Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department.

OBJECTIVE: The study aim was to test whether a brief motivational intervention, with or without a booster session, would improve drinking-related outcomes more than standard Emergency Department (ED) treatment. METHOD: The study population consisted of 539 (78% male) injured patients treated in the ED and discharged to the community following their treatment. Injured patients met inclusion criteria if they were assessed as hazardous or harmful drinkers by scoring eight or more on the AUDIT and/or having alcohol in their system at the time of their injury or ED visit. Patients were randomly assigned to either standard care (SC), brief intervention (BI) or brief intervention plus a booster session (BIB). At 1-year follow-up, 447 patients (83% of the sample) were re-interviewed to measure alcohol-related negative consequences, injuries and drinking. RESULTS: Patients receiving BIB, but not B1 patients, reduced alcohol-related negative consequences and alcohol-related injuries more than did those in the SC group. All three groups reduced their days of heavy drinking. Patients with histories of hazardous drinking responded to BIB, whether or not they had consumed alcohol prior to their injury. CONCLUSIONS: Together, these results indicate that the effects of a booster session that is added to a brief intervention in the ED can be helpful to injured patients with a history of hazardous or harmful drinking, irrespective of whether they have consumed alcohol prior to their injury.

Alcohol expectancies as a mediator of the relationship between injury and readiness to change drinking behavior.

There is a well-established relationship between alcohol expectancies and drinking behavior. The purpose of the present study was to extend the literature by examining the role of alcohol expectancies in determining readiness to change drinking behavior among injured emergency department patients who screened positive for hazardous drinking. Negative expectancies were found to partially mediate the relationships of alcohol-related injuries and injury aversiveness to readiness to change drinking behavior. Results suggest that negative alcohol expectancies are a potential means of increasing patients' readiness to change drinking behavior.

Sleep and pain complaints in symptomatic traumatic brain injury and neurologic populations.

OBJECTIVE: To compare the incidence of sleep and pain complaints in symptomatic traumatic brain injury (TBI) (mild vs moderate/severe) and neurologic populations. DESIGN: Case-control study. SETTING: Outpatient neuropsychology service at a university-affiliated tertiary care center. PATIENTS: A consecutive sample of mild (n = 127) and moderate to severe (n = 75) patients with TBI and a general neurologic (non-TBI) group (n = 123) referred for neuropsychological assessment. MAIN OUTCOME MEASURES: Patient report of sleep and/or pain problems. RESULTS: TBI subjects had significantly more insomnia (56.4% vs 30.9%) and pain complaints (58.9% vs 22%) than non-TBI subjects (p < .0001). For both subject groups, the presence of pain increased insomnia approximately twofold. Poor sleep maintainance was the most common sleep problem. In those subjects without pain, TBI patients reported more sleep complaints that non-TBI patients (p = .05). Mild TBI patients reported significantly (p < .0001) more pain than patients with a moderate to severe injury (70% vs 40%). In TBI subjects without pain, there were significantly more insomnia complaints in mild than in moderate to severe injuries (p < .01). CONCLUSIONS: TBI patients with persistent cognitive complaints have more sleep and pain concerns than general neurologic patients. Pain is strongly associated with sleep problems. Aggressive evaluation and treatment of pain and sleep problems in the TBI, especially mild TBI, population appears warranted and may contribute to increased disability. The etiology of greater sleep and pain problems in the mild than in the more severe TBI patients requires further study.

Order effects in the administration of a forced-choice procedure for detection of malingering in disability claimants' evaluations.

100 disability claimants of the Social Security Administration referred for neuropsychological evaluation and 40 undergraduate college students asked to simulate brain damage were administered a measure for the detection of malingering, an abbreviated version of the Hiscock Forced-choice Procedure, and other neuropsychological tests. Half of each group was administered the Hiscock Procedure at the beginning of the battery; the other half was administered this test last. For both groups, the results indicated poorer performance on the earlier administration of the abbreviated Hiscock Forced-choice Procedure. Formal measures for detection of malingering should be an integral and early part of any neuropsychological evaluation in which the subject has a financial incentive to perform poorly.

Identification of hazardous/harmful drinking among subcritically injured patients.

OBJECTIVES: To examine the relationship between a saliva alcohol test (SAT) and hazardous/harmful drinking, as measured by the Alcohol Use Disorders Identification Test (AUDIT), among a sample of subcritically injured patients. METHODS: Patients (n = 78) seeking treatment for a subcritical injury were saliva-tested for alcohol and interviewed regarding their drinking behaviors and related difficulties. Associations of SAT values with AUDIT results were determined. RESULTS: SAT results and hazardous/harmful drinking were not independent events (p < 0.001). Estimates of sensitivity and specificity (using a dichotomous SAT result [> or = 4 mmol/L] to identify positive AUDIT patients) were 65.2% and 83.6%, respectively. SAT-positive people had significantly higher AUDIT scores than did SAT-negative individuals (p < 0.0001). Patients experiencing assault-type injuries were much more likely to be SAT-positive than were patients incurring other types of injury. Discriminant function analysis suggests that AUDIT scores can successfully identify SAT-positive and SAT-negative patients; the analysis accounted for 42.5% of the variance and correctly classified 84.6% of the sample. CONCLUSIONS: The use of an easy-to-administer, noninvasive, routine SAT, among patients presenting for a subcritical injury in a hospital ED, provides a mechanism for the identification of individuals with a history of hazardous/harmful drinking. However, since discrimination of hazardous/harmful drinking is imperfect, some caution is warranted when conducting such screening activities.

Validity of neuropsychological test results in disability evaluations.

A group of 50 disability claimants referred by the Social Security Administration for neuropsychological screening were administered a 36-item, forced-choice, digit-recognition method of detecting malingering to assess effort and motivation to perform well. This abbreviated form of the 1989 Hiscock and Hiscock Forced-choice Procedure has been shown to be quite easy even for individuals with severe organic brain dysfunction. A perfect performance of 36 correct on this digit-recognition task is obtained by most individuals with moderate to severe brain damage. A performance of less than 90% correct is due more likely to poor effort or even malingering rather than brain damage. In this sample, 18% (n = 9) obtained scores of less than 90% correct, i.e., < 33, which calls into question the reliability and validity of test data obtained. An additional 20% (n = 10) obtained intermediate scores of 33 to 35 correct. These intermediate scores are more difficult to interpret although at least some proportion of those scores reflects poor motivation. The results over-all indicate that nearly one-fifth of potential disability claimants produced invalid and uninterpretable neuropsychological test protocols and an additional one-fifth obtained protocols that should be well scrutinized for evidence of poor effort as well. Neuropsychologists conducting disability evaluations are urged to use measures designed specifically to assess effort and motivation.

Distal anterior choroidal artery aneurysm: intraoperative localization and treatment.

Distal anterior choroidal artery aneurysms with intraventricular hemorrhage are rare and difficult to treat. We report the case of a 46-year-old woman with a left distal anterior choroidal artery aneurysm presenting as a typical subarachnoid hemorrhage from which she had no focal neurological signs. Because the aneurysm was located within the dominant deep temporal lobe, we used intraoperative computed tomography to guide a probe to the aneurysm to allow minimal dissection. This is the first report of a successfully treated distal anterior choroidal artery aneurysm. Reports of this unusual aneurysm and methods of approaching deep temporal lesions are reviewed.

Focal cognitive deficits accentuated by depression.

A patient with a postoperative posterior right hemisphere lesion underwent neuropsychological testing during a major depressive episode, and again following remission of the depression. Qualitative visuoconstructive deficits typical of right hemisphere damage were present when the patient was depressed, but were absent following treatment of the depression. Verbal intelligence, cooperation, and vigilance were normal. The case suggests that depression may accentuate focal cognitive signs of fixed lesions in the absence of global impairment of function.

Evaluation of a social-setting detoxication program.

Nonmedical social-setting detoxication (SSD) is proposed as a safe, cost-effective program which emphasizes referral to long-term treatment. An examination of patient characteristics, program safety, utilization and cost, referral rate, and patient-staff interaction at one SSD program indicated the viability of the SSD model.