Two concurrent appendiceal neoplasms in an elderly patient: A case report.

INTRODUCTION: Acute appendicitis, one of the commonest surgical diagnoses, is rare and more complex presentation in the elderly. Physicians must consider atypical causes appendicitis in this population, which could affect the management of the patient. PRESENTATION OF CASE: An elderly female presented with a two-day history of lower abdominal pain, associated with low-grade fevers and chills. Studies showed leukocytosis and computed tomography (CT) findings consistent with appendicitis. She underwent laparoscopic appendectomy. Intra-operatively, the Appendix had an unusual appearance, so a frozen-section was obtained, suggestive of a mucinous neoplasm with grossly clear margins. Despite the possibility that she may require a more extensive cancer operation pending the final Pathology results, the decision was made to complete the operation at this stage, and return at a later date if needed, after completing the patient's work-up with a colonoscopy to rule out any synchronous colonic lesions that could alter her surgical management. Final Pathology revealed both a low-grade appendiceal mucinous neoplasm, as well as a tip carcinoid tumor, both of which were adequately treated with appendectomy alone. DISCUSSION: Physicians treating elderly patients with appendicitis should suspect an atypical etiology, such as appendiceal cancer. Early identification and appropriate pre-operative counseling may alter the surgical management. CONCLUSION: The role and timing of right hemicolectomy in treating appendiceal cancers remain controversial, and should be evaluated on a case by case basis.

The relationship between self-reported sleep disturbance and polysomnography in individuals with traumatic brain injury.

PRIMARY OBJECTIVE: To characterize sleep architecture and self-reported sleep quality, fatigue and daytime sleepiness in individuals with TBI. Possible relationships between sleep architecture and self-reported sleep quality, fatigue and daytime sleepiness were examined. METHODS: Forty-four community-dwelling adults with TBI completed the Pittsburgh Sleep Quality Index (PSQI), Multidimensional Assessment of Fatigue (MAF) and Epworth Sleepiness Scale (ESS). They underwent two nights of in-laboratory nocturnal polysomnography (NPSG). Pearson product-moment correlation coefficients and hierarchical linear regression was used to analyse the data. RESULTS: Based on the PSQI cut-off score of ≥ 10, 22 participants were characterized as poor sleepers. Twenty-seven participants met criteria for clinically significant fatigue as measured by the GFI of the MAF. Fourteen participants met criteria for excessive daytime sleepiness as measured by the ESS. Poor sleep quality was associated with poor sleep efficiency, short duration of stage 2 sleep and long duration of rapid eye movement sleep. There was little-to-no association between high levels of fatigue or daytime sleepiness with NPSG sleep parameters. CONCLUSIONS: A high proportion of the sample endorsed poor sleep quality, fatigue and daytime sleepiness. Those who reported poorer sleep quality evidenced a shorter proportion of time spent in stage 2 sleep. These findings suggest that disruptions in stage 2 sleep might underlie the symptoms of sleep disturbance experienced following TBI.

Long-term social integration and community support.

TBI often results in reduced social participation. This decrease in social participation is independent of injury severity and time since injury. Thus, it is one of the many stable hallmarks of TBI. Changes in social participation have been related to many factors, including emotional dysregulation and disturbance and executive dysfunction. While there are evidenced-based treatments available to improve mood and executive functioning, none of the research has examined the impact of the various treatments on social participation or social integration. Therefore, while it is reasonable to expect that individuals who are feeling better about themselves and who improve their approach to day-to-day function will also experience increased social contact, there is no evidence to support this claim. This chapter reviews the literature on post-TBI social integration and its relationship to depression and executive dysfunction. In addition the intervention research in this area is briefly examined.

Comparison of cognitive behavioral therapy and supportive psychotherapy for the treatment of depression following traumatic brain injury: a randomized controlled trial.

OBJECTIVE: To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression. PARTICIPANTS: A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy. MEASURES: Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment. RESULTS: No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups. CONCLUSIONS: Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835.

Systematic review of interventions for fatigue after traumatic brain injury: a NIDRR traumatic brain injury model systems study.

OBJECTIVE: To conduct a systematic review of the evidence on interventions for posttraumatic brain injury fatigue (PTBIF). METHODS: Systematic searches of multiple databases for peer-reviewed studies published in English on interventions targeting PTBIF as a primary or secondary outcome through January 22, 2014. Reference sections were also reviewed to identify additional articles. Articles were rated using the 2011 American Academy of Neurology Classification of Evidence Scheme for therapeutic studies. RESULTS: The searches yielded 1526 articles. Nineteen articles met all inclusion criteria: 4 class I, 1 class II/III, 10 class III, and 4 class IV. Only 5 articles examined fatigue as a primary outcome. Interventions were pharmacological and psychological or involved physical activity, bright blue light, electroencephalographic biofeedback, or electrical stimulation. Only 2 interventions (modafinil and cognitive behavioral therapy with fatigue management) were evaluated in more than 1 study. CONCLUSIONS: Despite areas of promise, there is insufficient evidence to recommend or contraindicate any treatments of PTBIF. Modafinil is not likely to be effective for PTBIF. Piracetam may reduce it, as may bright blue light. Cognitive behavioral therapy deserves additional study. High-quality research incorporating appropriate definition and measurement of fatigue is required to explore the potential benefits of promising interventions, evaluate fatigue treatments shown to be effective in other populations, and develop new interventions for PTBIF.

Screening for traumatic brain injury: findings and public health implications.

OBJECTIVE: To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI). SETTING: Diverse community settings. PARTICIPANTS: Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396). DESIGN: Cross-sectional. MAIN MEASURE: Brain Injury Screening Questionnaire. RESULTS: Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms. CONCLUSION: Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

The factor structure of the Pittsburgh Sleep Quality Index in persons with traumatic brain injury. A NIDRR TBI model systems module study.

BACKGROUND: Sleep disturbances are common following traumatic brain injury (TBI). The Pittsburgh Sleep Quality Index (PSQI) is a widely used measure of sleep quality that has been used in numerous populations. Although this measure has been used in TBI research, there are few studies examining the psychometric properties in this population. OBJECTIVE: The current study examined the factor structure of the PSQI in a sample of persons with TBI and tested the one, two, and three factor models derived from previous studies in other populations. METHODS: A telephone interview was conducted with 243 individuals who had sustained a TBI. All participants were approximately one year post-injury. Factor analyses were conducted (exploratory and confirmatory) to examine the factor structure of the PSQI. RESULTS: Results confirm the fit of models previously tested in the literature but also reveal an alternative conceptualization of sleep containing both qualitative and quantitative factors. CONCLUSIONS: While the 3-factor model best fits the data in this TBI sample, the use of a 2-factor model is acceptable and may be more clinically relevant due to the grouping of time-related variables that could provide important information with regard to circadian rhythm disorders.

Variability of respiration and sleep during polysomnography in individuals with TBI.

BACKGROUND: Obstructive sleep apnea (OSA) is commonly found in individuals with traumatic brain injury (TBI) and may exacerbate TBI-related symptoms. Nocturnal polysomnography (NPSG) is considered the gold standard for detecting the presence of sleep apnea. However, there is a limitation with its use known as the "first-night effect" (aberrant polysomnography findings on the first night in a sleep lab). OBJECTIVE: The primary objectives were to investigate the night-to-night consistency of diagnosing and classifying obstructive sleep apnea in individuals with TBI, and ascertain if individuals with TBI are prone to a first-night effect. METHODS: 47 community-dwelling adults with self-reported mild-to-severe TBI underwent two nights of in-laboratory NPSG to examine variability between the first and second night with regards to OSA diagnosis and severity as well as sleep architecture. RESULTS: OSA detection and severity were consistent from night-to-night in 89% of participants with TBI. Participants with TBI demonstrated longer REM latency on the first night compared to the second night of sleep study. CONCLUSIONS: These findings indicate that two nights of in-laboratory NPSG are generally consistent in reliably diagnosing OSA in individuals with TBI and that first-night effects are minimal. One night of NPSG has diagnostic utility in the evaluation of sleep disorders in individuals with TBI.

Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization.

OBJECTIVE: To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI). DESIGN: Randomized, waitlist controlled trial with minimization and blinded outcome assessment. SETTING: Community. PARTICIPANTS: Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white). INTERVENTION: STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training. MAIN OUTCOME MEASURES: Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life. RESULTS: Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life. CONCLUSIONS: The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations.

Predictors of follow-up completeness in longitudinal research on traumatic brain injury: findings from the National Institute on Disability and Rehabilitation Research traumatic brain injury model systems program.

OBJECTIVE: To identify baseline participant variables in the domains of demographics, medical/psychosocial history, injury characteristics, and postinjury functional status associated with longitudinal follow-up completeness in persons with traumatic brain injury (TBI) using the TBI Model Systems (TBIMS) National Database (NDB). DESIGN: Exhaustive chi-square automatic interaction detection was used to identify factors that classified participants according to level of follow-up completeness. SETTING: Retrospective analysis of a multi-center longitudinal database. PARTICIPANTS: Individuals (N=8249) enrolled in the TBIMS NDB between 1989 and 2009 who were eligible for at least the first (year 1) follow-up up to the fifth (year 15) follow-up. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Follow-up completeness as defined by 6 different longitudinal response patterns (LRPs): completing all follow-ups, wave nonresponse, dropping out, completing no follow-ups without formally withdrawing, formally withdrawing before completing any follow-ups, and formally withdrawing after completing some follow-ups. RESULTS: Completing all follow-ups was associated with higher levels of education, living with parents or others, and having acute care payer data entered in the NDB. Subgroups more vulnerable to loss to follow-up (LTFU) included those with less education, racial/ethnic minority backgrounds, those with better motor functioning on rehabilitation discharge, and those for whom baseline data on education, employment, and acute care payer were not collected. No subgroups were found to be more likely to have the LRPs of dropping out or formal withdrawal. CONCLUSIONS: These data identify subgroups in which retention strategies beyond those most commonly used might reduce LTFU in longitudinal studies of persons with TBI, such as the TBIMS, and suggest future investigations into factors associated with missing baseline data.

Sexual functioning and the effect of fatigue in traumatic brain injury.

OBJECTIVES: The primary objective was to examine specific aspects of sexual functioning (frequency, desired frequency, importance, and satisfaction) and their relationship to fatigue in individuals with traumatic brain injury (TBI) compared with those without brain injury. The relationship of demographic variables, emotional well-being, and health-related quality of life to sexual functioning was also explored. PARTICIPANTS: 200 community-dwelling adults with self-reported mild-to-severe TBI and 83 individuals without brain injury. MEASURES: Participation Objective, Participation Subjective, Fatigue Assessment Instrument, Global Fatigue Index, Beck Depression Inventory, and SF-36 Health Survey. METHODS: Data were collected through administration of self-report measures and interviews as part of a larger study of post-TBI fatigue. RESULTS: Several aspects of sexual activity (frequency, desired frequency, and importance) were closely related to specific features of fatigue among individuals with TBI. Women with TBI reported lower frequency and lower importance of sex than men. In individuals without brain injury, the impact of fatigue was limited to the frequency of sexual activity with no sex differences observed. CONCLUSIONS: Fatigue plays a different role in the subjective experience of sexual activity for men and women with TBI than for those without brain injuries. Fatigue and sex should be taken into account in future research and interventions focused on sexual function after TBI.

Metastatic cholangiocarcinoma to the ovary: a case series.

Metastases to the ovary can be a challenging diagnostic dilemma as they often present similarly to a primary ovarian cancer, and there are many potential sites of origin. We present a case series of 5 patients with known cholangiocarcinoma recurrent in the ovary after completion of initial multimodality therapy including surgical resection of the primary tumor followed by adjuvant chemotherapy.

What is post TBI fatigue?

BACKGROUND: Fatigue is among the most common sequelae of traumatic brain injury (TBI). OBJECTIVES: To summarize the empirical and theoretical literature on Post TBI fatigue (PTBIF) and identify some of the challenges that continue to confront clinicians, researchers and individuals with TBI. METHODS: Qualitative literature review. The epidemiology, characteristics, and correlates of PTBIF are described. Challenges in the operational definition and measurement of fatigue are discussed and the empirical literature on measurement of PTBIF and theoretical models of the potential etiology of PTBIF is summarized. Existing treatments of PTBIF and the research supporting them are reviewed. Future directions for clinical research are presented. RESULTS: Although PTBIF is a high incidence condition after TBI that is related to significant suffering and reduced quality of life, it remains inadequately measured and treated. Its etiology and precipitants are poorly understood and intervention research is inadequate. CONCLUSION: Further research is necessary to develop psychometrically-sound objective and subjective measures of PTBIF and examine the efficacy of treatments for fatigue. Interventions shown to improve fatigue in other populations should be considered in treating PTBIF.

Mortality of elderly individuals with TBI in the first 5 years following injury.

INTRODUCTION: Although there has been a decline in the incidence of TBI in the general population, the rate of TBI in older adults has increased. Increased age has been long recognized as a predictor of worse outcomes after TBI. Despite the growing number of TBI in the elderly, our understanding of the long-term consequences of TBI is quite limited. METHODS: Chart review; individuals 55 years and older, who completed inpatient acute rehabilitation during the period 2003-2009 and who died one to four years after injury, were compared to matched patients who did not die. RESULTS: There were a significantly higher proportion of deceased subjects with a diagnosis of Abnormality of Gait (53%), respiratory medications at admission (32%) and discharge (17%). Deceased participants were more likely to be prescribed diabetes medication at discharge (35%) while controls were more likely to be prescribed cholesterol-lowering medications (27%) at admission. Deceased patients were discharged with significantly more medications, CONCLUSIONS: The results suggest the need for medical and lifestyle interventions for selected elderly TBI patients. The factors related to death following TBI in the elderly are in need of more research.

Cognitive problems in patients on androgen deprivation therapy: a qualitative pilot study.

OBJECTIVES: Androgen deprivation therapy (ADT; also known as hormone therapy) is a well-established treatment for prostate cancer patients with rising prostate-specific antigen levels after localized treatment, and for those with metastatic disease. The neurological impact of ADT has been likened to that of aging and is therefore theorized to impair cognitive functioning in prostate cancer patients. We briefly summarize the research that has examined cognitive functioning of ADT patients primarily through neuropsychological assessment. A qualitative pilot study is presented with the aim of describing ADT patients' experiences of cognitive changes since starting ADT. MATERIALS AND METHODS: Semistructured telephone interviews were undertaken with 11 community-dwelling prostate cancer patients undergoing ADT following definitive localized treatment. Participants were recruited via online prostate cancer support forums. Content analyses were conducted to establish relevant themes, which in this case were the cognitive domains of impairment. RESULTS: Eight of the 11 participants reported impairments in the domains of concentration, information processing, verbal fluency, visual information processing/visuospatial function, memory, and executive dysfunction. Neurobehavioral problems, including neurofatigue and apathy were also reported. CONCLUSIONS: The interviews illustrate the potential negative effects of ADT on cognitive and neurobehavioral functions, and their impact on patients' work and in their daily lives. We describe how the field of cognitive rehabilitation offers promising tools to assist ADT patients with cognitive problems.

An evidence-based review of cognitive rehabilitation in medical conditions affecting cognitive function.

OBJECTIVES: To perform a methodical review of the evidence available for the efficacy of cognitive rehabilitation in individuals with diagnosed medical conditions known to affect cognitive function, and to establish evidence-based recommendations for clinical practice, as appropriate. DATA SOURCES: Ovid Medline and PubMed literature searches were conducted using the terms cognition, cognitive, crossed with the terms rehabilitation, remediation, retraining, training, crossed with 11 medical diagnostic categories. Articles through December 2008 were accessed, with a resulting 2284 abstracts. STUDY SELECTION: A total of 211 articles were selected from initial abstract review. These articles were then assessed by committee members, with agreement of at least 2 members, using 9 exclusion and 3 inclusion criteria. A total of 34 remaining articles were submitted to full review. DATA EXTRACTION: Articles were reviewed under diagnostic categories using specific criteria recorded on structured data sheets. Classification was performed according to guidelines of the American Academy of Neurology, with agreement between 2 committee members necessary for final decisions. DATA SYNTHESIS: Of the 34 studies fully evaluated, 1 was rated as class I, 6 as class II, 2 as class III, and 25 as class IV. Evidence within each diagnostic area was synthesized for the formulation of Practice Standards, Practice Guidelines, and Practice Options, as possible. CONCLUSIONS: Two clinical practice recommendations were advanced, 1 each in the diagnostic areas of brain neoplasms and epilepsy/seizure disorders. Discussion included comments on the research status of the effectiveness of cognitive rehabilitation for cognitive deficits related to these medical conditions, as well as suggestions for future directions in research.

Insomnia, fatigue, and sleepiness in the first 2 years after traumatic brain injury: an NIDRR TBI model system module study.

OBJECTIVE: To determine the prevalence of insomnia and posttraumatic brain injury (TBI) fatigue (PTBIF) in individuals with moderate to severe TBI, to explore the relationship between PTBIF and insomnia and their association with outcomes. DESIGN: Cross-sectional study. SETTING: Five National Institute of Disability and Rehabilitation Research TBI Model Systems. PARTICIPANTS: Three hundred thirty-four individuals with TBI who completed 1-year (n = 213) or 2-year (n = 121) follow-up interviews between 2008 and 2012. MAIN OUTCOME RESULTS: Insomnia occurred in 11% to 24% and PTBIF in 33% to 44% of the individuals. Insomnia and fatigue were both related to sleep disturbance, sleep hygiene, satisfaction with life, anxiety, and depression. PTBIF was associated with greater disability and sleepiness. Insomnia without fatigue was rare (2%-3%) but PTBIF without insomnia occurred in 21% to 23% of the individuals. Comorbidity occurred in 9% to 22% of the individuals. CONCLUSIONS: Although PTBIF and insomnia are closely related and both associated with poorer quality of life, they are affected independently by a variety of factors, especially psychopathology and sleep quality. A majority of individuals with PTBIF do not have insomnia; and PTBIF appears to be related to disability severity and daytime sleepiness, where insomnia is not. Demographic and injury variables are not strong predictors of insomnia or PTBIF.

Psychometric properties of the Multidimensional Assessment of Fatigue scale in traumatic brain injury: an NIDRR Traumatic Brain Injury Model Systems study.

OBJECTIVE: To investigate the psychometric properties of the Multidimensional Assessment of Fatigue (MAF) scale in a traumatic brain injury (TBI) sample. DESIGN: Prospective survey study. SETTING: Community. PARTICIPANTS: One hundred sixty-seven individuals with TBI admitted for inpatient rehabilitation, enrolled into the TBI Model Systems national database, and followed up at either the first or second year postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Multidimensional Assessment of Fatigue. RESULTS: The initial analysis, using items 1 to 14, which are based on a 10-point rating scale, found that only 1 item ("walking") misfit the overall construct of fatigue in this TBI population. However, this 10-point rating scale was found to have disordered thresholds. When ratings were collapsed into 4 response categories, all MAF items used to calculate the Global Fatigue Index formed a unidimensional scale. CONCLUSION(S): Findings generally support the unidimensionality of the MAF when used in a TBI population but call into question the use of a 10-point rating scale for items 1 to 14. Further study is needed to investigate the use of a 4-category rating scale across all items and the fit of the "walking" item for a measure of fatigue among individuals with TBI.

Feasibility of computerized brain plasticity-based cognitive training after traumatic brain injury.

The present study investigates the feasibility and utility of using a computerized brain plasticity-based cognitive training (BPCT) program as an intervention for community-dwelling individuals with traumatic brain injury (TBI). In a pre-post pilot study, 10 individuals with mild to severe TBI who were 6 mo to 22 yr postinjury were asked to use a computerized BPCT intervention-designed to improve cognitive functioning through a graduated series of structured exercises-at their homes in an urban community. Outcome measures included objective neuropsychological and self-report measures of cognitive functioning. All participants were able to use the software in their homes. Some mild fatigue was reported, which tended to dissipate over time. Few technical difficulties were reported. Remote support was sufficient for what technical assistance was needed. Participants reported subjective improvement in cognitive functioning, and small to large effect sizes on self-report and neuropsychological measures are reported. We conclude that BPCT may be a viable intervention for TBI outpatients as an adjunct to comprehensive neurorehabilitation. The intervention can be delivered in patients' homes with support provided remotely. Results of this study demonstrate the potential for treatment-related improvements many years after injury. Further study in controlled trials is warranted.