Comparison of Patients Discharged to Skilled Nursing and Inpatient Rehabilitation Facilities After Hospitalization for COVID-19: A Retrospective Study

OBJECTIVE

The aim of the study is to identify differences in demographics, severity of disease, and rates of hospital readmission among adults discharged to skilled nursing facilities and inpatient rehabilitation facilities after hospitalization for coronavirus 2019.

DESIGN

This is a retrospective cohort study of adults hospitalized with coronavirus 2019 infection at academic medical centers participating in the Vizient Clinical Data Base between April 1, 2020, and June 30, 2021, who were discharged to skilled nursing facilities or inpatient rehabilitation facilities ( N = 39,882). Data from the Clinical Data Base are used with permission of Vizient, Inc. All rights reserved.

RESULTS

Among adults hospitalized with coronavirus 2019 infection, those discharged to skilled nursing facilities were 1.4 times more likely to require hospital readmission than those discharged to inpatient rehabilitation facilities. They were, on average, older (73 vs. 61 yrs, P < 0.001) and had shorter hospital lengths of stay (15 vs. 26 days, P < 0.0001) than the patients discharged to inpatient rehabilitation facilities. Persons discharged to inpatient rehabilitation facilities were more likely to have received intensive care and mechanical ventilation while hospitalized ( P < 0.001).

CONCLUSIONS

Individuals discharged to inpatient rehabilitation facilities after hospitalization for coronavirus 2019 differ from those discharged to skilled nursing facilities on a number of key variables, including age, hospital length of stay, having received intensive care, and odds of hospital readmission.

Predictors of discharge to home/community following inpatient-rehabilitation in a US national sample of Guillain-Barre-Syndrome patients

BACKGROUND

Guillain-Barre-Syndrome (GBS), an autoimmune polyneuropathy causing acute flaccid paralysis, is a rare condition with1-2 cases per 100,000 annually (approximately 5000 cases/year) in the United States (US). There is a paucity of published data regarding patient outcomes in association with discharge destinations following inpatient-rehabilitation (IR) in this patient population, thus this study.

OBJECTIVES

To analyze IR efficacy, and possible predictors of discharge to home/community in a US-national-sample of GBS patients.

METHODS

Retrospective-observational-cohort study of 1304 GBS patients admitted to IR comparing discharge disposition destinations (community/home, skilled-nursing-facility [SNF], or return to acute-care) by demographic (age, gender) and clinical variables (length-of-stay [LOS], case-mix-index [CMI], and Functional-Independence-Measure [FIM] score changes). Multinomial-logistic-regression and discriminant-function-analysis were performed to determine model fit in predicting discharge destination.

RESULTS

81.8% were discharged to home/community- average LOS 19-days, total-FIM-gain 43.2; 9.8% discharged to SNFs- average LOS 27.5-days, total-FIM-gain 27.2; and 8.4% discharged to acute-care- average LOS 15.4-days and total-FIM-gain 16.5, (F = 176, p < .001). Stepwise-linear-regression for prediction of community discharge showed change in FIM-Bed/chair/wheelchair-Transfers was the most significant predictor (Wald = 42.2; p < .001), followed by CMI (Wald = 26.9; p < .001), change in FIM-walking/wheelchair (Wald = 14.9; p < .001), and age (Wald = 9.5; p < .002). Using discriminant-function-analysis to test model validity for predicting discharge disposition, FIM-change for Bed/chair/wheelchair Transfers, Walking, and Self-Care as predictors resulted in a classification rate of 78.1%, 92% of variance explained, and Eigenvalue of .53 (p < .001).

CONCLUSIONS

Total-FIM scores improved in all groups, and most patients were discharged to home/community suggesting IR efficacy. The ability to transfer bed/chair/wheelchair was the most important predictive factor associated with discharge destination.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study

OBJECTIVE

To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS).

PARTICIPANTS

A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations.

DESIGN

Secondary analysis from multicenter prospective longitudinal study.

MAIN MEASURES

Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale.

RESULTS

The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores.

CONCLUSION

Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Neurocognitive status and return to work after moderate to severe traumatic brain injury

PURPOSE/OBJECTIVE

To examine the relationship of cognitive status to employment outcomes at 1-year post moderate-severe traumatic brain injury (TBI), using a brief telephone-administered instrument. Research Method/Design: Prospective longitudinal study in which 320 people with moderate-severe TBI, all employed at injury, were enrolled during inpatient rehabilitation and evaluated at 1-year postinjury. Follow-up measures included whether and when participants had returned to work (RTW), and cognitive status assessed with the Brief Test of Adult Cognition by Telephone (BTACT). Multivariable logistic regression and survival analyses were used to assess the contribution of BTACT (overall and subscale scores) to employment outcomes, controlling for covariates with known associations to those outcomes, including demographic variables, injury severity, and driving status.

RESULTS

Fewer than 40% of participants (n = 124) were employed at 1-year follow-up. BTACT scores were strongly associated with RTW even after controlling for known covariates. Females had faster and higher rates of RTW compared to males. Resumption of driving and injury severity were also related to RTW.

CONCLUSIONS/IMPLICATIONS

Neurocognitive status is a potentially modifiable factor with an important relationship to RTW following TBI. Vocational rehabilitation efforts should provide cognitive remediation or compensation as well as addressing transportation barriers. As a brief telephone-based assessment, the BTACT offers a new and efficient tool for evaluation of episodic memory and executive function. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Sleep quality in well-defined Lyme disease: a clinical cohort study in Maryland

Study Objectives

Lyme disease (LD) is the most common vector-borne disease in the United States. Approximately 5-15 per cent of patients develop postantibiotic treatment symptoms termed post-treatment Lyme disease syndrome (PTLDS). The primary objective of this study is to examine and quantify sleep quality among patients with early LD during the acute and convalescent periods, including among the subset who met criteria for PTLDS.

Methods

This paper draws from a clinical cohort study of participants with early LD (n = 122) and a subcohort of individuals who later met criteria for PTLDS (n = 6). Participants were followed for 1 year after antibiotic treatment. The Pittsburgh Sleep Quality Index and standardized measures of pain, fatigue, depressive symptoms, and functional impact were administered at all visits for participants and controls (n = 26). Participants meeting criteria for PTLDS at 1 year post-treatment were compared with a subset of PSQI-defined poor sleeping controls (n = 10).

Results

At the pretreatment visit, participants with early LD reported poorer sleep than controls. By 6 months post-treatment, participant sleep scores as a group returned to control levels. Participants with PTLDS reported significantly worse global sleep and sleep disturbance scores and worse fatigue, functional impact, and more cognitive-affective depressive symptoms compared with poor sleeping controls.

Conclusions

Participants with early LD experienced poor sleep quality, which is associated with typical LD symptoms of pain and fatigue. In the subset of patients who developed PTLDS, sleep quality remains affected for up to 1 year post-treatment and is commonly associated with pain. Sleep quality should be considered in the clinical picture for LD and PTLDS.

Association of Urinary Incontinence with Cognition, Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

BACKGROUND

Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination.

OBJECTIVE

To examine if urinary incontinence is associated with inpatient-rehabilitation (IR) outcomes in cognition, transfers, and discharge destinations.

DESIGN

Retrospective observational study of 303 of 579(52%) acute-stroke patients admitted to IR 2012-2015 with complete urinary incontinence (total assistance for bladder management). Discharge Functional Independence Measure (FIM) scores were correlated for continence, cognition, transfers-(bed/chair/wheelchair), and discharge destination.

RESULTS

Patients were admitted to IR on average 7.4 days after acute stroke. Average length-of-stay in IR was 14 days. At discharge 118 of 303(39%) remained urinary incontinent (total assistance). Continence/bladder-management FIM scores at discharge were associated with cognition FIM scores at discharge (chi square =105.8; P < .0001), and associated with transfer FIM scores at discharge (chi square = 153.1; P < .0001). Patients total to moderate assistance for continence at discharge included greater percentage that were dependent to moderate assistance for cognition and transfers than those minimal assistance to independent for continence. Continence/bladder-management FIM scores at discharge were associated with discharge disposition destinations (chi square = 29.98; P < .002). Patients total to moderate assistance for continence at discharge included greater percentage of acute care transfers, and skilled-nursing-facility dispositions, than patients that recovered to minimal assist to independent for continence. Urinary-incontinence recovery to minimal assistance to independent was associated with a home/community disposition rate of 82%.

CONCLUSIONS

52% stroke patients were total assistance with bladder management for urinary incontinence on IR admission. Partial to complete continence recovery occurred in 61%. Continence/bladder-management FIM scores at discharge were associated with cognition and transfer FIM scores, and discharge destinations.

The Feasibility of Telephone-Administered Cognitive Testing in Individuals 1 and 2 Years after Inpatient Rehabilitation for Traumatic Brain Injury

Traumatic brain injury (TBI) often results in cognitive impairment, and trajectories of cognitive functioning can vary tremendously over time across survivors. Traditional approaches to measuring cognitive performance require face-to-face administration of a battery of objective neuropsychological tests, which can be time- and labor-intensive. There are numerous clinical and research contexts in which in-person testing is undesirable or unfeasible, including clinical monitoring of older adults or individuals with disability for whom travel is challenging, and epidemiological studies of geographically dispersed participants. A telephone-based method for measuring cognition could conserve resources and improve efficiency. The objective of this study is to examine the feasibility and usefulness of the Brief Test of Adult Cognition by Telephone (BTACT) among individuals who are 1 and 2 years post-moderate-to-severe TBI. A total of 463 individuals participated in the study at Year 1 post-injury, and 386 participated at Year 2. The sample was mostly male (73%) and white (59%), with an average age of (mean ± standard deviation) 47.9 ± 20.9 years, and 73% experienced a duration of post-traumatic amnesia (PTA) greater than 7 days. A majority of participants were able to complete the BTACT subtests (61-69% and 56-64% for Years 1 and 2 respectively); score imputation for those unable to complete a test due to severity of cognitive impairment yields complete data for 74-79% of the sample. BTACT subtests showed expected changes between Years 1-2, and summary scores demonstrated expected associations with injury severity, employment status, and cognitive status as measured by the Functional Independence Measure. Results indicate it is feasible, efficient, and useful to measure cognition over the telephone among individuals with moderate-severe TBI.

Prognostic models for predicting posttraumatic seizures during acute hospitalization, and at 1 and 2 years following traumatic brain injury

OBJECTIVE

Posttraumatic seizures (PTS) are well-recognized acute and chronic complications of traumatic brain injury (TBI). Risk factors have been identified, but considerable variability in who develops PTS remains. Existing PTS prognostic models are not widely adopted for clinical use and do not reflect current trends in injury, diagnosis, or care. We aimed to develop and internally validate preliminary prognostic regression models to predict PTS during acute care hospitalization, and at year 1 and year 2 postinjury.

METHODS

Prognostic models predicting PTS during acute care hospitalization and year 1 and year 2 post-injury were developed using a recent (2011-2014) cohort from the TBI Model Systems National Database. Potential PTS predictors were selected based on previous literature and biologic plausibility. Bivariable logistic regression identified variables with a p-value < 0.20 that were used to fit initial prognostic models. Multivariable logistic regression modeling with backward-stepwise elimination was used to determine reduced prognostic models and to internally validate using 1,000 bootstrap samples. Fit statistics were calculated, correcting for overfitting (optimism).

RESULTS

The prognostic models identified sex, craniotomy, contusion load, and pre-injury limitation in learning/remembering/concentrating as significant PTS predictors during acute hospitalization. Significant predictors of PTS at year 1 were subdural hematoma (SDH), contusion load, craniotomy, craniectomy, seizure during acute hospitalization, duration of posttraumatic amnesia, preinjury mental health treatment/psychiatric hospitalization, and preinjury incarceration. Year 2 significant predictors were similar to those of year 1: SDH, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Corrected concordance (C) statistics were 0.599, 0.747, and 0.716 for acute hospitalization, year 1, and year 2 models, respectively.

SIGNIFICANCE

The prognostic model for PTS during acute hospitalization did not discriminate well. Year 1 and year 2 models showed fair to good predictive validity for PTS. Cranial surgery, although medically necessary, requires ongoing research regarding potential benefits of increased monitoring for signs of epileptogenesis, PTS prophylaxis, and/or rehabilitation/social support. Future studies should externally validate models and determine clinical utility.

Evaluating the Siebens Model in Geriatric-Stroke Inpatient Rehabilitation to Reduce Institutionalization and Acute-Care Readmissions

BACKGROUND

The objective of the study is to evaluate the use of Siebens Domain Management Model (SDMM) in geriatric-stroke patients during inpatient rehabilitation (IR) to increase functional independence, and to reduce institutionalization and acute-care readmissions, which are quality indicators under the U.S. Affordable Care Act.

METHODS

In 2010 (preintervention), 66 stroke patients aged more than 75 years were admitted to an IR facility, on average, 8.8 days postacute care. In 2012 (postintervention), 58 patients aged more than 75 years were admitted to the same IR facility, on average, 5.0 days postacute care. SDMM intervention involved weekly adjustments of clinical care focused on potential barriers to discharge home. Functional Independence Measure (FIM) efficiency, length of stay (LOS), and disposition rates to community or home, acute care, and long-term care were compared pre- and postintervention within facility, and facility data were compared to national case-mix-group-adjusted data from the Uniform Data System for Medical Rehabilitation for both years (2010/2012).

RESULTS

Pre- and postintervention demographics and prestroke living support/setting were similar, but preintervention had on average 4 more days LOS in IR and 3.8 more days to IR onset. There were significantly more discharges to community in postintervention (79.3%) compared to preintervention (56.9%) (chi-square = 6.02, P < .013). The preintervention group did not significantly differ from 2010 national data whereas the postintervention/2012 group significantly differed from 2012 national data for higher FIM efficiency (t = -3.1, P < .002) and more discharges to community (chi-square = 19.7; P < .0001). From 2010 to 2012, there were 3.8 times more discharges to community (chi-square = 8535; P < .0001) and 6 times fewer acute-care dispositions postintervention than nationally (chi-square = 58.7; P < .0001).

The relationship between performances on neuropsychological symptom validity testing and the MCMI-III in patients with fibromyalgia

Fibromyalgia is a disorder that frequently presents with both cognitive complaints and psychiatric symptoms. This study investigated the association between Symptom Validity Test (SVT) performance and psychiatric symptoms as measured by the Millon Clinical Multiaxial Inventory-III (MCMI-III), a common measure of psychopathology. A total of 72 fibromyalgia patients at a tertiary care clinic completed the MCMI-III, an embedded cognitive symptom validity test (Reliable Digit Span), and a stand-alone cognitive symptom validity test (the Word Memory Test or Test of Memory Malingering). Of these patients, 21% failed a stand-alone SVT, whereas an additional 15% failed both a stand-alone and embedded SVT. Individuals who failed both stand-alone and embedded cognitive SVTs had higher scores on a number of MCMI-III personality subscales and had elevated scores on MCMI-III modifying indices compared to individuals who passed cognitive SVTs. Moreover, SVT performance was significantly correlated with multiple MCMI-III scores, including modifying indices, as well as the somatoform, depression, and anxiety subscales. In sum, cognitive and psychological symptom validity scores were significantly related. Given the new emphasis on cognitive complaints as part of the fibromyalgia diagnostic criteria, neuropsychological evaluation of both cognitive and psychological symptom validity should be a part of a comprehensive diagnostic assessment.

Characteristics of American Psychological Association Division 40 (clinical neuropsychology) Fellows

Fellow status is an honor bestowed on American Psychological Association (APA) members who have made unusual and outstanding contributions to the field of psychology that have had a national impact. Thus far no studies have examined the characteristics of the individuals who have received this honor. This study examined publicly available data for 157 Division 40 Fellows. Fellows comprise 3.7% of the 4273 members of the division compared to 5.7% of the entire APA membership. Fellows are predominantly male (73%). All but two fellows had earned a Ph.D. with the average time since granting of the doctoral degree of 17.1 ± 6 years (median=16 years) with a range of 7-40 years post-degree. Slightly over half of the fellows hold board certification (53%) in the American Board of Professional Psychology. The largest group of fellows reports their primary employment currently as a university-affiliated medical setting (48%). These data serve to characterize current Division 40 Fellows for the field of neuropsychology and may provide useful information to assist prospective fellow applicants.

Functional cooking skills and neuropsychological functioning in patients with stroke: an ecological validity study

Efforts to relate neuropsychological performance to real-world task functioning have predominantly yielded lackluster results, typically with neuropsychological performance accounting for modest amounts of variance in function. Nonetheless, the ecological validity of neuropsychological measures for predicting functional abilities remains a strong research interest and clinical necessity. This study relates neuropsychological performance to performance on a standardised cooking task (Rabideau Kitchen Evaluation - Revised; RKE-R) in persons with stroke. Results showed that while the composite score of mean neuropsychological performance had the largest association with meal preparation, several neuropsychological measures were significantly related to the RKE-R. Groups of left and right hemisphere stroke patients were not significantly different in terms of RKE-R performance. These results suggest that functional cooking task performance is related to intact cognitive abilities in delayed verbal memory, simple auditory attention, and visuospatial skills, as well as overall cognitive performance. Implications for neuropsychologists are discussed.

Screening for hazardous drinking using the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) in elderly persons with acute cerebrovascular accidents

BACKGROUND

Effective and valid screening methods are needed to identify hazardous drinking in elderly persons with new onset acute medical illness. The goal of the current study was to examine the effectiveness of the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) in identifying hazardous drinking among elderly patients with acute cerebrovascular accidents (CVA) and to compare the effectiveness of 2 shorter versions of the MAST-G with the full instrument.

METHODS

The study sample included 100 men and women who averaged 12 days posthemorrhagic or ischemic CVA admitted to a rehabilitation unit and who were at least 50 years of age and free of substance use other than alcohol. This cross-sectional validation study compared the 24-item full MAST-G, the 10-item Short MAST-G (SMAST-G), and a 2-item regression analysis derived Mini MAST-G (MMAST-G) to the reference standard of hazardous drinking during the past 3 months. Alcohol use was collected using the Timeline Followback (TLFB). Recent and lifetime alcohol-related consequences were collected using the Short Inventory of Problems (SIP).

RESULTS

Nearly one-third (28%) of the study sample met the World Health Organization (WHO) criteria for hazardous drinking. Moderately strong associations were found for the MAST-G, SMAST-G, and MMAST-G with alcohol quantity and frequency and recent and lifetime alcohol consequences. All 3 MAST-G versions could differentiate hazardous from nonhazardous drinkers and had nearly identical area under the curve characteristics. Comparable sensitivity was found across the 3 MAST-G measures. The optimal screening threshold for hazardous drinking was 5 for the MAST-G, 2 for the SMAST-G, and 1 for the MMAST-G.

CONCLUSIONS

The 10-item SMAST-G and 2-item MMAST-G are brief screening tests that show comparable effectiveness in detecting hazardous drinking in elderly patients with acute CVA compared with the full 24-item MAST-G. Implications for research and clinical practice are discussed.

The Hopkins Rehabilitation Engagement Rating Scale: development and psychometric properties

OBJECTIVE

To conduct an initial investigation of the psychometric properties of the Hopkins Rehabilitation Engagement Rating Scale (HRERS), a 5-item, clinician-rated measure developed to quantify engagement in acute rehabilitation services.

DESIGN

We used a cross-sectional design to conduct correlational and multivariate analyses to establish the measure's internal consistency, interrater reliability, construct validity, and criterion validity.

SETTING

Acute inpatient rehabilitation in 3 metropolitan hospitals.

PARTICIPANTS

A total of 206 subjects with spinal cord injury, ischemic or hemorrhagic stroke, amputation, or hip or knee replacement.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The HRERS, Positive and Negative Affect Schedule, Brief Symptom Inventory, Levine's Denial of Illness Scale, Craig Handicap Assessment and Reporting Technique, and FIM instrument.

RESULTS

The HRERS has good internal consistency (alpha=.91) and interrater reliability (intraclass correlation coefficient, .73) and represents a unidimensional construct. It correlated negatively with symptoms of depression (r=-.24, P<.01), higher ratings of denial of illness (r=-.30, P<.001), and self-rated negative affect (r=-.23, P<.01), and correlated positively with self-rated positive affect (r=.36, P<.001) and level of functioning 3 months postdischarge (r=.22, P<.01).

CONCLUSIONS

The HRERS is a valid and reliable measure of rehabilitation engagement that relates to intermediate-term functional outcomes.

Hip migration percentage in children with cerebral palsy treated with botulinum toxin type A

OBJECTIVE

To determine hip radiographic findings in children with cerebral palsy (CP) treated with botulinum toxin type A (BTX-A).

DESIGN

Retrospective chart review with correlation to radiographic findings.

SETTING

Academic center.

PARTICIPANTS

Sixteen subjects with CP.

INTERVENTION

BTX-A treatment to adductor muscles.

MAIN OUTCOME MEASURE

The Reimers hip migration percentage before and after BTX-A.

RESULTS

Thirty-two hips in 16 children with CP were treated. We examined the effect of initial migration percentage and initial migration percentage age on the change in migration percentage after BTX-A injection. A significant effect for initial migration percentage (<30% or >/=30%; F=19.05, P <.001) and a significant interaction between initial migration percentage and initial migration percentage age (F=7.5, P <.01) was noted. Initial migration percentage age (</=24 mo or >24 mo) was not significant (F=.95, P =.34). Patients who had an initial migration percentage of 30% or more and were less than 24 months old were more likely to have a decrease in migration percentage after BTX-A injection compared with patients who were older than 24 months and who had an initial migration percentage of 30% or more.

CONCLUSIONS

Improvement in hip migration percentage after BTX-A injection is a function of age and the initial migration percentage. BTX-A injections to adductor muscles may be beneficial for some children with CP.

Optimal Resistance Training

OBJECTIVE

Progressive resistive exercises, such as the DeLorme or Oxford techniques, improve strength by adding weights to arrive at the ten-repetition maximum (10RM; DeLorme) or by starting at the 10RM and removing weight (Oxford). The goal of this study was to examine the efficacy of each training method.

DESIGN

In this randomized, prospective, group design, evaluator-blind clinical trial, 50 subjects performed either the Oxford or DeLorme weight-training techniques. Three times a week for 9 wks, subjects completed three sets of ten-repetition knee extensions based on the 10RM measured weekly. Incremental or decremental changes in training weight were utilized in training sessions based on the protocol randomly assigned to each subject.

RESULTS

The mean 10RM increase was 71.9 kg for the DeLorme group and 67.5 kg for the Oxford group, which was not significantly different. Examination with repeated measures multivariate analysis of variance revealed no significant difference between the two groups for 10RM increase, and no significant sex differences were found. Percentage change scores were not significantly different for 1RM and 10RM for both protocols and sexes.

CONCLUSION

Both protocol groups were able to complete their lifting assignments and progressed similarly in weekly 10RM weight lifted. It can be concluded that both the DeLorme and Oxford protocols improve strength with equivalent efficacy. Further studies involving a larger sample size are needed to address potential sex-specific changes in strength improvement in response to the protocols.

Interface of information technology and neuropsychology: ethical issues and recommendations

Rapid advancements in information technology and telecommunications (ITT) offer exciting opportunities for neuropsychology. However, guidelines and recommendations for identifying and negotiating ethical challenges have not kept pace with the expansion of ITT. Because many neuropsychologists evaluate and/or treat individuals with cognitive, emotional, and/or physical limitations, neuropsychologists have a responsibility to be aware of the ethical issues associated with ITT use in order to avoid harming those who may be less able to understand or independently manipulate such technology themselves. The purpose of this paper is to raise awareness of potential implications of the interface between ethics and information technology for neuropsychologists. The first steps in this process include defining terms, identifying relevant issues and challenges, and identifying initial mechanisms to address ethical challenges. In addition, strategies for avoiding ethical misconduct related to information technology are discussed and specific recommendations are offered.

Relationship between neuropsychological and emotional functioning in severe chronic alcoholism

Previous studies of patients with severe chronic alcoholism have shown a high prevalence of emotional distress such as anxiety and depression, and neuropsychological impairments such as executive deficits, but few have examined the relationship between these disorders. We addressed this issue in 51 abstinent patients with histories of severe chronic alcoholism utilizing the Minnesota Multiphasic Personality Inventory (MMPI) and the Halstead-Reitan Neuropsychological Test Battery (HRNTB). Applying factor analysis to the MMPI clinical and validity scales, we derived four dimensions accounting for 78% of the available variance. We found that Factor 1, which loaded on most clinical scales of the MMPI, was significantly correlated (p <.01) with performance on the Halstead Category Test (HCT), a measure of executive functioning. Further, group analysis with MANOVA using HCT (impaired and nonimpaired) as the independent variable revealed a significant main effect for Factor 1 (p <.004), which was maintained and strengthened when age and education were controlled as covariates (p <.001). The results suggest a relationship between emotional distress and executive functioning as measured by the HCT, reflecting differing facets of frontal lobe dysfunction common to cognitive and affective domains in patients with severe chronic alcoholism.

Perspectives on rehabilitation of individuals with cognitive impairment after brain injury: rationale for reconsideration of theoretical paradigms

BACKGROUND

The frequency of cognitive impairment associated with traumatic brain injury (TBI) has led to the widespread use of cognitive rehabilitation as a discrete rehabilitative service. This service has become controversial in part because of disagreements regarding its theoretical base and implementation procedures, and in part because of insufficient experimental support.

OBJECTIVE

We outline two paradigms for cognitive rehabilitation that are interestingly different, both theoretically and procedurally. These paradigms are defined in relation to the goals of intervention, orientation to assessment, modalities of treatment, organization of treatment, and logistics of service delivery (setting, content, and provider). A rationale for each paradigm is described.

CONCLUSION

We conclude with a call for (a) additional research into the effectiveness of interventions for individuals with cognitive impairment after TBI and (b) clinicians' thoughtful reflection on the foundations of their service.

Ethical considerations for peer review in forensic neuropsychology

The role of an expert is to assist the trier of fact in weighing evidence and reaching conclusions. Critical evaluation of opposing experts is an integral part of this process. In more recent times, cross-examination has given way to critical evaluation of opposing experts outside of the courtroom, a tactic we refer to as peer review in this paper. Though neuropsychologists frequently review the work of their colleagues, we are concerned here primarily with commentary that is at best misleading, and occasionally malicious, unethical, and unprofessional. Despite a growing trend to use experts as peer reviewers in the medicolegal arena, expectations concerning ethical and professional conduct of neuropsychologists have been absent. Enforcement of appropriate conduct is further complicated by the ambiguity of existing ethical standards and state statutes, and their limited applicability to all neuropsychologists who provide forensic services. This article provides an overview of ethical and professional issues pertaining to forensic peer review and concludes with recommendations for appropriate professional conduct.

Promoting ethical and objective practice in the medicolegal arena of disability evaluation

As providers of medical information and testimony, clinicians have ultimate responsibility for ethical conduct as it relates to this information. The authors offer the following recommendations for enhancing ethical relationships between expert clinicians and the courts. 1. Avoid or resist attorney efforts at enticement into joining the attorney-client team. Such compromises of scientific boundaries and ethical principles exist on a continuum ranging from standard attorney-client advocacy at the beginning of the expert consultation phase (e.g., promotional information at the forefront of retaining an expert, with either provision of selective or incomplete records or less than enthusiastic efforts to produce all records) and extending to completion of evaluation, when requests for changes in reports and documentation might be made. 2. Respect role boundaries and do not mix conflicting roles. Remember that the treating doctor possesses a bond with the patient but does not as a rule obtain complete preinjury and postinjury information in the context of assessing causality and apportionment. In contrast, the expert witness must conduct a thorough and multifaceted case analysis sans the physician-patient relationship in order to facilitate objectivity and allow optimum diagnostic formulations. Finally, the trial consultant's function in this adversarial process is to assist with critically scrutinizing and attacking positions of experts for the opposing side. These roles all represent inherently different interests, and mixing them can only reduce objectivity. 3. Insist on adequate time for thorough record review, evaluation, and report generation. Also insist on sufficient time and preparation for deposition and court appearances. 4. Work at building a reputation for general objectivity, reliance on multiple data sources, reaching opinions only after reviewing complete information from both sides, and completing the evaluation. 5. Spend a good amount of time actually treating the patient population being examined or being offered testimony about. This treatment should be current and should be of a similar frequency to treating practitioner specialists. Be able to discuss relevant research and scientific methodology issues competently and without notes. 6. Arrive at opinions only after reviewing all of the evidence from both sides of the adversarial fence, employing multiple data sources, completing the evaluation, and interpreting data within the full context of comprehensive historical, behavioral observation, and contextual information. Being otherwise favorable to retaining attorney interests suggests endorsement of "opinion prostitute," "scientific perjurer," or "hired gun" status. The only way a practitioner can reduce the likelihood of facing an "opinion prostitute" on the opposing side in future cases is to insist on establishing and maintaining a reputation for scientific objectivity. 7. Balance cases from plaintiff and defense attorneys. Predilection for one side or the other suggests bias and sets up predisposition to nonobjectivity. For example, a preponderance of plaintiff work suggests an overdiagnosis or uncritical sympathy bias, whereas a ratio that favors hiring by the defense suggests an underdiagnosis or skepticism bias. Perhaps Brodsky's suggested cut-off ratio of .8 for favorability findings would represent an initial cutoff for defense versus plaintiff ratio. That is, experts should do at least 20% work for the opposite side of the current case being represented. Further, it might be a reasonable expectation that data on these ratios be collected as an important method for ensuring objective opinions. 8. Ensure against excessive favorability to the side of the retaining attorney or firm. Objectivity demands that scientific opinions not be influenced by the position of the legal advocate. Importantly, Brodsky recommends using a ratio of .8 as a cut-off for detecting excessive bias. That is, practitioners should possess prerequisite objectivity to disagree with the referring attorney at least 20% of the time. We suggest that a more useful cut-off would be .75, where experts are expected to generate findings that do not support the referring attorney's position at least 25% of the time. 9. Never arrive at opinions that are inconsistent with plaintiff records, examination data, test data, behavioral presentation, and so forth, especially when such opinions are favorable to the side of the retaining attorney firm. Instead, use the following recommendations. (ABSTRACT TRUNCATED)

Advance directives: making them more available to hospitals patients

This article details methods developed to facilitate patients' understanding and execution of an advance directive (e.g., living will, treatment preferences, and durable power of attorney for healthcare). The approach takes advantage of the computerization of patient records, using automatically generated e-mail messages sent to an advance directives consultation team.

Decreased striatal monoaminergic terminals in severe chronic alcoholism demonstrated with (+)[11C]dihydrotetrabenazine and positron emission tomography

We used (+)[11C]dihydrotetrabenazine, a new ligand for the type 2 vesicular monoamine transporter, with positron emission tomography to study striatal monoaminergic presynaptic terminals in 7 male severe chronic alcoholic subjects without Wernicke-Korsakoff disease compared with 7 male normal controls of similar ages. We found reduced specific binding in the caudate nucleus and putamen in the alcoholic group, and the difference reached significance in the putamen. Specific binding was not decreased in the thalamus, which was examined as a reference structure. We also detected deficits in blood-to-brain transfer rate, K1, in the same regions of the alcoholic group, with a significant difference in the putamen. K1 was unchanged in the thalamus. The finding of reduced striatal VMAT2 in severe chronic alcoholic patients suggests that nigrostriatal monoaminergic terminals are reduced, with or without loss of neurons from the substantia nigra. The findings suggest that the damaging effects of severe chronic alcoholism on the central nervous system are more extensive than previously considered.

The significance of family history status in relation to neuropsychological test performance and cerebral glucose metabolism studied with positron emission tomography in older alcoholic patients

Patients with severe chronic alcoholism have decreased rates of glucose metabolism in the medial frontal lobe and correlated abnormalities of neuropsychological functioning. The potential influence of family history of alcoholism has not been examined in these patients. In a retrospective study, we used neuropsychological tests and neuroimaging employing [18F]fluorodeoxyglucose with positron emission tomography to study 48 older subjects who had histories of severe, chronic alcohol dependence. These patients were divided into two groups: 27 with a first-degree relative with chronic alcoholism and 21 patients without first-degree relative with chronic alcoholism. No differences were found between groups on either neuropsychological or neuroimaging tests. These results suggest that a family history of alcoholism does not moderate the damaging effects of severe chronic alcoholism on the functioning of the medial frontal lobe.

Effects of abstinence and relapse upon neuropsychological function and cerebral glucose metabolism in severe chronic alcoholism

Prolonged excessive consumption of alcohol has been associated with a variety of cognitive disorders accompanied by neuropathological and neurochemical abnormalities of the brain, particularly in the frontal lobes. Studies with positron emission tomography (PET) have shown decreased local cerebral metabolic rates for glucose (lCMRglc) in frontal regions, with correlated abnormalities on neuropsychological tests sensitive to executive functioning. This investigation was designed as a pilot study to examine the effects of abstinence and relapse in patients with severe chronic alcoholism studied longitudinally with PET and with neuropsychological evaluation to assess both general and executive functioning. Six patients, including 4 who remained relatively abstinent and 2 who relapsed following their initial evaluation, were studied twice, with inter-evaluation intervals ranging from 10 to 32 months. The patients who remained abstinent or who had minimal alcohol use showed partial recovery of lCMRglc in two of three divisions of the frontal lobes and improvement on neuropsychological tests of general cognitive and executive functioning, whereas the patients who relapsed had further declines in these areas. These results, although based upon a relatively small number of subjects, provide preliminary support for at least partial recovery of metabolic and cognitive functioning in individual patients who abstain from alcohol.

Impaired upper limb coordination in alcoholic cerebellar degeneration

BACKGROUND

Alcoholic cerebellar degeneration (ACD) is a disorder resulting from severe chronic alcoholism and malnutrition and is characterized by cognitive disturbances, ataxia of gait, and truncal instability, with generally preserved coordination of the upper extremities.

OBJECTIVES

To determine whether cognitive deficits in patients with ACD are the same as those seen in patients with severe chronic alcoholism without ACD and to determine whether upper limb motor coordination is different in the 2 groups.

DESIGN

We examined cognitive function and upper limb coordination in 56 patients with severe chronic alcoholism, 13 with ACD and 43 without ACD, who had comparable levels of total alcohol intake. Neuropsychological and motor function was measured using an expanded Halstead-Reitan Neuropsychological Test Battery, including the Tactual Performance Test and Grooved Pegboard Test.

RESULTS

Neither group had impaired coordination of upper limb function on clinical neurological examination. Both groups had impaired performance on neuropsychological tests involving executive function, but the patients with ACD had greater impairment of upper limb coordination than the patients without ACD as measured by the Tactual Performance Test and Grooved Pegboard Test.

CONCLUSIONS

The findings suggest that these 2 groups have similar cognitive deficits but that upper extremity motor functions are more significantly impaired in the ACD group and that quantitative tasks of motor function reveal these impairments.