Evaluating the effectiveness of reasoning training in military and civilian chronic traumatic brain injury patients: study protocol.

BACKGROUND: Individuals who sustain traumatic brain injuries (TBIs) often continue to experience significant impairment of cognitive functions mediated by the prefrontal cortex well into chronic stages of recovery. Traditional brain training programs that focus on improving specific skills fall short of addressing integrative functions that draw upon multiple higher-order processes critical for social and vocational integration. In the current study, we compare the effects of two short-term, intensive, group-based cognitive rehabilitation programs for individuals with chronic TBI. One program emphasizes learning about brain functions and influences on cognition, while the other program adopts a top-down approach to improve abstract reasoning abilities that are largely reliant on the prefrontal cortex. These treatment programs are evaluated in civilian and military veteran TBI populations. METHODS/DESIGN: One hundred individuals are being enrolled in this double-blinded clinical trial (all measures and data analyses will be conducted by blinded raters and analysts). Each individual is randomly assigned to one of two treatment conditions, with each condition run in groups of five to seven individuals. The primary anticipated outcomes are improvement in abstract reasoning and everyday life functioning, measured through behavioral tasks and questionnaires, and attention modulation, as measured by functional neuroimaging. Secondary expected outcomes include improvements in the cognitive processes of working memory, attention, and inhibitory control. DISCUSSION: Results of this trial will determine whether cognitive rehabilitation aimed at teaching TBI-relevant information about the brain and cognition versus training in TBI-affected thinking abilities (e.g., memory, attention, and executive functioning) can improve outcomes in chronic military and civilian TBI patient populations. It should shed light on the nature of improvements and the characteristics of patients most likely to benefit. This trial will also provide information about the sustainability of treatment-related improvements 3 months post-training. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01552473.

Right diagnosis, wrong care: patient management reasoning errors in emergency care computer-based case simulations.

The pervasiveness of reasoning errors in emergency care (EC) is commonly acknowledged in clinical research. Much of this work has focused on diagnostic errors; yet, in EC, providing a specific diagnosis is generally secondary to managing the patient. To gain insights into non-diagnostic, treatment-related errors, we presented EC residents with computer-based case simulations and recorded their actions and verbalized thoughts. Nearly all participants diagnosed both study cases correctly yet made a variety of patient management errors, some with serious consequences. More substantial errors could be classified as stemming from incorrect patient status and treatment inferences. These EC reasoning errors are discussed within the framework of underlying cognitive processes.

Considering complexity in healthcare systems.

A recent trend in the literature has been to characterize healthcare activities in terms of complex systems theory. Complexity has often been loosely and variously defined, with meanings ranging from "not simple" to "complicated" to "intractable." In this paper, we consider various aspects of complexity and how they relate to modern healthcare practice, with the aim of developing research approaches for studying complex healthcare environments. We propose a theoretical lens for understanding and studying complexity in healthcare systems based on degrees of interrelatedness of system components. We also describe, with relevant caveats, how complex healthcare systems are generally decomposable, rendering them more tractable for further study. The ideas of interrelatedness among the components of a system as a measure of complexity and functional decomposition as a mechanism for studying meaningful subcomponents of a complex system can be used as a framework for understanding complex healthcare systems. Using examples drawn from current literature and our own research, we explain the feasibility of this approach for understanding, studying, and managing complex healthcare systems.

Patterns of brain atrophy that differentiate corticobasal degeneration syndrome from progressive supranuclear palsy.

BACKGROUND: Progressive brain atrophy is associated with the corticobasal degeneration syndrome (CBDS) and progressive supranuclear palsy (PSP). Regional differences in brain atrophy may reflect the clinical features of disease. OBJECTIVE: To quantify the structural neuroanatomical differences between CBDS and PSP. DESIGN: A survey of neurologic deficits was conducted in all patients. Voxel-based morphometry was used to quantify structural neuroanatomical differences on magnetic resonance images in each subject group. SETTING: University hospital dementia clinic. PARTICIPANTS: Fourteen patients who met clinical research criteria for CBD and 15 patients who met clinical research criteria for PSP, who were matched for severity of disease, age, and functional status, and 80 age-matched control subjects. MAIN OUTCOME MEASURES: Statistically significant differences in regional gray and white matter volume, after multiple comparisons correction, between groups of subjects. RESULTS: The patients with CBDS displayed an asymmetric (left > right) pattern of brain atrophy that involved the bilateral premotor cortex, superior parietal lobules, and striatum. Progressive supranuclear palsy was associated with atrophy of the midbrain, pons, thalamus, and striatum, with minimal involvement of the frontal cortex. Midbrain structures were more atrophied in PSP than in CBD, whereas dorsal frontal and parietal cortices were more atrophied in CBD than in PSP. The degree of atrophy of the midbrain and pontine tegmentum and the left frontal eye field differentiated the 2 patient groups with 93% accuracy. CONCLUSIONS: Distinct patterns of brain atrophy exist in CBDS and PSP that can be used to differentiate the 2 diseases. Assessments of brain atrophy in these disorders should be focused on cortical and brainstem ocular motor control areas.

Neuroanatomical correlates of impaired recognition of emotion in dementia.

Neurodegenerative diseases frequently affect brain regions important for emotional processing, offering a valuable opportunity to study the effects of brain injury on emotion. The current study examined the neuroanatomical correlates of impaired recognition of emotions in patients with neurodegenerative disease. Performance on recognition of facial expressions, as measured by the Florida Affect Battery, was correlated with regional changes in gray matter tissue content in 50 patients with neurodegenerative disease using voxel-based morphometry. Recognition accuracy in the group was poor for negative emotions (fear, anger and sadness) and good for happiness, consistent with previous studies. For negative emotions, a region in the right lateral inferior temporal gyrus (Brodman's area (BA) 20) extending into the right middle temporal gyrus (BA 21) was correlated with accuracy. This effect appeared to be strongest for sadness, which was also independently correlated with atrophy in the superior temporal gyrus. These data suggest that regions in the right lateral and inferolateral temporal lobe are important for visual processing of negative emotions from faces and that functioning of this right temporal network is most critical for recognition of sad faces.

Neuroanatomical correlates of behavioural disorders in dementia.

Neurodegenerative diseases are associated with profound changes in social and emotional function. The emergence of increasingly sophisticated methods for measuring brain volume has facilitated correlation of local changes in tissue content with cognitive and behavioural changes in neurodegenerative disease. The current study examined neuroanatomical correlates of behavioural abnormalities, as measured by the Neuropsychiatric Inventory, in 148 patients with dementia using voxel-based morphometry. Of 12 behaviours examined, 4 correlated with tissue loss: apathy, disinhibition, eating disorders and aberrant motor behaviour. Increasing severity across these four behaviours was associated with tissue loss in the ventral portion of the right anterior cingulate cortex (vACC) and adjacent ventromedial superior frontal gyrus (vmSFG), the right ventromedial prefrontal cortex (VMPC) more posteriorly, the right lateral middle frontal gyrus, the right caudate head, the right orbitofrontal cortex and the right anterior insula. In addition, apathy was independently associated with tissue loss in the right vmSFG, disinhibition with tissue loss in the right subgenual cingulate gyrus in the VMPC, and aberrant motor behaviour with tissue loss in the right dorsal ACC and left premotor cortex. These data strongly support the involvement of the right hemisphere in mediating social and emotional behaviour and highlight the importance of distinct regions on the medial wall of the right frontal lobe in regulating different behaviours. Furthermore, the findings underscore the utility of studying patients with dementia for understanding the neuroanatomical basis of social and emotional functions.

Right and left medial orbitofrontal volumes show an opposite relationship to agreeableness in FTD.

Recent investigations of the neuroanatomy of complex social behaviors suggest that the underlying brain circuits involve multiple cortical and subcortical structures. The neuroanatomic origins of agreeableness have not yet been clearly elucidated. However, frontotemporal dementia (FTD) patients can evidence dramatic alterations in agreeableness arising from frontal and temporal lobe damage. Based on previous research, we hypothesized that agreeableness would be negatively correlated with left medial orbitofrontal cortex size and positively correlated with right amygdala volume. First-degree relatives of 27 FTD patients (diagnosed according to the Lund-Manchester criteria) were asked to fill out the NEO-Five Factor Inventory to assess the patients' current level of agreeableness, a construct comprised of the facets trust, straightforwardness, altruism, compliance, modesty, and tender-mindedness. These patients underwent T(1)-weighted MRI imaging, and gray matter volumes for right and left orbitofrontal lobes and amygdalas were derived via segmentation and region of interest tracing, normalizing for total intracranial volume. Regression analysis revealed that 38% of the variance in the NEO agreeableness score was predicted by a model in which right orbitofrontal volume (beta = 0.731) was positively correlated with agreeableness, and left orbitofrontal lobe volume (beta = -0.638) was negatively correlated with agreeableness (p < 0.01). Contrary to our hypothesis, amygdala volume did not significantly predict agreeableness. This finding partly replicates a previous study that used a different measure of social functioning, the Interpersonal Adjective Scale, to delineate a left frontal-right amygdala circuit for agreeableness. These data support the hypothesis that regulation of agreeableness arises from a balanced, mutually inhibitory circuit involving both hemispheres.