Postmarketing Analysis of Misuse, Abuse, and Diversion of Xtampza ER.

OBJECTIVE: To evaluate abuse, misuse, and diversion of Xtampza ER, an extended-release (ER) abuse-deterrent formulation (ADF) of oxycodone. METHODS: Abuse, misuse, and diversion of Xtampza ER were assessed using Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System data sources. Xtampza ER was compared with immediate-release (IR) oxycodone, other ADF ER products combined, and non-ADF ER products combined. RESULTS: Xtampza ER prescriptions increased 50-fold during the study period. In contrast, cases from poison centers, substance abuse treatment centers, and diversion were infrequent and did not increase. Adjusted for prescriptions dispensed, poison center exposures were greater for IR oxycodone (rate ratio [RR] = 2.3, P = 0.008), other ADF ER opioids (RR = 5.2, P < 0.001), and non-ADF ER opioids (RR = 2.5, P = 0.004) than for Xtampza ER. In Treatment Center Programs Combined, past-month abuse prevalence for other ADF ER opioids (odds ratio [OR] = 7.4, P < 0.001) and non-ADF ER opioids (OR = 2.0, P = 0.002) was greater than Xtampza ER; IR oxycodone was not significantly different (OR = 1.2, P = 0.349). In the Drug Diversion Program, rates for IR oxycodone (RR = 3.7, P = 0.003), other ADF ER opioids (RR = 4.2, P = 0.002), and non-ADF ER opioids (RR = 3.4, P = 0.007) were greater than Xtampza ER. Adjustment using morphine equivalents provided similar results, except that IR oxycodone in Treatment Center Programs Combined became higher than Xtampza ER. Nonoral abuse cases involving Xtampza ER were infrequent; Web monitoring data support findings that Xtampza ER is difficult to abuse nonorally. CONCLUSION: Xtampza ER abuse, misuse, and diversion and tampering are low relative to other prescription opioid analgesics. Abuse and diversion did not increase over the study period.

Mortality following Traumatic Brain Injury among Individuals Unable to Follow Commands at the Time of Rehabilitation Admission: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

Severe traumatic brain injury (TBI) has been associated with increased mortality. This study characterizes long-term mortality, life expectancy, causes of death, and risk factors for death among patients admitted within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS) who lack command following at the time of admission for inpatient TBI rehabilitation. Of the 8084 persons enrolled from 1988 and 2009, 387 from 20 centers met study criteria. Individuals with moderate to severe TBI who received inpatient rehabilitation were 2.2 times more likely to die than individuals in the U.S. general population of similar age, gender, and race, with an average life expectancy (LE) reduction of 6.6 years. The subset of individuals who were unable to follow commands on admission to rehabilitation was 6.9 times more likely to die, with an average LE reduction of 12.2 years. Relative to the U.S. general population matched for age, gender, and race/ethnicity, these non-command following individuals were more than four times more likely to die of circulatory conditions, 44 times more likely to die of pneumonia, and 38 times more likely to die of aspiration pneumonia. The subset of individuals with TBI who are unable to follow commands upon admission to inpatient rehabilitation are at a significantly increased risk of death when compared with the U.S. general population and compared with all individuals with moderate to severe TBI receiving inpatient rehabilitation. Respiratory causes of death predominate, compared with the general population.

Epidemiology of adults receiving acute inpatient rehabilitation for a primary diagnosis of traumatic brain injury in the United States.

OBJECTIVE: To estimate the overall and by age-group characteristics at admission and discharge from rehabilitation between 2001 and 2010 of all late-teens and adults undergoing inpatient rehabilitation for a primary diagnosis of traumatic brain injury (TBI) in the United States. DESIGN: Secondary data analysis. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: Patients aged 16 years and older receiving inpatient rehabilitation for a primary diagnosis of TBI between 2001 and 2010. MAIN OUTCOME MEASURES: Functional independence, level of disability, and living situation. RESULTS: The incidence of TBI by age group found the largest proportion of cases to be aged 80 years and older, with a gradual decline in incidence in the age group of 30 years, at which point there was a slight increase. Injuries resulted predominantly from falls (49.8%) and motor vehicle crashes (40.8%); however, injuries to the youngest individuals were largely from motor vehicle crashes with decreasing rates as age increased, while injuries due to falls rose as age increased, with the oldest age groups most likely to incur a TBI. Preinjury alcohol misuse and substance use were found to occur in 22.9% and 12.2% of the total population, respectively; however, age distributions demonstrated high preinjury use among individuals younger than 50 years (eg, 46.4% and 30.6% for those aged 20 and 29 years, respectively) with decreasing misuse as age increased. Of the total population, 49.2% were retired, 31.1% employed, 14.1% not working, and 5.6% students. Trends by age showed that younger individuals were more likely to be students or employed (eg, 14.5% and 62.0% for those aged 20 and 29 years, respectively), with employment status peaking for those aged 30 to 39 years, and declining to 3.2% for the oldest age group (80 years and older). The trend of person(s) living alone between pre- and postrehabilitation showed the least amount of change for those aged 16 to 19 years with steadily increasing changes as age increased. Similar trends were seen for residence changes pre- and postrehabilitation, with the youngest most likely to return to living at a private residence, and a gradual decrease in return to living at a private residence as age increased. FIM instrument ("FIM") Motor and Cognitive subscale scores demonstrated that younger individuals had lower scores at admission to rehabilitation and higher scores at rehabilitation discharge. CONCLUSION: This study provides population estimates for all patients 16 years of age and older receiving inpatient rehabilitation for a primary diagnosis of TBI in the United States between 2001 and 2010. A recent trend shows the aging of the inpatient TBI rehabilitation population. Many characteristics important to rehabilitation outcomes are influenced by age, with older individuals trending toward being female, having less severe TBIs, incurring TBIs as a result of falls, but showing less improvement during rehabilitation, greater resulting disability, and more changes in their living situation postrehabilitation. These findings are of particular interest, as the oldest age groups considered in these analyses did not include the baby boom population.

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.

Effects of inspired oxygen concentration on ventilation, ventilatory rhythm, and gas exchange in isoflurane-anesthetized horses.

OBJECTIVE: To compare the effects of 2 fractions of inspired oxygen, 50% and > 95%, on ventilation, ventilatory rhythm, and gas exchange in isoflurane-anesthetized horses. ANIMALS: 8 healthy adult horses. PROCEDURES: In a crossover study design, horses were assigned to undergo each of 2 anesthetic sessions in random order, with 1 week separating the sessions. In each session, horses were sedated with xylazine hydrochloride (1.0 mg/kg, IV) and anesthesia was induced via IV administration of diazepam (0.05 mg/kg) and ketamine (2.2 mg/kg) Anesthesia was subsequently maintained with isoflurane in 50% or > 95% oxygen for 90 minutes. Measurements obtained during anesthesia included inspiratory and expiratory peak flow and duration, tidal volume, respiratory frequency, end-tidal CO(2) concentration, mixed expired partial pressures of CO(2) and O(2), PaO(2), PaCO(2), blood pH, arterial O(2) saturation, heart rate, and arterial blood pressure. Calculated values included the alveolar partial pressure of oxygen, alveolar-to-arterial oxygen tension gradient (PaO(2) - PaO(2)), rate of change of PAO(2) - PaO(2), and physiologic dead space ratio. Ventilatory rhythm, based on respiratory rate and duration of apnea, was continuously observed and recorded. RESULTS: Use of the lower inspired oxygen fraction of 50% resulted in a lower arterial oxygen saturation and PaO(2) than did use of the higher fraction. No significant difference in PaCO(2), rate of change of PAO(2) - PaO(2), ventilatory rhythm, or other measured variables was observed between the 2 sessions. CONCLUSION AND CLINICAL RELEVANCE: Use of 50% inspired oxygen did not improve the ventilatory rhythm or gas exchange and increased the risk of hypoxemia in spontaneously breathing horses during isoflurane anesthesia. Use of both inspired oxygen fractions requires adequate monitoring and the capacity for mechanical ventilation.

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.

Mortality after surviving traumatic brain injury: risks based on age groups.

OBJECTIVE: To assess mortality, life expectancy, risk factors, and causes of death by age groups among persons who received inpatient traumatic brain injury (TBI) rehabilitation. DESIGN: Prospective cohort study. SETTING: The TBI Model Systems. PARTICIPANTS: 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized mortality ratio, life expectancy, and cause of death. RESULTS: Moderate-severe TBI increases risk of mortality compared with the general population in all age groups, with the exception of those 85 years or older at the time of injury. Teenagers to middle-aged adults are at particular risk. Risk factors for death varied by age group and included gender, marital and employment status, year and cause of injury, and level of disability. External causes of death predominate in younger groups. For the youngest male participants in the sample, longevity was reduced up to 16 years. CONCLUSION: Risk factors and causes of death varied considerably by age group for individuals with moderate-severe TBI who were receiving acute care rehabilitation. Moderate-severe TBI is a chronic health condition.

Life expectancy following rehabilitation: a NIDRR Traumatic Brain Injury Model Systems study.

OBJECTIVE: To characterize overall and cause-specific mortality and life expectancy among persons who have completed inpatient traumatic brain injury rehabilitation and to assess risk factors for mortality. DESIGN: Prospective cohort study. SETTING: The Traumatic Brain Injury Model Systems. PARTICIPANTS: A total of 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized mortality ratio (SMR), life expectancy, cause of death. RESULTS: SMR was 2.25 overall and was significantly elevated for all age groups, both sexes, all race/ethnic groups (except Native Americans), and all injury severity groups. SMR decreased as survival time increased but remained elevated even after 10 years postinjury. SMR was elevated for all cause-of-death categories but especially so for seizures, aspiration pneumonia, sepsis, accidental poisonings, and falls. Life expectancy was shortened an average of 6.7 years. Multivariate Cox regression showed age at injury, sex, race/ethnic group, marital status and employment status at the time of injury year of injury, preinjury drug use, days unconscious, functional independence and disability on rehabilitation discharge, and comorbid spinal cord injury to be independent risk factors for death. CONCLUSION: There is an increased risk of death after moderate or severe traumatic brain injury. Risk factors and causes of death have been identified that may be amenable to intervention.

Use of neighborhood characteristics to improve prediction of psychosocial outcomes: a traumatic brain injury model systems investigation.

OBJECTIVE: To determine whether use of neighborhood characteristics derived from U.S. Census Bureau information contributes to the prediction of outcomes after traumatic brain injury (TBI) beyond the variance accounted for by individual characteristics. DESIGN: Cross-sectional analysis of follow-up interviews conducted 1, 2, and 5 years postinjury. SETTING: Twelve Traumatic Brain Injury Model Systems (TBIMS) centers. PARTICIPANTS: Patients 16 years of age and older with moderate or severe TBI enrolled in the TBIMS National Database (N=472). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Satisfaction With Life Scale and Participation Assessment with Recombined Tools-Objective. RESULTS: Individual characteristics alone accounted for 26% and 48% of variance in life satisfaction and participation, respectively; neighborhood characteristics alone accounted for 6% and 9% of variance, respectively. Models combining both types of characteristics included significant neighborhood and individual predictors for participation but not life satisfaction; however, for participation, prediction only improved beyond that found for individual characteristics alone by 1.2%. CONCLUSIONS: The results did not support the hypotheses that characteristics of a person's neighborhood would increase outcome prediction beyond that which can be accomplished based on characteristics of the individual alone. Though neighborhood characteristics were statistically significant in prediction models, the improvement in percent of variance accounted for was negligible. Refinements in conceptualization and methodology are suggested for continued exploration of the contribution of neighborhood characteristics to TBI outcomes.

Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: the SCIRehab project.

BACKGROUND/OBJECTIVE: To examine associations of patient characteristics along with treatment quantity delivered by seven clinical disciplines during inpatient spinal cord injury (SCI) rehabilitation with outcomes at rehabilitation discharge and 1-year post-injury. METHODS: Six inpatient SCI rehabilitation centers enrolled 1376 patients during the 5-year SCIRehab study. Clinicians delivering standard care documented details of treatment. Outcome data were derived from SCI Model Systems Form I and II and a project-specific interview conducted at approximately 1-year post-injury. Regression modeling was used to predict outcomes; models were cross-validated by examining relative shrinkage of the original model R(2) using 75% of the dataset to the R(2) for the same outcome using a validation subsample. RESULTS: Patient characteristics are strong predictors of outcome; treatment duration adds slightly more predictive power. More time in physical therapy was associated positively with motor Functional Independence Measure at discharge and the 1-year anniversary, CHART Physical Independence, Social Integration, and Mobility dimensions, and smaller likelihood of rehospitalization after discharge and reporting of pressure ulcer at the interview. More time in therapeutic recreation also had multiple similar positive associations. Time spent in other disciplines had fewer and mixed relationships. Seven models validated well, two validated moderately well, and four validated poorly. CONCLUSION: Patient characteristics explain a large proportion of variation in multiple outcomes after inpatient rehabilitation. The total amount of treatment received during rehabilitation from each of seven disciplines explains little additional variance. Reasons for this and the phenomenon that sometimes more hours of service predict poorer outcome, need additional study. Note: This is the first of nine articles in the SCIRehab series.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

BACKGROUND/OBJECTIVE: Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury. METHODS: Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia. RESULTS: PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries. CONCLUSION: Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.

Relationship of occupational therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

BACKGROUND/OBJECTIVE: Describe associations of occupational therapy (OT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and 1-year post-injury. METHODS: Occupational therapists at six inpatient rehabilitation centers documented detailed information about treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary for a 75% subset; models were validated with the remaining 25%. Functional outcomes for injury subgroups (motor complete low tetraplegia and motor complete paraplegia) also were examined. RESULTS: OT treatment variables explain a small amount of variation in Functional Independence Measure (FIM) outcomes for the full sample and significantly more in two functionally homogeneous subgroups. For patients with motor complete paraplegia, more time spent in clothing management and hygiene related to toileting was a strong predictor of higher scores on the lower body items of the self-care component of the discharge motor FIM. Among patients with motor complete low tetraplegia, higher scores for the FIM lower body self-care items were associated with more time spent on lower body dressing, manual wheelchair mobility training, and bathing training. Active patient participation during OT treatment sessions also was predictive of FIM and other outcomes. CONCLUSION: OT treatments add to explained variance (in addition to patient characteristics) for multiple outcomes. The impact of OT treatment on functional outcomes is more evident when examining more homogeneous patient groupings and outcomes specific to the groupings. Note: This is the third of nine articles in the SCIRehab series.

Relationship of therapeutic recreation inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

OBJECTIVE: To investigate associations of therapeutic recreation (TR) interventions during inpatient rehabilitation for patients with traumatic spinal cord injury (SCI) with functional, participation, and quality of life outcomes. METHODS: In this prospective observational study, data were obtained from systematic recording of TR services by certified TR specialists, chart review, and patient interview. RESULTS: TR interventions, including exposure to community settings and leisure activities, add to the variance explained (in addition to the strong predictors of injury classification, admission motor Functional Independence Measure (FIM), and other patient characteristics) in outcomes at the time of rehabilitation discharge (FIM, discharge to home) and at the 1-year injury anniversary (FIM, working or being in school, residing at home, and societal participation as measured by the Craig Handicap Assessment and Reporting Technique (CHART)). They also are associated with less rehospitalization and less pressure development after discharge. In addition, more time spent in specific TR activities during rehabilitation is associated with more participation in the same type of activities at the 1-year injury anniversary. CONCLUSION(S): Greater participation in TR-led leisure skill and community activities during rehabilitation is a positive predictor of multiple outcomes at rehabilitation discharge and the 1-year injury anniversary demonstrating that TR activities are associated with a return to a productive and healthy life after SCI. Further research should focus on the impact of TR on longer-term outcomes to determine whether relationships continue or change as persons continue to adapt to their life after SCI. Note: This is the fourth of nine articles in the SCIRehab series.

Relationship of speech-language pathology inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

BACKGROUND/OBJECTIVE: Describe associations of patient characteristics and speech-language pathology (SLP) interventions provided during impatient rehabilitation for spinal cord injury (SCI) to outcomes at discharge and 1-year post-injury. METHODS: Speech-language pathologists at six inpatient rehabilitation centers documented details of treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary. Cognitive, participation, and mood outcomes for a subsample of patients with traumatic brain injury (TBI) and cognitive-communication limitations (CCLs) were examined. RESULTS: SLP treatment factors explain a small amount of variation in cognitive Functional Independence Measure (FIM), participation, and mood. Variation explained by treatment factors for cognitive outcomes at the time of discharge increased when the patient group was more homogeneous (patients with TBI and CCLs). More time in SLP cognitive-communication interventions had a negative relationship, while longer length of stay was positive. The added explanatory power was not seen for similar outcomes at 1-year post-injury. CONCLUSION: Patients with SCI who have the greatest need for interventions to address cognitive limitations due to TBI receive the most SLP cognitive-communication treatment and show the greatest amount of improvement during rehabilitation. Their cognitive functioning remained impaired at discharge; this likely accounts for the consistent finding that more hours of SLP cognitive-communication treatment is associated with lower cognitive FIM scores at discharge. Future research on individuals with dual SCI and TBI should include more comprehensive assessment of individual differences in cognitive performance in order to better examine the complex relationships between SLP treatments and outcomes. Note: This is the fifth of nine articles in this SCIRehab series.

Relationship of psychology inpatient rehabilitation services and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

CONTEXT AND OBJECTIVE: To evaluate the effects of psychological interventions on rehabilitation outcomes, including residence and functional status at discharge, and residence, school attendance, or employment, and physical, social, occupational, and mobility aspects of participation 1 year after spinal cord injury (SCI). DESIGN: Prospective observational cohort study. SETTING: Six inpatient rehabilitation facilities in the United States. PARTICIPANTS: Inpatients with SCI 12 years of age and older. INTERVENTIONS: Usual rehabilitation care. OUTCOME MEASURES: Functional Independence Measure at rehabilitation discharge and 1-year injury anniversary; discharge destination and residence at 1-year anniversary; Craig Handicap Assessment and Reporting Technique, Diener Satisfaction with Life Scale, Patient Health Questionnaire, employment or school attendance, rehospitalization, and occurrence of a pressure ulcer at 1-year anniversary. RESULTS: More time in psycho-educational interventions was associated with better function, discharge to home, home residence at 1 year, and the absence of pressure ulcers at 1 year. More psychotherapeutic sessions focusing on processing emotions and/or locus of control were associated with poorer function at discharge and 1 year, less physical independence and community mobility, lower satisfaction with life, and the presence of pressure sores at 1 year. CONCLUSIONS: Psychological services are an important component of comprehensive medical rehabilitation and tailored to patient needs and readiness to benefit from rehabilitation. Services focused on remediating deficits tend to be associated with negative outcomes, while services intended to foster adjustment and growth tend to be associated with favorable outcomes. Further research is needed to determine the optimal type and timing of psychological services during inpatient rehabilitation based on individuals' strengths and vulnerabilities. Note: This is the sixth in this third series of SCIRehab articles.

Outcomes of social work and case management services during inpatient spinal cord injury rehabilitation: the SCIRehab project.

OBJECTIVE: To investigate associations of social work/case management (SW/CM) services during inpatient rehabilitation following spinal cord injury (SCI) and patient characteristics with outcomes. DESIGN: Prospective observational cohort of individuals with SCI receiving inpatient rehabilitation. SETTING: Six inpatient rehabilitation centers. PARTICIPANTS: 1032 individuals with traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Type of residence at the time of rehabilitation discharge. Employment/school status, presence of a pressure ulcer, Patient History Questionnaire, Satisfaction with Life Scale, Craig Handicap Assessment and Reporting Technique (CHART) subscales, and rehospitalization at 1-year post-injury. RESULTS: The intensity of specific SW/CM services is associated with multiple outcomes examined. More sessions dedicated to discharge planning for a home discharge and financial planning were associated positively with more discharge to home, while more sessions focused on planning for discharge to a location other than home, e.g. nursing home or long-term acute care facilities, have negative associations with societal participation outcomes (CHART Social Integration, Occupation, and Mobility scores) as well as with residing at home at the time of the 1-year injury anniversary. CONCLUSION(S): The intensity and type of SW/CM services are associated with outcomes at rehabilitation discharge and at 1-year post-injury. Discharge to home may require assistance from SW/CM in the area of discharge planning and financial planning, while discharge to non-home residence demands directed SW/CM services for such placement. Note: This is the eighth of nine articles of this SCIRehab series.

Relationship of nursing education and care management inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

OBJECTIVE: To investigate associations of nursing bedside education and care management activities during inpatient rehabilitation with functional, participation, and quality-of-life outcomes for patients with traumatic spinal cord injury (SCI). METHODS: In a prospective observational study, data were obtained by means of systematic recording of nursing activities by registered nurses (RNs), chart review and patient interview. RESULTS: Greater patient participation in nursing activities is associated with better outcomes. More time spent by RNs in coordination with other members of the care team, consultants and specialists, along with participation in physician rounds (team process) is associated with patient report of higher life satisfaction and higher CHART mobility at the one-year injury anniversary; more time providing psychosocial support is associated with higher CHART mobility and occupation scores and with greater likelihood of working or being in school at the anniversary. More time spent providing education about specific care needs is associated with several outcomes but not as consistently as might be expected. CONCLUSION(S): Higher levels of patient participation in nursing care activities is associated with multiple better outcomes, and hence, nurses should promote active patient participation during all aspects of care and interactions between themselves and patients with SCI. Time spent providing psychosocial support of patients and their families should be evaluated to ensure that other necessary education or care management interventions are not minimized. Note: This is the seventh of nine articles in the SCIRehab series.

Effects of tidal volume, ventilatory frequency, and oxygen insufflation flow on the fraction of inspired oxygen in cadaveric horse heads attached to a lung model.

OBJECTIVE: To measure the effects of tidal volume, ventilatory frequency, and oxygen insufflation flow on the fraction of inspired oxygen in cadaveric horse heads attached to a lung model. SAMPLE: 8 heads of equine cadavers. PROCEDURES: Each cadaveric horse head was intubated with a nasotracheal tube that extended into the proximal portion of the trachea. Oxygen was delivered through an oxygen catheter contained within and extending to the tip of the nasotracheal tube. The trachea was connected to the lung model by use of a spiral-wound hose with a sampling adaptor. Eight treatment combinations involving 2 tidal volumes (5 and 8 L), 2 ventilatory frequencies (6 and 12 mechanical breathes/min), and 2 insufflation rates (10 and 15 L/min) were applied to each head. Hand-drawn inspired gas samples were collected and analyzed for oxygen concentrations. RESULTS: The fraction of inspired oxygen (measured at mid trachea) ranged from 26.8% to 39.4%. Fraction of inspired oxygen was significantly higher with a smaller tidal volume, lower ventilatory frequency, and higher insufflation rate. CONCLUSIONS AND CLINICAL RELEVANCE: In the study model, measured fraction of inspired oxygen varied with ventilatory pattern as well as oxygen insufflation rate. Clinically, this information could be beneficial for interpretation of data regarding arterial blood gases and hemoglobin saturation and in making appropriate oxygen insufflation decisions for anesthetized horses that are breathing room air.