviors of AUD women and support the need for further research, testing the SSB+A intervention in a larger sample of women and across different treatment modalities. The present study also illustrates the critical link between practice and use of a step by step model of intervention research.

Lessons learned from a randomized trial of fixed and escalating contingency management schedules in opioid-dependent pregnant women

BACKGROUND

Contingency management (CM) has shown promise for treating substance use disorders in pregnant women.

METHODS

A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment.

RESULTS

As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention.

CONCLUSIONS

The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer.

SCIENTIFIC SIGNIFICANCE

This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change.

Randomized multi-site trial of the Job Seekers' Workshop in patients with substance use disorders

BACKGROUND

Unemployment is associated with negative outcomes both during and after drug abuse treatment. Interventions designed to increase rates of employment may also improve drug abuse treatment outcomes. The purpose of this multi-site clinical trial was to evaluate the Job Seekers' Workshop (JSW), a three session, manualized program designed to train patients in the skills needed to find and secure a job.

METHOD

Study participants were recruited through the NIDA Clinical Trials Network (CTN) from six psychosocial counseling (n=327) and five methadone maintenance (n=301) drug treatment programs. Participants were randomly assigned to either standard care (program-specific services plus brochure with local employment resources) (SC) or standard care plus JSW. Three 4-h small group JSW sessions were offered weekly by trained JSW facilitators with ongoing fidelity monitoring.

RESULTS

JSW and SC participants had similar 12- and 24-week results for the primary outcome measure (i.e., obtaining a new taxed job or enrollment in a training program). Specifically, one-fifth of participants at 12weeks (20.1-24.3%) and nearly one-third at 24 weeks (31.4-31.9%) had positive outcomes, with "obtaining a new taxed job" accounting for the majority of cases.

CONCLUSION

JSW group participants did not have higher rates of employment/training than SC controls. Rates of job acquisition were modest for both groups, suggesting more intensive interventions may be needed. Alternate targets (e.g., enhancing patient motivation, training in job-specific skills) warrant further study as well.

Addressing Perinatal Disparities in Urban Setting: Using Community Based Participatory Research

Striking racial disparities in infant mortality exist in the United States, with rates of infant death among African Americans (AA) nearly twice the national average. Community-based participatory research (CBPR) approaches have been successful in fostering collaborative relationships between communities and researchers focused on developing effective and sustainable interventions and programs targeting needs of the community. The current paper details use of the Perinatal Period of Risk (PPOR) model as a method to engage communities by identifying factors influencing racial disparities in infant mortality and examining changes in those factors over a ten year period.

EFFECT OF JOB SKILLS TRAINING ON EMPLOYMENT AND JOB SEEKING BEHAVIORS IN AN AMERICAN INDIAN SUBSTANCE ABUSE TREATMENT SAMPLE

Employment difficulties are common among American Indian individuals in substance abuse treatment. To address this problem, the Southwest Node of NIDA's Clinical Trials Network conducted a single-site adaptation of its national Job Seekers Workshop study in an American Indian treatment program, Na'Nizhoozhi Center (NCI). 102 (80% men, 100% American Indian) participants who were in residential treatment and currently unemployed were randomized to (1) a three session, manualized program (Job seekers workshop: JSW) or (2) a 40-minute Job Interviewing Video: JIV). Outcomes were assessed at 3-month follow up: 1) number of days to a new taxed job or enrollment in a job-training program, and 2) total hours working or enrolled in a job-training program. No significant differences were found between the two groups for time to a new taxed job or enrollment in a job-training program. There were no significant differences between groups in substance use frequency at 3-month follow-up. These results do not support the use of the costly and time-consuming JSW intervention in this population and setting. Despite of the lack of a demonstrable treatment effect, this study established the feasibility of including a rural American Indian site in a rigorous CTN trial through a community-based participatory research approach.

Behavioral strategies to improve treatment participation and retention by pregnant drug-dependent women

The present study examined the utility of behavioral incentives for improving early treatment participation and retention in a sample of 91 pregnant opiate and/or cocaine dependent women enrolled in an urban, university-based drug user treatment program between 1996 and 1997. An escalating voucher incentive system was compared to standard care. The relationship between treatment participation and retention and maternal and infant outcomes were examined using logistic regression, chi-square analyses, and t-tests. Behavioral incentives did not decrease rates of very early dropout from residential treatment, although improved outpatient treatment participation and retention during the transition from residential care was noted. Behavioral strategies demonstrate utility as adjuncts to counseling for high-risk substance dependent patients. They appear ineffective, however, for improving early residential treatment participation and retention, suggesting other variables (e.g., psychiatric comorbidity) may be operating during the first 24-48 hours post treatment admission.

Supported employment for persons with traumatic brain injury: a preliminary investigation of long-term follow-up costs and program efficiency

OBJECTIVE

To investigate the long-term follow-up costs of supported employment as well as the wage and employment characteristics for individuals with moderate to severe traumatic brain injury (TBI) who participated in supported employment services over a 14-year time period.

DESIGN

Longitudinal design with prospectively collected data.

SETTING

A university-based supported employment program that uses the individual placement model of supported employment.

PARTICIPANTS

Fifty-nine individuals with moderate to severe TBI who were consecutively referred for supported employment services. The sample was restricted to individuals who were placed into a least 1 supported employment position during the study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Data were collected on clients placed into at least 1 competitive supported employment position from 1985 to 1999. Analyses were performed to examine the costs of supported employment, employment characteristics (eg, wages, length of employment), and benefit-cost ratios of supported employment for individuals with TBI.

RESULTS

The average length of employment for the current sample was 42.58 months. Average gross earnings were US dollars 26,129.74 for individuals during their entire duration of employment. Billing charges accrued for employment services averaged US dollars 10,349.37. Individuals with TBI earned an average of US dollars 17,515 more than the costs associated with their supported employment.

CONCLUSIONS

Our investigation provides additional support for the conclusion that supported employment is cost effective for individuals with disabilities, including individuals with TBI, and that the costs of supported employment decrease over time.

Alterations of medial preoptic area neurons following pregnancy and pregnancy-like steroidal treatment in the rat

There is a marked increase in the maternal behavior displayed by a female rat following pregnancy-due primarily to exposure to the gonadal hormones progesterone and estradiol (P and E(2), respectively). We examined Golgi-Cox silver-stained, Vibratome-sectioned neurons visualized and traced using computerized microscopy and image analysis. In Part One, we examined the hormonal-neural concomitants in the medial preoptic area (mPOA), an area of the brain that regulates maternal behavior, by comparing cell body size (area in microm(2); also referred to as soma and perikaryon) in the mPOA and cortex of five groups (n = 4-6/group) of ovariectomized (OVX-minus), diestrous, sequential P and E(2)-treated (P+E(2)), late-pregnant, and lactating rats; for Part Two, we examined a subset of mPOA neurons, which were traced in their entirety, from these same subjects. In Part One, whereas there was no difference between OVX-minus and diestrous females, both had smaller somal areas compared to OVX+P+E(2)-treated and late-pregnant females. The area of the soma returned to diestrous/OVX-minus levels in the lactating females. We found no change among the five groups in area of cell body in cortical neurons, which generally lack steroid receptors. In Part Two, which included a more detailed morphometric analysis of mPOA neurons, we examined several additional measures of dendritic structure, including number of proximal dendritic branches (the largest proximal dendrite was defined as the one with the largest diameter leaving the soma); cumulative length of the largest proximal dendrite; area of the cell body; number of basal dendrites; cumulative basal dendritic length; number of basal dendritic branches; and branch-point (distance from cell body to first branch of largest proximal dendrite). Again, we found similar effects on cell body size as in Part One, together with effects on number of basal dendritic branches and cumulative basal dendritic length in pregnant and P+E(2)-treated groups compared to OVX, diestrous, and lactating. An increase in somal area denotes increased cellular activity, and stimulatory effects on additional neuronal variables represents modifications in information processing capacity. Pregnancy and its attendant hormonal exposure, therefore, may stimulate neurons in the mPOA, which then contribute (in an as yet undetermined manner) to the display of maternal behavior. During the postpartum lactational period, when cues from pups primarily maintain maternal attention, the neuronal soma appears to return to a pre-pregnancy, non-hormonally dependent state, whereas other aspects of the dendrite remain altered. Collectively, these data demonstrate a striking plasticity in the brains of females that may be reflected in modifications in behavior.

Functional assessment in patients with chronic pain: can physicians predict performance?

OBJECTIVES

To determine the appropriateness of using physicians to estimate the functional abilities of patients with chronic pain. Specific objectives included the following: (1) to compare the physician's predicted performance on functional assessment with actual performance, and (2) to compare the physician's predicted effort during functional assessment with an objective measure of effort.

DESIGN

A total of 201 outpatients with chronic pain completed this prospective, multicenter, cohort study. Fifteen physicians, who were trained to administer the standardized evaluation, performed the evaluations and predicted performance and effort on functional assessment. Therapists, blinded to the physician's evaluation, administered a functional assessment (maximal and sustained lifts [n = 3 types]; repetitive activities [n = 4 types]) and a grip dynamometry test (effort measure) on each subject.

RESULTS

Pearson's correlation testing demonstrated significant correlations between the physician's predicted performance and the observed performance for all lifting items and repetitive activities in both men (0.52, 0.50, 0.55) and women (0.36, 0.40, 0.18). Analysis of variance and post hoc t tests showed agreement between the physician's predicted effort and the dynamometry effort measure in only a small subset of patients (men were predicted to put forth absolutely no effort; n = 4).

CONCLUSIONS

A trained physician, performing a standardized evaluation, can estimate with reasonable accuracy the work-related functional ability in patients with chronic pain. The prediction of effort seems to be more problematic.

Functional outcomes in patients with brain tumor after inpatient rehabilitation: comparison with traumatic brain injury

OBJECTIVE

To compare the functional outcome, length of stay, and discharge disposition of individuals with brain tumor versus those with acute traumatic brain injury.

DESIGN

In this study, 78 brain tumor patients were one-to-one matched by location of lesion and age with 78 acute traumatic brain injury patients. Outcome was measured by using the Functional Independence Measure (FIM 228) on admission and discharge. The FIM change and FIM efficiency were also calculated. FIM data were analyzed in three subsets, i.e., activities of daily living, mobility, and cognition. Discharge disposition and rehabilitation length of stay were also compared.

RESULTS

Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and the traumatic brain injury populations with respect to total admission FIM, total discharge FIM, and FIM efficiency. The brain injury population had a significantly greater change in FIM. The tumor group had a significantly shorter rehabilitation length of stay and a greater discharge to community rate.

CONCLUSIONS

Thus, individuals with brain tumor can achieve comparable functional outcome and have a shorter rehabilitation length of stay and greater discharge to community rate than individuals with brain injury.

Functional outcome of individuals with traumatic brain injury and lower extremity deep venous thrombosis

OBJECTIVE

To determine the impact of acute lower extremity (LE) deep venous thrombosis (DVT) on functional outcome after traumatic brain injury (TBI).

SETTING

Tertiary university medical center rehabilitation unit.

SUBJECTS

Ninety-two TBI rehabilitation patients (46 patients with DVT and 46 patients without DVT). Forty-six TBI patients with a diagnosis of LE DVT were 1:1 matched with non-DVT TBI patients. Matching criteria included: primary diagnosis of TBI, admission Functional Independence Measure (FIM), Glasgow Coma Scale (GCS), and age.

OUTCOME MEASURES

FIM (admission, discharge, change, and efficiency), FIM subscores (activities of daily living [ADL], mobility, cognition), length of stay ([LOS] acute and rehabilitation), and discharge living disposition.

DESIGN

Cohort study utilizing prospectively collected data. DVT diagnoses were made upon rehabilitation admission using color flow duplex Doppler ultrasonography. Descriptive statistics were run on demographic variables. Analyses of variance (ANOVAs) were performed on the sample with regard to outcome measures, including FIM scores, FIM subscores, and LOS (acute and rehabilitation).

RESULTS

No significant between-group differences were found concerning LOS, rehabilitation costs, FIM total, or FIM subgroup scores. Chi-squared analyses revealed significant differences between groups with regard to discharge living disposition (chi(2) = 4.7, P <.03).

CONCLUSION

Lower extremity DVT does not appear to interfere with functional outcome after TBI. The data suggest that this patient population is appropriate for admission or continued participation in acute inpatient rehabilitation, despite the presence of LE DVT.

Impact of clinically significant heterotopic ossification on functional outcome after traumatic brain injury

OBJECTIVE

To assess heterotopic ossification's (HO) impact on functional outcome after TBI.

DESIGN

Retrospective with matched control group, single center.

SETTING

TBI Model System of Care at the Medical College of Virginia of Virginia Commonwealth University, Richmond, VA.

PARTICIPANTS

Twenty-six patients with TBI and triple-phase bone scan confirmed HO were matched with 26 patients without clinical evidence of HO.

MAIN OUTCOME MEASURES

Acute and rehabilitation lengths of stay (LOS), Admission and Discharge Functional Independence Measure (FIM) scores, FIM change, FIM efficiency (FIM gains per week), and discharge disposition.

RESULTS

The two groups had similar acute care LOS. Patients with HO had significantly longer inpatient rehabilitation LOS and significantly lower FIM mobility and activities of daily living subscale scores on admission and discharge. FIM efficiency was significantly lower for the group with HO. Significantly fewer patients with HO were able to be discharged to home.

CONCLUSIONS

HO is associated with a poorer functional outcome; however, it is not clear whether HO causes the decreased function or whether it may serve more generally as an indicator of those patients who will not progress as far or as rapidly during inpatient rehabilitation.

Functional outcome after brain tumor and acute stroke: a comparative analysis

OBJECTIVE

To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke.

DESIGN

Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit.

SUBJECTS

Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion.

MAIN OUTCOME MEASURES

The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared.

RESULTS

Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01).

CONCLUSION

Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.

Rehabilitation outcome of individuals with nontraumatic myelopathy resulting from spinal stenosis

A study was undertaken of 46 patients (19 cervical and 27 lumbar) admitted to an inpatient rehabilitation unit following surgical decompression for myelopathy or cauda equina syndrome resulting from spinal stenosis (SS). Individuals with SS represented 16 percent of all spinal cord injury (SCI) admissions. When compared to patients with traumatic SCI, patients with SS were significantly (t-test, p < .01) older (mean age 68 versus 39 years), more frequently retired/unemployed (89 percent versus 43 percent), more often married (57 percent versus 36 percent) and less often male (54 percent versus 82 percent) but with similar ethnicity. Significant (p < .01) Functional Independence Measurement (FIM) changes for the SS patients were noted after rehabilitation in the categories of self-care, sphincter control and mobility/locomotion. Additionally, outcome comparisons with a group of traumatic SCI patients who had similar motor function revealed similar lengths of stay, discharge FIM scores and discharge-to-community rates. This study suggests that individuals with weakness secondary to SS represent a significant proportion of individuals with SCI, make significant functional gains following inpatient rehabilitation and can achieve functional outcomes similar to those of traumatic SCI individuals.

Comparison of rehabilitation outcomes in violent versus non-violent traumatic SCI

This paper represents the results of a cohort study comparing functional outcomes of individuals with violent and non-violent traumatic spinal cord injury (SCI) following inpatient rehabilitation. Twenty-seven consecutive patients with a diagnosis of traumatic SCI of violent etiology (gunshot wound, stabbing or assault) and 27 patients with non-violent etiology (motor vehicle accident and falls) were matched for neurological level of injury and classification. Demographic comparison of violent versus non-violent groups revealed mean age 30 versus 39, gender 93 percent versus 78 percent male, race 89 percent versus 59 percent non-white, 74 percent versus 41 percent unmarried and 56 percent versus 22 percent unemployed, respectively. Violent and non-violent traumatic SCI groups had similar lengths of stay, admission and discharge functional independent measures (FIM), FIM improvement, payor sources, hospital charges and discharge to home rates. Despite the differences noted in the demographics of violent and non-violent traumatic SCI, these two matched groups achieved similar functional outcomes and discharge disposition following inpatient rehabilitation.

Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis

OBJECTIVE

To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients.

DESIGN

Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results.

SETTING

Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services.

PARTICIPANTS

Patients were selected from a national database of 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up.

MAIN OUTCOME MEASURE

Return to work at 1-year follow-up.

RESULTS

Persons employed at 1-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts.

CONCLUSIONS

Persons obtaining better scores on certain acute measures (e.g., Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patient's ability to return to work, as well as an operational definition for successful employment.