Predictive utility of an adapted Marshall head CT classification scheme after traumatic brain injury.

OBJECTIVE: To study the predictive relationship among persons with traumatic brain injury (TBI) between an objective indicator of injury severity (the adapted Marshall computed tomography [CT] classification scheme) and clinical indicators of injury severity in the acute phase, functional outcomes at inpatient rehabilitation discharge, and functional and participation outcomes at 1 year after injury, including death. PARTICIPANTS: The sample involved 4895 individuals who received inpatient rehabilitation following acute hospitalization for TBI and were enrolled in the Traumatic Brain Injury Model Systems National Database between 1989 and 2014. DESIGN: Head CT variables for each person were fit into adapted Marshall CT classification categories I through IV. MAIN MEASURES: Prediction models were developed to determine the amount of variability explained by the CT classification categories compared with commonly used predictors, including a clinical indicator of injury severity. RESULTS: The adapted Marshall classification categories aided only in the prediction of craniotomy or craniectomy during acute hospitalization, otherwise making no meaningful contribution to variance in the multivariable models predicting outcomes at any time point after injury. CONCLUSION: Results suggest that head CT findings classified in this manner do not inform clinical discussions related to functional prognosis or rehabilitation planning after TBI. ABBREVIATIONS: CT: computed tomography; DRS: disability rating scale; EGOS: extended Glasgow outcome scale; FIM: functional independence measure; NDB: National Data Base; PTA: posttraumatic amnesia; RLOS: rehabilitation length of stay; SPOS: semipartial omega squared statistic; TBI: traumatic brain injury; TBIMS: Traumatic Brain Injury Model Systems.

Longitudinal Investigation of Rehospitalization Patterns in Spinal Cord Injury and Traumatic Brain Injury Among Medicare Beneficiaries.

OBJECTIVES: To model 12-month rehospitalization risk among Medicare beneficiaries receiving inpatient rehabilitation for spinal cord injury (SCI) or traumatic brain injury (TBI) and to create 2 (SCI- and TBI-specific) interactive tools enabling users to generate monthly projected probabilities of rehospitalization on the basis of an individual patient's clinical profile at discharge from inpatient rehabilitation. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare beneficiaries receiving inpatient rehabilitation for SCI (n=2587) or TBI (n=10,864). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Monthly rehospitalization (yes/no) based on Medicare claims. RESULTS: Results are summarized through computer-generated interactive tools, which plot individual level trajectories of rehospitalization probabilities over time. Factors associated with the probability of rehospitalization over time are also provided, with different combinations of these factors generating different individual level trajectories. Four case studies are presented to demonstrate the variability in individual risk trajectories. Monthly rehospitalization probabilities for the individual high-risk TBI and SCI cases declined from 33% to 15% and from 41% to 18%, respectively, over time, whereas the probabilities for the individual low-risk cases were much lower and stable over time: 5% to 2% and 6% to 2%, respectively. CONCLUSIONS: Rehospitalization is an undesirable and multifaceted health outcome. Classifying patients into meaningful risk strata at different stages of their recovery is a positive step forward in anticipating and managing their unique health care needs over time.

Trajectories of Life Satisfaction After Spinal Cord Injury.

OBJECTIVE: To describe individual-level temporal change in life satisfaction after spinal cord injury. DESIGN: Individual growth curve (IGC) analysis of prospectively collected data from the National Institute on Disability, Independent Living, and Rehabilitation Research National Spinal Cord Injury Database (NSCID). SETTING: Multicenter, longitudinal database study. PARTICIPANTS: Participants (N=4846) in the NSCID. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Rasch-transformed Satisfaction With Life Scale scores. RESULTS: Individual-level trajectories reflecting life satisfaction vary extensively and are associated with demographic and injury-related characteristics. Demographic characteristics include race, sex, pre-employment and discharge marital status, and level of education; injury-related factors include days in rehabilitation, neurologic level, age at injury, and injury etiology. Results are displayed graphically by way of a computer-generated interactive tool and represent different trajectories of individual-level changes in life satisfaction. CONCLUSIONS: IGC methodology allows researchers and clinicians to anticipate patient-specific trajectories through use of an automated interactive tool. Projected trajectories hold promise in facilitating planning for inpatient and outpatient services, which could enhance long-term outcomes.

A Multidimensional Rasch Analysis of the Functional Independence Measure Based on the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database.

A number of studies have evaluated the psychometric properties of the Functional Independence Measure (FIM™) using Rasch analysis, although none has done so using the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database, a longitudinal database that captures demographic and outcome information on persons with moderate to severe traumatic brain injury across the United States. In the current study, we examine the psychometric properties of the FIM as represented by persons within this database and demonstrate that the FIM comprises three subscales representing cognitive, self-care, and mobility domains. These subscales were analyzed simultaneously using a multivariate Rasch model in combination with a time dependent concurrent calibration scheme with the goal of creating a raw score-to-logit transformation that can be used to improve the accuracy of parametric statistical analyses. The bowel and bladder function items were removed because of misfit with the motor and cognitive items. Some motor items exhibited step disorder, which was addressed by collapsing Categories 1-3 for Toileting, Stairs, Locomotion, Tub/Shower Transfers; Categories 1 and 2 for Toilet and Bed Transfers; and Categories 2 and 3 for Grooming. The strong correlations (r = 0.82-0.96) among the three subscales suggest they should be modeled together. Coefficient alpha of 0.98 indicates high internal consistency. Keyform maps are provided to enhance clinical interpretation and application of study results.

Trajectories of Life Satisfaction Over the First 10 Years After Traumatic Brain Injury: Race, Gender, and Functional Ability.

OBJECTIVE: This study investigated the influence of race, gender, functional ability, and an array of preinjury, injury-related, and sociodemographic variables on life satisfaction trajectories over 10 years following moderate to severe traumatic brain injury (TBI). SETTING/PARTICIPANTS: A sample of 3157 individuals with TBI from the TBI Model Systems database was included in this study. DESIGN: Hierarchical linear modeling (HLM) analyses were conducted to examine the trajectories of life satisfaction. MAIN MEASURES: The Functional Independence Measure, Glasgow Coma Scale, and the Satisfaction With Life Scale were utilized. RESULTS: Initial models suggested that life satisfaction trajectories increased over the 10-year period and Asian/Pacific Islander participants experienced an increase in life satisfaction over time. In a comprehensive model, time was no longer a significant predictor of increased life satisfaction. Black race, however, was associated with lower life satisfaction, and significant interactions revealed that black participants' life satisfaction trajectory decreased over time while white participants' trajectory increased over the same time period. Life satisfaction trajectories did not significantly differ by gender, and greater motor and cognitive functioning were associated with increasingly positive life satisfaction trajectories over the 10 years. CONCLUSION: Individuals with more functional impairments are at risk for decreases in life satisfaction over time. Further research is needed to identify the mechanisms and factors that contribute to the lower levels of life satisfaction observed among black individuals post-TBI. This work is needed to determine strategic ways to promote optimal adjustment for these individuals.

Ten-Year Employment Patterns of Working Age Individuals After Moderate to Severe Traumatic Brain Injury: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURE: Employment. RESULTS: Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury. CONCLUSIONS: These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors.

A validation study for using iterative proportional fitting to weight the Traumatic Brain Injury Model Systems National Database: an NIDRR-sponsored study.

OBJECTIVE: To verify that iterative proportional fitting (IPF), or raking, has the desired effect of aligning estimates and parameters so that researches have confidence in population projections when weighting the Traumatic Brian Injury Model Systems National Database. DESIGN: Secondary data analysis using IPF. SETTING: Inpatient rehabilitation. PARTICIPANTS: People aged 16 years and older with a primary diagnosis of traumatic brain injury receiving initial inpatient rehabilitation. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Age at injury, race, sex, marital status, rehabilitation length of stay, payer source, and motor and cognitive FIM scores. RESULTS: This study demonstrates the utility of applying IPF to weight the TBI Model System National Database so that results of ensuing statistical analyses better reflect those in the United States who are 16 years and older with a primary diagnosis of TBI and are receiving inpatient rehabilitation. CONCLUSIONS: In general, IPF aligns population estimates on the basis of weighted Traumatic Brian Injury Model Systems data and known population parameters. It is reasonable to assume that IPF has the same effect on unknown variables. This provides confidence to researchers wishing to use IPF for making population projections in analyses.

Atomoxetine for attention deficits following traumatic brain injury: results from a randomized controlled trial.

OBJECTIVE: To determine if atomoxetine would improve attention impairment following traumatic brain injury (TBI). SETTING: Outpatients from a free-standing, private, not-for-profit rehabilitation hospital. POPULATION: Fifty-five adult participants with a history of a single moderate-to-severe TBI, who were at least 1 year from injury and with self-reported complaints of attention difficulties. INTERVENTION: Atomoxetine, a selective norepinephrine re-uptake inhibitor with a primary indication for attention dosed at 40 mg twice a day for 2 weeks, compared to placebo. DESIGN: Randomized double-blind placebo controlled trial, with placebo run-in. MEASURES: Cognitive Drug Research (CDR), Computerized Cognitive Assessment System, Stroop Color and Word Test, Adult ADHD Self-Report Scale (ASRS-v1.1), Neurobehavioural Functioning Inventory (NFI). RESULTS: Atomoxetine was well-tolerated by the subject sample. The use of atomoxetine by individuals with reported attention difficulty following TBI did not significantly improve scores on measures of attention, the CDR Power of Attention domain or the Stroop Interference score. In addition, no significant relationship was found between atomoxetine use and self-reported symptoms of attention or depression. CONCLUSION: Atomoxetine did not significantly improve performance on measures of attention among individuals post-TBI with difficulties with attention. This study follows a trend of other pharmacological studies not demonstrating significant results among those with a history of TBI. Various possibilities are discussed, including the need for a more sophisticated system of classification of TBI.

Components of traumatic brain injury severity indices.

The purpose of this study was to determine whether there are underlying dimensions common among traditional traumatic brain injury (TBI) severity indices and, if so, the extent to which they are interchangeable when predicting short-term outcomes. This study had an observational design, and took place in United States trauma centers reporting to the National Trauma Data Bank (NTDB). The sample consisted of 77,470 unweighted adult cases reported to the NTDB from 2007 to 2010, with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) TBI codes. There were no interventions. Severity indices used were the Emergency Department Glasgow Coma Scale (GCS) Total score and each of the subscales for eye opening (four levels), verbal response (five levels), and motor response (six levels); the worst Abbreviated Injury Scale (AIS) severity score for the head (six levels); and the worst Barell index type (three categories). Prediction models were computed for acute care length of stay (days), intensive care unit length of stay (days), hospital discharge status (alive or dead), and, if alive, discharge disposition (home versus institutional). Multiple correspondence analysis (MCA) indicated a two dimensional relationship among items of severity indexes. The primary dimension reflected overall injury severity. The second dimension seemed to capture volitional behavior without the capability for cogent responding. Together, they defined two vectors around which most of the items clustered. A scale that took advantage of the order of items along these vectors proved to be the most consistent index for predicting short-term health outcomes. MCA provided useful insight into the relationships among components of traditional TBI severity indices. The two vector pattern may reflect the impact of injury on different cortical and subcortical networks. Results are discussed in terms of score substitution and the ability to impute missing values.

US population estimates of health and social outcomes 5 years after rehabilitation for traumatic brain injury.

OBJECTIVE: To estimate the number of adults in the United States from 2006 to 2012 who manifest selected health and social outcomes 5 years following a traumatic brain injury (TBI) that required acute inpatient rehabilitation. DESIGN: Secondary data analysis. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients 16 years and older receiving acute inpatient rehabilitation for a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Mortality, functional independence, societal participation, subjective well-being, and global outcome. RESULTS: Annually from 2001 to 2007, an average of 13 700 patients aged 16 years or older received acute inpatient rehabilitation in the United States with a primary diagnosis of TBI. Approximately 1 in 5 patients had died by the 5-year postinjury assessment. Among survivors, 12% were institutionalized and 50% had been rehospitalized at least once. Approximately one-third of patients were not independent in everyday activities. Twenty-nine percent were dissatisfied with life, with 8% reporting markedly depressed mood. Fifty-seven percent were moderately or severely disabled overall, with 39% having deteriorated from a global outcome attained 1 or 2 years postinjury. Of those employed preinjury, 55% were unemployed. Poorer medical, functional, and participation outcomes were associated with, but not limited to, older age. Younger age groups had poorer mental and emotional outcomes. Deterioration in global outcome was common and not age-related. CONCLUSIONS: Significant mortality and morbidity were evident at 5 years postinjury. The deterioration in global outcomes observed regardless of age suggests that multiple influences contribute to poorer outcomes. Public health interventions intended to reduce post-acute inpatient rehabilitation mortality and morbidity rates will need to be multifaceted and age-specific.

An introduction to analyzing dichotomous outcomes in a longitudinal setting: a NIDRR traumatic brain injury model systems communication.

An untapped wealth of temporal information is captured within the Traumatic Brain Injury Model Systems National Database. Utilization of appropriate longitudinal analyses can provide an avenue toward unlocking the value of this information. This article highlights 2 statistical methods used for assessing change over time when examination of noncontinuous outcomes is of interest where this article focuses on investigation of dichotomous responses. Specifically, the intent of this article is to familiarize the rehabilitation community with the application of generalized estimating equations and generalized linear mixed models as used in longitudinal studies. An introduction to each method is provided where similarities and differences between the 2 are discussed. In addition, to reinforce the ideas and concepts embodied in each approach, we highlight each method, using examples based on data from the Rocky Mountain Regional Brain Injury System.

Application and clinical utility of the Glasgow Coma Scale over time: a study employing the NIDRR traumatic brain injury model systems database.

OBJECTIVE: To examine possible changes in Glasgow Coma Scale (GCS) scores related to changes in emergency management, such as intubation and chemical paralysis, and the potential impact on outcome prediction. PARTICIPANTS: 10 228 patients from the Traumatic Brain Injury Model Systems national database. DESIGN: Retrospective study examining 5-year epochs from 1987 to 2012. MAIN MEASURES: GCS score assessed in the Emergency Department (GCS scores for intubated, but not paralyzed, patients were estimated with a formula using 2 of the 3 GCS components), Outcome: Functional Independence Measure (FIM) assessed at rehabilitation admission. RESULTS: The rate of intubation prior to GCS scoring averaged 43% and did not increase across time. However, a clear increase over time was observed in the use of paralytics or heavy sedatives, with 27% of patients receiving this intervention in the most recent epoch. Estimated GCS scores classified 69% of intubated patients as severely brain injured and 8% as mildly injured. The GCS accounted for a modest, yet consistent, amount of variability (approximately 5%-7%) in FIM scores during most epochs. CONCLUSIONS: Given the frequency of intubation and/or paralysis following brain injury in this sample, estimating GCS or exploring other means to gauge injury severity is beneficial, particularly because a portion likely did not sustain severe brain injury. There is no evidence for declining predictive utility of the GCS over time.

Self-scoring templates for motor and cognitive subscales of the FIM instrument for persons with spinal cord injury.

OBJECTIVE: To provide self-scoring templates for the FIM instrument's motor and cognitive scales that enable clinicians to monitor progress during rehabilitation using equal-interval Rasch-calibrated measures instead of ordinal raw scores. DESIGN: Secondary analysis of a prospective, observational cohort study. SETTING: Six geographically dispersed hospital-based rehabilitation centers in the United States. PARTICIPANTS: Subset of consecutively enrolled individuals with new traumatic spinal cord injuries discharged from participating rehabilitation centers (N=1146). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Subscores of the FIM instrument, including a 13-item motor scale, a 5-item cognitive scale, an 11-item (without sphincter control items) motor scale, a 3-item transfer scale, a 6-item self-care scale, a 3-item self-care upper extremity scale, and a 3-item self-care lower extremity scale. RESULTS: KeyForms for the FIM instrument scales allow clinicians and investigators to estimate patients' functional status and monitor progress. In cases with no missing data, the look-up tables provide more accurate estimates of patients' functional status. CONCLUSION: Clinicians can use KeyForms and look-up tables for FIM instrument subscales to monitor patients' progress and communicate improvement in equal-interval units.

Longitudinal description of the disability rating scale for individuals in the National Institute on Disability and Rehabilitation Research traumatic brain injury model systems national database.

OBJECTIVE: To develop a detailed understanding of temporal change (ie, estimated trajectories) at the individual level as measured by the Disability Rating Scale (DRS). DESIGN: Individual growth curve (IGC) analysis of retrospective data obtained from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury (TBI) Model Systems National Database. SETTING: Multicenter longitudinal database study. PARTICIPANTS: Individuals with TBI (N=8816) participating in the TBI Model Systems National Database project. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE DRS RESULTS: The negative exponential consisting of 3 growth parameters (pseudointercept, asymptote, rate) was successfully used to predict trajectory of recovery on the DRS qualified by the following covariates: race, sex, level of education and age at admission, rehabilitation length of stay, and cognitive and motor FIM scores at rehabilitation admission. Based on these results, an interactive tool was developed to allow prediction of the trajectory of recovery for individuals and subgroups with specified characteristics on the selected covariates. CONCLUSIONS: With the use of IGC analysis, the longitudinal trajectory of recovery on the DRS for individuals sharing common characteristics and traits can be described. This methodology allows researchers and clinicians to predict numerous individual-level trajectories through use of a web-based computer automated interactive tool.

Longitudinal description of the glasgow outcome scale-extended for individuals in the traumatic brain injury model systems national database: a National Institute on Disability and Rehabilitation Research traumatic brain injury model systems study.

OBJECTIVE: To comprehensively describe the temporal patterns of global outcome after traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems National Database (TBIMS NDB). DESIGN: Longitudinal prospective cohort study. SETTING: TBI Model Systems centers. PARTICIPANTS: Patients (N=3870) ≥16 years of age with moderate or severe TBI enrolled in the TBIMS NDB. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Glasgow Outcome Scale-Extended (GOS-E). RESULTS: The trajectory of the GOS-E scores is best described with a model of quadratic change, in which scores initially increase and peak approximately 10 years after the first GOS-E assessment, and then decrease. Change occurs most rapidly in the initial and final years of the timeline. There was significant variability in each growth parameter (P<.05). A reduced multilevel model was built, including all covariates (age at first GOS-E assessment, FIM, race, sex, rehabilitation length of stay) that related significantly to the growth parameters. An interactive tool was created to generate individual level trajectories based on various combinations of covariate values. Results provide an individual level account of the chronological progression of TBI outcomes, as measured by the GOS-E. CONCLUSIONS: Individual growth curve analysis is a statistically rigorous approach to describe temporal change with respect to the GOS-E at the individual level for participants within the TBIMS NDB. Results indicated that, for individuals in the TBIMS NDB as a group, functional status as measured by the GOS-E initially improves, plateaus, and then begins to decline. Factors such as age at first GOS-E assessment, race, FIM score at rehabilitation admission, and rehabilitation length of stay were found to influence baseline GOS-E scores, as well as the rate and extent of both improvement and decline over time. Additional research may be required to determine the generalizability of these findings and the usefulness of this tool for clinical applications.

An introduction to applying individual growth curve models to evaluate change in rehabilitation: a National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems report.

The abundance of time-dependent information contained in the Spinal Cord Injury and the Traumatic Brain Injury Model Systems National Databases, and the increased prevalence of repeated-measures designs in clinical trials highlight the need for more powerful longitudinal analytic methodologies in rehabilitation research. This article describes the particularly versatile analytic technique of individual growth curve (IGC) analysis. A defining characteristic of IGC analysis is that change in outcome such as functional recovery can be described at both the patient and group levels, such that it is possible to contrast 1 patient with other patients, subgroups of patients, or a group as a whole. Other appealing characteristics of IGC analysis include its flexibility in describing how outcomes progress over time (whether in linear, curvilinear, cyclical, or other fashion), its ability to accommodate covariates at multiple levels of analyses to better describe change, and its ability to accommodate cases with partially missing outcome data. These features make IGC analysis an ideal tool for investigating longitudinal outcome data and to better equip researchers and clinicians to explore a multitude of hypotheses. The goal of this special communication is to familiarize the rehabilitation community with IGC analysis and encourage the use of this sophisticated research tool to better understand temporal change in outcomes.

Descriptive modeling of longitudinal outcome measures in traumatic brain injury: a National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems study.

Establishing accurate mathematical models of outcome measures is essential in understanding change throughout the rehabilitation process. The goal of this study is to identify the best-fitting descriptive models for a set of commonly adopted outcome measures found within the Traumatic Brain Injury Model Systems National Database where the modeling is based on data submission through 2011 and the complete range of recorded time points since injury for each individual, where time points range from admission to rehabilitation to 20 years postinjury. The statistical methodology and the application of the methodology contained herein may be used to assist researchers and clinicians in (1) modeling the outcome measures considered, (2) modeling various portions of these outcomes by stratification and/or truncating time periods, (3) modeling longitudinal outcome measures not considered, and (4) establishing models as a necessary precursor in conducting individual growth curve analysis.

Mechanical ventilation, health, and quality of life following spinal cord injury.

OBJECTIVE: To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not. DESIGN: Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database. SETTING: Community. PARTICIPANTS: People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status. RESULTS: Significant differences were found between the ventilator-user (VU) group and non-ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status. CONCLUSIONS: People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.

Municipal solid waste generation in Kathmandu, Nepal.

Waste stream characteristics must be understood to tackle waste management problems in Kathmandu Metropolitan City (KMC), Nepal. Three-stage stratified cluster sampling was used to evaluate solid waste data collected from 336 households in KMC. This information was combined with data collected regarding waste from restaurants, hotels, schools and streets. The study found that 497.3 g capita(-1) day(-1) of solid waste was generated from households and 48.5, 113.3 and 26.1 kg facility(-1) day(-1) of waste was generated from restaurants, hotels and schools, respectively. Street litter measured 69.3 metric tons day(-1). The average municipal solid waste generation rate was 523.8 metric tons day(-1) or 0.66 kg capita(-1) day(-1) as compared to the 320 metric tons day(-1) reported by the city. The coefficient of correlation between the number of people and the amount of waste produced was 0.94. Key household waste constituents included 71% organic wastes, 12% plastics, 7.5% paper and paper products, 5% dirt and construction debris and 1% hazardous wastes. Although the waste composition varied depending on the source, the composition analysis of waste from restaurants, hotels, schools and streets showed a high percentage of organic wastes. These numbers suggest a greater potential for recovery of organic wastes via composting and there is an opportunity for recycling. Because there is no previous inquiry of this scale in reporting comprehensive municipal solid waste generation in Nepal, this study can be treated as a baseline for other Nepalese municipalities.