Completion of Multidisciplinary Treatment for Persistent Postconcussive Symptoms Is Associated With Reduced Symptom Burden.

OBJECTIVE: To investigate the pre- to posttreatment changes in both posttraumatic stress disorder (PTSD) and persistent postconcussive symptoms (PPCSs). SETTING AND PARTICIPANTS: We studied 257 active-duty patients with a history of mild traumatic brain injury (mTBI) who completed multidisciplinary outpatient treatment at Brooke Army Medical Center TBI Clinic from 2008 to 2013. This treatment program included cognitive rehabilitation; vestibular interventions; headache management; and integrated behavioral healthcare to address co-occurring psychiatric conditions such as PTSD, depression, and sleep disturbance. DESIGN: A 1-group; preexperimental, pre- to posttreatment study. MAIN MEASURES: The Neurobehavioral Symptom Inventory (NSI) was used to assess PPCSs, and the PTSD Checklist-Military Version (PCL-M) was used to asses PTSD symptoms. RESULTS: Global PPCS resolution (mean NSI: 35.0 pre vs 23.8 post; P < .0001; d = 0.72) and PTSD symptom resolution (mean PCL-M: 43.2 pre vs 37.7 post; P < .0001; d = 0.34) were statistically significant. Compared with those with only mTBI, patients with mTBI and PTSD reported greater global PPCS impairment both pretreatment (mean NSI: 48.7 vs 27.9; P < .0001) and posttreatment (mean NSI: 36.2 vs 17.4; P < .0001). After adjusting for pretreatment NSI scores, patients with comorbid PTSD reported poorer PPCS resolution than those with mTBI alone (mean NSI: 27.9 pre vs 21.7 post; P = .0009). CONCLUSION: We found a reduction in both self-reported PPCSs and PTSD symptoms; however, future studies are needed to identify specific components of care associated with symptom reduction.

Trends in hip fracture-related mortality in Texas, 1990-2007.

BACKGROUND: There are limited data about trends in hip fracture-related mortality. In this study, we examined temporal trends in hip fracture mortality rates among persons aged 50 years or older in Texas between 1990 and 2007. MATERIALS AND METHODS: Hip fracture-related mortality was defined as a death on the multiple cause of death record for which hip fracture was listed as a contributing cause. Population estimates for Texas were used as the denominator to calculate mortality rates per 100,000 persons. The joinpoint regression analysis was used to identify points where a statistically significant change occurred in the linear slope of the rates. RESULTS: A total of 14,350 death certificates listed hip fracture as a contributing cause of death. Hip fracture rates decreased predominantly among men by 0.8% (95% CI, -1.5 to -0.1) per year. Conversely, age-adjusted rates among women increased by 0.3% (95% CI, -0.4 to 1.0) per year. By race/ethnicity, hip fracture mortality rates increased annually 2.2% (95% CI, -0.1 to 4.4) among blacks, whereas the rates among whites and Hispanics remained steady. Moreover, the proportion of death records that listed nursing homes and residence as a place of death increased by 2.2% (95% CI, 1.6 to 2.9) and 8.7% (95% CI, 6.3 to 11.0) per year, respectively. CONCLUSION: Hip fracture mortality rates decreased predominantly among men in Texas during the study period. Increasing hip fracture mortality rates among blacks and nursing home residents merit further research.

Evaluating health-related quality-of-life studies in paediatric populations: some conceptual, methodological and developmental considerations and recent applications.

Although numerous paediatric-based health-related quality-of-life (HR-QOL) instruments are currently in use, there still remain conceptual, methodological and developmental issues to address. This paper provides an up-to-date critical review of the HR-QOL literature in paediatric medicine. Our analysis indicates that there is no consensus on how HR-QOL and overall QOL should be defined and measured in children. It is recommended that future studies focus on operationalising and distinguishing these constructs from each other and from traditional health-status measures. A clear empirical basis for generating instrument items and for prioritising specific domains must be described. Researchers should consider using the data gathered during their first interviews as a springboard from which to test their ideas of HR-QOL and QOL, reformulate concepts and subsequently retest their notions before developing instruments. Related to methodological challenges, consistency and agreement are still used interchangeably when comparing child and parent reports of children's HR-QOL. The Pearson correlation is a measure of co-variation in scores, and not a measure of agreement. We recommend that researchers focus on determining agreement as opposed to consistency. Few, if any, attempts have been made to account for the possibility that a response shift may have occurred in the evaluation of HR-QOL. Most studies have compared HR-QOL scores of children with illness with their healthy peers. As such, there is a dearth of knowledge regarding the normative process of adaptation within the context of illness. It is recommended that researchers focus on gathering data using a relative standard of comparison. We further recommend that researchers interpret HR-QOL data in line with their intended purpose. Regarding developmental consideration, particular attention ought to be paid to developing instruments that consider children's emerging sense of self, cognitive capacity and emotional awareness. Instruments that include items that are age appropriate are more likely to maximise reliability and validity of reports. The results of many HR-QOL instruments are applied in pharmacotherapeutic and pharmacoeconomic assessments. However, there has been relative infrequent application of economically valid HR-QOL tools (utility scales) and the use of HR-QOL scales as outcome measures in paediatric drug trials. As such, few cost-utility analyses have been performed to inform paediatric decision making. In addition, many of the concerns in the development of HR-QOL instruments should also be applied to the utility scales such that they reflect adequately children's preferences for health states.

Infliximab treatment of rheumatoid arthritis and Crohn's disease.

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, safety, and pharmacoeconomic impact of infliximab in the treatment of Crohn's disease (CD) and rheumatoid arthritis (RA). DATA SOURCES: MEDLINE and Pre-MEDLINE (1966-June 2002) and manufacturer prescribing literature were employed to find English-language articles on infliximab. Additional studies and abstracts were identified from the bibliographies of reviewed literature and conference proceedings. STUDY SELECTION/DATA EXTRACTION: All articles identified from data sources were evaluated, and all information deemed relevant was included in this review. Information regarding basic pharmacology was collected from studies in animals. Pharmacokinetic data were collected from human trials. Safety data were extracted from clinical trials and postmarketing surveillance. Priority was given to randomized, double-blind, placebo-controlled studies for the assessment of efficacy. All available economic evaluations were included. DATA SYNTHESIS: Infliximab is a new monoclonal antibody that appears to work by a unique mechanism: inhibiting the action of tumor necrosis factor-alpha (TNF-alpha). Infliximab is administered by intravenous infusion. In clinical trials in CD, infliximab significantly decreased the CD activity index compared with placebo in treatment-resistant disease and significantly reduced the number of draining fistulas in fistulizing disease. In RA, when infliximab was added to methotrexate (MTX), it resulted in a significant improvement in most disease outcome measures when compared with MTX plus placebo. Few major adverse effects were reported in the clinical trials; however, serious adverse events, including malignancy and demyelination, have been reported in postmarketing surveillance. Also, increased susceptibility to infections (including tuberculosis) has been reported. CONCLUSIONS: Infliximab is an effective new agent for the treatment of CD and RA. Its apparent unique mechanism of action makes infliximab an important addition to therapy. Caution should be exercised when considering infliximab for individuals who have chronic or recurrent infections, mild congestive heart failure (New York Heart Association [NYHA] class I/II), nervous system disorders, or live or have lived in an area endemic for histoplasmosis. Infliximab is contraindicated for patients with a clinically important, active infection, moderate to severe congestive heart failure (NYHA class III/IV), or an allergy to mouse proteins or any of the ingredients in infliximab. Further long-term efficacy, safety, and economic data on infliximab are required. Also, for the treatment of RA, the burden of administering infliximab (as a 2-hour supervised infusion) has to be considered when choosing among anti-TNF-alpha medication (as the other 2 approved agents, etanercept and adalimumab, can be self-administered by subcutaneous injection).