Ethical considerations in the management of military related concussion

Since the year 2000 over 300,000 military service members have been diagnosed with mild traumatic brain injury/concussion. Consequently, this injury has become the subject of increased awareness and study within the military healthcare environment. Although single and/or isolated concussions typically heal in a relatively rapid fashion with limited to no long-term sequelae, there is debate in the field about the impact of repeat concussion. To this end, various ethical challenges arise when managing patients with such injuries. Several papers outlining these issues with regard to athletes have been published in the sports medicine literature. However, because providers caring for military service members must make return-to-duty-decisions, practice within the military setting results in a number of unique ethical considerations. More specifically, management of service members with a history of repeat concussion and increasingly complicated recoveries, as well as the potential for premature return-to-duty are topics of concern for military health care providers. Using the American Psychological Association ethical principles and standards, the current article outlines various ethical challenges to concussion management in the military setting. The ethical principles of Beneficence and Nonmaleficence and Respect for People’s Rights and Dignity, as well as the 3 related ethical standards of Competence, Avoiding Harm, and Conflict of Interest are discussed. Policy changes are highlighted as a proximal solution to these ethical challenges.     

Depressive Symptomatology Mediates Associations With Community Reintegration in Veterans With TBI

Community reintegration (CR) is a challenge for military veterans with traumatic brain injury (TBI). Posttraumatic stress disorder (PTSD), depression, bodily pain, and limitations in physical functioning—common comorbidities with TBI in veterans—have all been associated with problems in CR, but their interrelationships are unclear. The role of depression as a possible mediator of effects on CR has not been examined. We tested depressive symptoms as a possible mediator of CR’s associations with physical limitations, PTSD, and bodily pain. This cross-sectional study used baseline data from a larger randomized controlled trial that evaluated the impact of an in-home intervention for veterans with TBI and their families. Eighty-three military veterans with TBI recruited from a medical rehabilitation service at an urban U.S. Department of Veterans Affairs medical center participated in the study. Interview instruments measured CR, depressive symptoms, physical limitations (limitations in physical functioning), bodily pain, quality of the relationship with key family members, and sociodemographic characteristics. PTSD was determined through review of the electronic medical record. Interview data were collected in veterans’ homes. Depressive symptoms totally mediated the association between physical limitations and CR and the association between PTSD and CR. The bodily pain–CR association was not significant after quality of relationship had been entered into the regression models. Findings suggest that interventions to increase CR of veterans with TBI should address depression, a treatable condition. Replication of our mediation findings in larger veteran and civilian samples with TBI is needed.     

Applying a traumatic stress approach to understanding PCS following pediatric mild TBI

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children’s posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.     

Using a Computer as an Environmental Facilitator to Promote Post-Head Injury Social Role Resumption

Abstract

The purpose of this case study was to determine if an adult man with traumatic brain injury could use a computer as an environmental facilitator to assume adult social roles post-injury. The participant received four months of intervention in which (a) modifications to the computer's internal system, monitor, and keyboard were made, (b) the participant received instruction in adapted word processing and e-mail packages, and (c) the participant was provided with computer-related activities that were designed to enhance his participation in desired social roles. Participant observation and qualitative interview methods were used as data collection and analysis processes. As a result of his participation in the intervention, the participant was able to (a) re-establish his roles as a brother and an adult son, (b) develop and maintain an extended family of others beyond his family of origin, and (c) create a more satisfying adult work role that has brought greater meaning to his post-injury life.     

ABOLISHING AND ESTABLISHING OPERATION ANALYSES OF SOCIAL ATTENTION AS POSITIVE REINFORCEMENT FOR PROBLEM BEHAVIOR

Three participants whose problem behavior was maintained by contingent attention were exposed to 45‐min presessions in which attention was withheld, provided on a fixed‐time (FT) 15‐s schedule, or provided on an FT 120‐s schedule. Following each presession, participants were then tested in a 15‐min session similar to the social attention condition of an analogue functional analysis. The results showed establishing operation conditions increased problem behavior during tests and that abolishing operation conditions decreased problem behavior during tests.     

两种术式治疗腰椎管狭窄症的疗效分析

探讨后路椎弓根螺钉系统固定、Cage加自体骨椎间融合(PLIF)与传统术式(开窗减压、半椎板切除、全椎板截骨回植)治疗腰椎管狭窄症的疗效差异。2006年6月～2008年8月,对85例腰椎管狭窄症患者行传统术式减压(A组38例)、PLIF治疗(B组47例)。术后随访16个月～43个月,平均23个月。采用JOA评分评估疗效并行统计学分析。结果A组有效率78.94%,B组有效率95.74%。A组与B组比较,B组疗效优于A组,差异有统计学意义。因此,后路椎弓根螺钉系统固定、Cage加自体骨椎间融合治疗腰椎管狭窄症的疗效优于传统术式。     

The relationship between self‐harm and alexithymia

This paper presents a systematic review of the literature concerning the relationship between alexithymia and self‐harm. Fifteen studies were selected following a systematic search of relevant databases. Results indicate significantly higher levels of alexithymia in women who self‐harm compared with women who do not self‐harm. Studies of men were less conclusive and require further investigation. A subsample of the studies found that childhood abuse and bullying were more likely to be associated with self‐harm if alexithymia was present as a mediator. Other studies found that depression mediated between alexithymia and self‐harm. The results indicate that the poor emotional cognition and expression associated with alexithymia may increase vulnerability to self‐harm, particularly in women.     

The Needle in the Haystack

Summary

Despite the significant damages in sexual abuse cases, the plaintiff's ability to collect the money awarded in settlement or judgment is often precluded by the limited financial resources of the defendant(s). In this chapter, practicing attorney Julian Hubbard introduces the basics of individual and corporate insurance coverage and reviews the development of very limited coverage in sexual abuse cases in statutory and case law. While direct coverage for sexual abuse injuries is as rare as a “needle in a haystack,” indirect coverage can be found in some cases, especially those in which the acts of negligent individuals other than the perpetrator facilitated the abuse and thus the plaintiff's injuries. After an overview of relevant insurance issues and law, Mr. Hubbard delineates a practical model for research and legal strategies to ensure reaching any available insurance coverage, and explores the benefits and drawbacks of drawing on administrative resources to help pay for survivors' medical and mental health care.