Venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation: successful transplantation after 155 days of support.

We present a case of a woman with acute respiratory distress syndrome and irrecoverable lung function that was successfully bridged to lung transplantation after 155 consecutive days of venovenous extracorporeal membrane oxygenation.

Is there a role for robotic totally endoscopic coronary artery bypass in patients with a colostomy?

Preoperative colostomy presents a significant risk of sternal wound complications, mediastinitis, and ostomy injury in patients requiring coronary artery bypass grafting. Less invasive procedures in coronary surgery have a potential to reduce the risk of sternal wound healing problems. Robotic totally endoscopic coronary artery bypass grafting in patients with a colostomy has not been reported. We describe a case of completely endoscopic coronary surgery using the da Vinci Si system in a patient with a transverse colostomy. Single left internal mammary artery grafting to the left anterior coronary artery was performed successfully on the beating heart. We regard this technique as the least invasive method of surgical coronary revascularization with a potential to reduce the risk of surgical site infection and mediastinitis in patients with a colostomy.

Determining impairment following spinal cord injury.

Determining the level of impairment and disability of an individual with SCI is reasonably straightforward. An impairment rating may be determined by either analyzing the impact of the SCI on various bodily systems or by considering the injury as a more global diagnostic category. Functional abilities based on level of neurologic preservation are well recognized. Although secondary medical complications, which may affect both impairment and disability, can arise at any time after SCI, neurologic and functional abilities are overwhelmingly stabilized by 12 months postinjury. A comprehensive history and physical examination should allow even the inexperienced examiner to obtain a valid determination of impairment after SCI. Although a more functionally oriented and perhaps interdisciplinary evaluation is needed to assess disability, it is also fairly straightforward. On the other hand, an evaluation of handicap is a more challenging undertaking, requiring a more detailed knowledge of the field of vocational rehabilitation.

Return to work for persons with traumatic brain injury.

Individuals with traumatic brain injuries experience an array of physical, cognitive, and emotional changes that often make return to preinjury employment unlikely and locating new employment difficult. The authors review the literature related to the return to work for persons with traumatic brain injuries. This includes return to work outcomes, factors influencing return to work, and vocational programs that enhance employment, including a supported employment approach. Guidelines for professionals engaged in supported employment practices are also provided.

Employment satisfaction of individuals with spinal cord injury.

OBJECTIVES: Community reentry after a spinal cord injury is a long-term integrative process, because individuals must adjust to an extraordinary new set of circumstances. In this study, quality-of-life and work satisfaction variables associated with employed or unemployed individuals with spinal cord injury were examined. METHODS: Quality-of-life and work satisfaction variables associated with 109 employed or unemployed individuals with spinal cord injury were examined by using an employment satisfaction survey. RESULTS: Most of those employed indicated that they would either change jobs or some employment variable such as duties, supervisor, or hours worked. Participants who were not working attributed unemployment to an array of factors including ongoing health problems, lack of transportation, and impact of and/or lost disability benefits. Both groups offered feedback related to information provided to them by medical professionals about return-to-work resources. CONCLUSIONS: The following three themes emerged from this analysis: (1) more comprehensive provider training about spinal cord injury is needed; (2) increased communication between consumer and family would be beneficial; and (3) an increase in the flexibility and availability of services would help to ensure access to essential care.

An evaluation of affected-sib-pair methods and transmission/disequilibrium tests for detecting genes underlying a complex trait.

For the analysis of complex traits, it is of interest to compare a few nonparametric methods such as affected-sib-pair (ASP) analyses and transmission/disequilibrium tests (TDT). The affected-sib-pair approaches we have examined here are ASP and ALL-SP which are implemented in SIBPAIR program. We also applied the BETA program which has not so far been extensively compared with other methods. The study indicates that the ASP program and the BETA program give concordant results although BETA tends to give higher lod scores. However, when all sibs were included in the analysis (ALL-SP), linkage signals became weaker, compared with ASP and BETA. The TDT detected 66 positive signals at a significance level of 0.05 and identified a true locus. Overall, our results suggest that affected-sib-pair analysis has reasonable power (p < 0.0001) to detect linkage given the disease model and the family structure specified in the GAW11 Problem 2 data set.

Enhancing work outcome for three persons with traumatic brain injury.

A case study approach is used to illustrate how three survivors of severe traumatic brain injury were able to gain and maintain employment with the assistance of a supported employment programme. Emphasis on the different types of accommodations, including the design and implementation of compensatory strategies, is provided for each case. Finally, on overview of steps that can be taken to enhance the use of such strategies on the job is presented.

Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis.

OBJECTIVE: To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients. DESIGN: Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results. SETTING: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Patients were selected from a national database of 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up. MAIN OUTCOME MEASURE: Return to work at 1-year follow-up. RESULTS: Persons employed at 1-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts. CONCLUSIONS: Persons obtaining better scores on certain acute measures (e.g., Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patient's ability to return to work, as well as an operational definition for successful employment.

Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations.

The psychosocial problems of decreased social contact, depression, and loneliness that occur for many with traumatic brain injury (TBI) create a major challenge for enhancing efforts at community re-entry. Despite dramatic physical progress within the first six months after injury, these psychosocial problems remain a persistent long-term problem for the majority of individuals with severe TBI. Researchers have consistently suggested that the psychosocial problems associated with TBI may actually be the major challenge facing rehabilitation. The majority of individuals who sustain TBI are young males between the ages of 19 and 25, who are in the early stages of establishing their independence in areas including friendships, leisure activities, intimate relationships, residence, and employment. The problem of social isolation and decreased leisure activities create a renewed dependence of the survivor on his/her family to meet these needs. In this article we review a large number of papers which examine the psychosocial and emotional sequelae for TBI patients. The results of those studies demonstrate four primary themes. The first theme depicts that individuals who experience severe TBI are at high risk for a significant decrease in their friendships and social support. The second theme relates to the lack of opportunity for establishing new social contacts and friends. The third theme relates to the decrease in leisure activities for individuals with severe TBI. Finally, anxiety and depression are found at high levels for prolonged periods of time following severe TBI. Several clinical recommendations are drawn from this literature review. They are: (1) Clinicians such as psychiatric social workers, psychologists, or psychiatrists may need to be called upon more quickly for intervention. The treating physiatrist cannot be expected to provide the insight and frequency of psychological services that may be necessary for many of these patients. (2) Since the literature seems to suggest that the presence of one psychosocial deficit, e.g., anxiety, will often be followed by other similar types of problems, e.g. depression, the treatment team needs to be sensitive to how rapidly these problems can cascade into a very dangerous situation. (3) Perhaps the most compelling recommendation we can make is for community rehabilitation specialists to focus significantly more energies and resources upon the psychological health of clients with TBI. Staff need to be trained to detect these signals that clients with TBI are often sending. It is apparent that psychosocial factors contribute to a rising obstacle level to community adjustment.

Traumatic brain injury rehabilitation: Issues in vocational outcome.

Since the population with a traumatic brain injury is principally young with many years of potential future earning capacity, understanding the issues affecting the vocational outlook for this group is critical. This article overviews the research to date on vocational outcome, emphasizing newly developed multivariate prediction models and encouraging a focus on actually examining the effects of different vocational interventions. The reasons for the variability in current study findings are reviewed with a framework proposed for more meaningful future research on the vocational rehabilitation process for this disability group. It is only through utilization of more standard intake and outcome variables and manipulation of interventions within this more standardized context that efficient and effective vocational rehabilitation for these survivors will be understood.

Return to work for patients with traumatic brain injury. Analysis of costs.

This brief report describes staff time commitment and program cost outcomes for a return to work program of supported employment for persons with brain injuries. The mean cost of providing services was $10,198 for the first year of service (median, $6,942). Clients achieved job stabilization after an average of 18 wk of time-limited job coaching services, during which they received mean intervention time of 245.7 h (median, 219) at a cost of $7,789. A mean of 2.24 h/wk of extended services intervention was required to maintain clients in employment for the remainder of the first year of service, at a mean weekly cost of $71.01. Results are compared with findings reported in a previous study using a smaller sample.

Return to work for patients with low back pain: two case studies.

Dismal return to work rates and mounting disability costs in the chronic low back pain (LBP) population imply the need for innovative re-employment strategies. The supported employment approach utilizes a vocational specialist under close physician supervision. It is more proactive, less biased, and more specialized than the more traditional case management approach used by many insurance companies. Supported employment has been used extensively at our institution in the brain injured population and we have recently begun exploring its use in LBP patients. Herein, we describe the successful use of supported employment in two individuals with chronic disabling LBP.

Return to work for persons following severe traumatic brain injury. Supported employment outcomes after five years.

Supported employment is a recently developed rehabilitation alternative that is being used to assist individuals with traumatic brain injury to return to work. The present study reports the results of a supported employment program that has placed 80 individuals into competitive employment during a 5-year time period. All individuals had sustained a severe traumatic brain injury; 72% of the injuries involved a motor vehicle. A mean of 6.1 years had passed since injury for all participants, who had been unconscious an average of 48 days. Neuropsychologic evaluation revealed defective cognitive functioning, which contributed to diminished employment potential. A key outcome indicator used to assess return to work capacity is the monthly employment ratio, which is computed by dividing the number of months employed during an employment phase (i.e., pre/post injury) by the total possible months an individual would have the opportunity to be employed. The monthly employment ratio increased from 13% after injury with no supported employment to 67% with supported employment services. The majority of individuals were employed in warehouse, clerical and service-related occupations. A mean of 250 staff intervention hours were required to train and provide follow-up services to program participants.

Changes in HIV rates and sexual behavior among homosexual men, 1984 to 1988/92.

Data were collected from 1614 homosexual and bisexual men in 1984 through 1985 and from 1988 to 1992 in Pittsburgh. Of the men entering the study since 1988, 16% reported engaging in unprotected anal receptive intercourse with more than one partner during the 6 months before their visit. Approximately 7% of the younger men and 18% of the men over 22 years of age in the recent cohort were already infected with the human immunodeficiency virus, the same rates as those described 8 years ago. Aggressive risk-reduction programs are needed in high schools and existing networks in the gay community.

Critical factors associated with the successful supported employment placement of patients with severe traumatic brain injury.

A number of investigations have recently demonstrated the effectiveness of supported employment programmes in improving the vocational status of clients with traumatic brain injuries. The present study investigated a sample of 39 individuals participating in a return to work programme emphasizing a supported employment approach to identify key functional characteristics which differentiated successful and unsuccessful clients. Clinical ratings of employment specialists were used to identify two groups of individuals rated least and most difficult to place and maintain. Results indicated that the two groups differed markedly on key employment outcomes. Individuals rated most difficult tended to be younger, possess functional limitations such as visual and fine motor impairments, and display significant deficits in numerous work-related skills. Recommendations are made for applying these findings to assessment, placement, and training activities within vocational rehabilitation programmes for persons with traumatic brain injuries.

Supported employment and compensatory strategies for enhancing vocational outcome following traumatic brain injury.

This paper describes two approaches to improving the employment prospects of those suffering from head injury. It is noted that unemployment within the first 7 years post-head injury is as high as 70% and that this contributes to the long-term difficulties faced by the head-injured and their families. A 'supportive' approach to employment involving the use of job coordinators or job coaches is described and a number of 'compensatory' strategies described. These two approaches are compatible and are derived from the individual needs of the head injured person in relation to retaining or seeking employment.

Substance abuse and crime patterns among persons with traumatic brain injury referred for supported employment.

The present investigation examined the incidence of alcohol use, drug use and criminal behaviour among persons with traumatic brain injury referred for supported employment services. Primary caretakers of 74 consecutive referrals completed the General Health and History Questionnaire, the brief version of the Michigan Alcohol Screening Test, and the Quantity-Frequency-Variability Index. Pre-injury, a fifth of the sample were abstinent from alcohol and 66% were labelled as moderate or heavy drinkers. Post-injury alcohol use declined. Half of the sample were abstinent and 28% were moderate or heavy drinkers. Thirty-six percent reported illicit drug use pre-injury. Reportedly, post-injury drug use declined to an incidence of 4%. Nearly 20% of the sample had been arrested pre-injury and 10% were arrested post-injury. Implications for further research and programme development are discussed.

Supported employment: an alternative model for vocational rehabilitation of persons with severe neurologic, psychiatric, or physical disability.

Participation in paid work in competitive industry through placement in supported employment is compared and analyzed for 278 severely disabled persons. Differential outcomes are described for persons with chronic mental illness, cerebral palsy, traumatic brain injury, and dual diagnosis of chronic mental illness and mental retardation. Results indicated that supported employment appears to be an effective means of assisting these historically unemployable individuals to acquire and retain work. Cross-disability group differences were found in areas such as hourly wages, type of employment, services provided by employment specialists, and job retention. The results represent a baseline from which to evaluate future efforts at competitive work placement for persons with severe disabilities, using the supported-employment model.

Costs of operating a supported work program for traumatically brain-injured individuals.

This paper presents a preliminary analysis of costs associated with a return-to-work program emphasizing a supported employment approach for persons who had sustained severe traumatic brain injuries. This analysis spans almost three years. Results indicated that a mean of 237.8 hours of staff intervention time was required to achieve job stabilization, at a cost of +6896. Ongoing follow-along and support services averaged 1.64 hours per week at a cost of +47.56. Over 68% of total staff time and costs were expended in job-site training and advocacy efforts. Application of these findings to state-level and agency-level policies should be weighed against individual characteristics and needs of clients, program design, and outcomes which clients achieve as a result of services.