Adopting and adapting clinical practice guidelines for timing of decompressive surgery in acute spinal cord injury from a developed world context to a developing region.

PURPOSE: The proper application of high-quality clinical practice guidelines improves trauma patients' care and outcomes. This study aimed to adopt and adapt guidelines on the timing of decompressive surgery in acute spinal cord injury (SCI) in Iranian clinical settings. METHODS: This study followed a systematic search and review of the literature to enter them into the selection process. The source guidelines' clinical suggestions were converted into clinical scenarios for clinical questions on the timing of decompressive surgery. After summarizing the scenarios, we prepared an initial list of recommendations based on the status of the Iranian patients and the health system. The ultimate conclusion was reached with the help of a national interdisciplinary expert panel comprising 20 experts throughout the country. RESULTS: A total of 408 records were identified. After title and abstract screening, 401 records were excluded, and the full texts of the remaining seven records were reviewed. Based on our screening process, only one guideline included recommendations on the topic of interest. All of the recommendations were accepted by the expert panel with slight changes due to resource availability in Iran. The final two recommendations were the consideration of early surgery (≤24 h) as a treatment option in adult patients with traumatic central cord syndrome and in adult patients with acute SCI regardless of the level of injury. CONCLUSION: Considering early surgery for adult patients with acute traumatic SCI regardless of the level of injury was the final recommendation for Iran. Although most of the recommendations are adoptable in developing countries, issues with infrastructure and availability of resources are the limitations.

Can executive functions of the brain predict official driving test success?

Human factors, including the level of cognitive functioning, are the most influential factors in road traffic crashes. Among cognitive abilities, executive functions (EFs) of the brain play a pivotal role in driving performance and outcomes, including crash numbers. The current study was aimed to explore, for the first time, the ability of EF tests to predict success on the official driving tests in applicants of driving license in Iran. We administered a relevant set of commonly used EF tests, including a computerized Stroop test and six tests from the Delis-Kaplan Executive Function System (D-KEFS) and the Behavioral Assessment of the Dysexecutive Syndrome (BADS), to 87 healthy new drivers applying for a driver's license (Mage = 25.9 years, SD = 8.2; 43 female). We also administered a series of demographic and psychological questionnaires. The data regarding the participants' official driving tests were extracted from the official records. To determine the relations of the EF tests with success on the driving tests, several correlation and regression analyses were conducted. Most of the EF measures had significant correlations with the road test success, while having no significant relations with the theory test success. Moreover, in our regression analyses, The EF measures predicted success on the official driving road test, but not success on the driving theory test, even after controlling for the effects of previous unlicensed driving experience and stress symptoms. The results demonstrate the predictability of the driving road test success from executive functioning.

Ecological validity of executive function tests in predicting driving performance.

Almost all of our everyday activities depend on executive function (EF) skills. In line with the increasing attention to the ecological validation of neuropsychological assessment and intervention methods, this study aimed to explore the ecological validity of a relevant set of widely used EF tests, mostly from well-known paradigms of EF assessment, in predicting driving ability. Ninety-six healthy novice drivers (Mage = 26.2 years, SD = 8.4; 48 female) completed four stages of our data collection including psychological, EF, and driving assessments. For the psychological assessment, validated measures of sensation-seeking, risk-taking, personality traits, ADHD symptoms, depression, anxiety, and stress were administered. For the EF assessment, selected tests from the Delis-Kaplan Executive Function System (D-KEFS: Trail Making, Design Fluency, and Tower) and the Behavioral Assessment of the Dysexecutive Syndrome (BADS: Key Search, Zoo Map, and Modified Six Elements) along with a computerized Stroop test were administered. For the driving assessment, we used a simulated driving test comprising of 14 key dimensions of driving skills. Several correlations and multiple regression analyses were conducted. Significant correlations were found between all the EF measures and driving performance. Moreover, the EF measures predicted the driving ability over and above the effects of previous driving experience and the psychological variables. These results provide supporting evidence for the ecological validity of the EF tests in predicting driving performance. The incorporation of assessment and intervention targeting multiple domains of EF into driving rehabilitation and education programs could be a focus of future research.

Adopting Clinical Practice Guidelines for Pharmacologic Management of Acute Spinal Cord Injury from a Developed World Context to a Developing Global Region.

BACKGROUND: Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients' outcomes on the ability and knowledge of "individual" health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods. METHODS: This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each suggestion and the triad of feasibility, acceptance and adoptability for the Iranian health-care context. RESULTS: Two guidelines were included in the adaptation process. Based on high-quality of these guidelines and the feasibility and adoptability evaluation of the organizing committee, we decided to adopt the suggestion of both guidelines. Overall, seven suggestions were extracted from the source guidelines. CONCLUSION: This work provides a framework to apply guidelines for acute SCI to the developing regions of the world. Attempts should be made to implement these suggestions in order to improve the health outcomes of Iranian SCI patients.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients.

BACKGROUND: Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran. METHODS: The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2). RESULTS: A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation. CONCLUSION: Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Executive functioning of complicated-mild to moderate traumatic brain injury patients with frontal contusions.

Executive dysfunctions are among the most prevalent neurobehavioral sequelae of traumatic brain injuries (TBIs). Using culturally validated tests from the Delis-Kaplan Executive Function System (D-KEFS: Trail Making, Verbal Fluency, Design Fluency, Sorting, Twenty Questions, and Tower) and the Behavioural Assessment of the Dysexecutive Syndrome (BADS: Rule Shift Cards, Key Search, and Modified Six Elements), the current study was the first to examine executive functioning in a group of Iranian TBI patients with focal frontal contusions. Compared with a demographically matched normative sample, the frontal contusion patients showed substantial impairments, with very large effect sizes (p ≤ .003, 1.56 < d < 3.12), on all the executive measures. Controlling for respective lower-level/fundamental conditions, the differences on the highest-level executive (cognitive switching) conditions were still significant. The frontal patients also committed more errors. Patients with lateral prefrontal (LPFC) contusions were qualitatively worst. For example, only the LPFC patients committed perseverative repetition errors. Altogether, our results support the notion that the frontal lobes, specifically the lateral prefrontal regions, play a critical role in cognitive executive functioning, over and above the contributions of respective lower-level cognitive abilities. The results provide clinical evidence for validity of the cross-culturally adapted versions of the tests.

Cross-Cultural adaptation of executive function tests for assessments of traumatic brain injury patients in southeast Iran / Adaptación transcultural de tests de la función ejecutiva para la evaluación de pacientes con lesiones cerebrales traumáticas en el sudeste de Irán

The Delis-Kaplan Executive Function System (D-KEFS) is a "greatest hits" collection of commonly used tests of executive functioning. We mainly aimed to develop a Persian version of D-KEFS for brain-damaged patients in Zahedan, Iran, and to provide preliminary validation evidence, applying a normal sample with demographic traits of the patients. In the judgmental phase, we conducted several local field studies and non-standard pilot administrations, and accordingly we made various cross-cultural adaptations. For the statistical phase, the provided materials along with four tests from the Behavioral Assessment of the Dysexecutive Syndrome (BADS) were administered to 75 healthy individuals. Within 12 to 30 days, 24 subjects were retested. Relatively high reliabilities were obtained for most of the D-KEFS measures. In validity analysis, strong correlations were found among the majority of the scores within the tests; correlations between various D-KEFS tests were in the range of weak to moderate; and significant correlations were found between the majority of D-KEFS executive scores and BADS scores. In conclusion, the adapted tests show acceptable psychometric properties in assessing the complex, multidimensional construct of executive functioning

El "Sistema Delis-Kaplan de la función ejecutiva" (Delis-Kaplan Executive Function System; D-KEFS) es una colección de "grandes éxitos" de tests utilizados para la evaluación del funcionamiento ejecutivo. Nuestro objetivo principal fue desarrollar una versión persa del D-KEFS para pacientes con dano cerebral en Zahedan, Iran, y proporcionar pruebas preliminares de su validación al aplicarlo a una muestra de pacientes locales. En la fase de evaluación, llevamos a cabo varios estudios de campo y aplicaciones piloto no estandar y, en consonancia, realizamos varias adaptaciones transculturales. En la fase estadística, dichos materiales junto con cuatro tests de la "Evaluación conductual del síndrome disejecutivo" (Behavioral Assessment of the Dysexecutive Syndrome; BADS) se administraron a 75 individuos sanos. Entre 12 y 30 dias despues, se volvio a evaluar (retest) a 24 sujetos. Se obtuvieron fiabilidades relativamente elevadas para la mayoría de las medidas del D-KEFS. En los análisis de validación, se encontraron elevadas correlaciones entre la mayoría de las puntuaciones intratests. Las correlaciones entre varios de los tests del D-KEFS se hallaban en el rango de débiles a moderadas y se encontraron correlaciones significativas entre la mayoría de las puntuaciones ejecutivas del D-KEFS y de la BADS. En conclusión, los tests adaptados muestran propiedades psicométricas aceptables para evaluar el complejo constructo multidimensional del funcionamiento ejecutivo