Study Suggests Depression After Traumatic Brain Injury Could Represent a New, Distinct Disease

Brigham and Women's Hospital

A new study led by Shan Siddiqi, MD, from Brigham and Women's Hospital, a founding member of the Mass General Brigham health care system, suggests that depression after traumatic brain injury (TBI) could be a clinically distinct disorder rather than traditional major depressive disorder, with implications for patient treatment. The findings are published in Science Translational Medicine.

"Our findings help explain how the physical trauma to specific brain circuits can lead to development of depression. If we're right, it means that we should be treating depression after TBI like a distinct disease," said corresponding author Shan Siddiqi, MD, of the Brigham's Department of Psychiatry and Center for Brain Circuit Therapeutics.

"Many clinicians have suspected that this is a clinically distinct disorder with a unique pattern of symptoms and unique treatment response, including poor response to conventional antidepressants—but until now, we didn't have clear physiological evidence to prove this."

Siddiqi collaborated with researchers from Washington University in St. Louis, Duke University School of Medicine, the University of Padua, and the Uniformed Services University of the Health Sciences on the study.

The work started as a side project seven years ago when Siddiqi was motivated by a patient he shared with David Brody, MD, Ph.D., a co-author on the study and a neurologist at Uniformed Services University. The two started a small clinical trial that used personalized brain mapping to target brain stimulation as a treatment for TBI patients with depression. In the process, they noticed a specific pattern of abnormalities in these patients' brain maps.

A unique brain network architecture in depression after traumatic brain injury: the study and the story behind the science. Credit: Shan H. Siddiqi

The current study included 273 adults with TBI, usually from sports injuries, military injuries, or car accidents. People in this group were compared to other groups who did not have a TBI or depression, people with depression without TBI, and people with post-traumatic stress disorder.

Study participants went through a resting-state functional connectivity MRI, a brain scan that looks at how oxygen is moving in the brain. These scans gave information about oxygenation in up to 200,000 points in the brain at about 1,000 different points in time, leading to about 200 million data points in each person. Based on this information, a machine learning algorithm was used to generate an individualized map of each person's brain.

The location of the brain circuit involved in depression was the same among people with TBI as people without TBI, but the nature of the abnormalities was different. Connectivity in this circuit was decreased in depression without TBI and was increased in TBI-associated depression. This implies that TBI-associated depression may be a different disease process, leading the study authors to propose a new name: "TBI affective syndrome."

"I've always suspected it isn't the same as regular major depressive disorder or other mental health conditions that are not related to traumatic brain injury," said Brody. "There's still a lot we don't understand, but we're starting to make progress."

One limitation of the trial is that with so much data, the researchers were not able to do detailed assessments of each patient beyond brain mapping. As a future step, investigators would like to assess participants' behavior in a more sophisticated way and potentially define different kinds of TBI-associated neuropsychiatric syndromes.

Siddiqi and Brody are also using this approach to develop personalized treatments. Originally, they set out to design a new treatment in which they used this brain mapping technology to target a specific brain region for people with TBI and depression, using transcranial magnetic stimulation (TMS). They enrolled 15 people in the pilot and saw success with the treatment. Since then, they have received funding to replicate the study in a multi-center military trial.

"We hope our discovery guides a precision medicine approach to managing depression and mild TBI, and perhaps even intervene in neuro-vulnerable trauma survivors before the onset of chronic symptoms," said Rajendra Morey, MD, a professor of psychiatry at Duke University School of Medicine, and co-author on the study.
 

Salaried Exempt Employee Deductions from Salary

SESCO Management

To qualify for exemption, employees generally must be paid at least $684 per week on a salary basis. Being paid on a “salary basis” means an employee regularly receives a predetermined amount of compensation each pay period on a weekly, or less frequent, basis.

There are circumstances when deductions can be made from an exempt employee’s pay. Deductions can be made if the exempt employee is absent for a day or more for personal reasons (personal leave).

Also, deductions may be made for absences of a full day or more due to sickness or disability, if the deduction is made in accordance with a bona fide plan of providing compensation for loss of salary caused by sickness or disability (such as sick leave, PTO time, vacation, etc.). For example, if an exempt employee has accrued sick leave or PTO time and he is absent for 4 hours of the workday, he would be paid for the full day, but 4 hours would be deducted from his bank of sick leave. However, if the exempt employee has not yet qualified for sick leave or has exhausted his sick leave, there would be a deduction in his pay only if he is absent for a full day or longer.

An exempt employee’s salary may be reduced to offset amounts the employee receives for jury duty or military pay. Deductions are also allowed for penalties imposed for major violations of safety rules or for unpaid disciplinary suspensions of one or more full days for violation of the organization’s work rules.

Also, note that under the Family and Medical Leave Act (FMLA), an exempt employee’s pay may be reduced when unpaid FMLA leave is taken. This is the case even when less than a full day is taken as FMLA leave.

Inclement Weather

Poor weather conditions of the winter months can often raise pay-related questions for employers. Employees may not report to work because of hazardous conditions, or your business may close for the day. The issue is straightforward for non-exempt employees (i.e., employees paid on an hourly basis, subject to overtime pay). Non-exempt employees are paid for the actual time worked. Thus, if they do not report for work or the business is closed, they are not paid for the day. An employer may choose to allow these employees to use vacation or other paid time off to cover the lost wages.

The issue is a little more complex for salaried exempt employees. The question of pay is determined by whether or not the employer is open for business and whether the exempt employee works any part of the day. An employer that remains open for business during a weather emergency may lawfully deduct one full-day’s absence from the salary of an exempt employee who does not report for work for the day due to adverse weather conditions. In a recent opinion letter, the Department of Labor considers this an absence due to personal reasons; therefore, a deduction of a full-day’s pay will not violate the salary basis rule or otherwise affect the employee’s exempt status. It should be noted that deductions from salary for less than a full-day’s absence are not permitted for such reasons under the wage and hour regulations. The Wage and Hour Division has stated that an employer may, as an option, require an exempt employee who fails to report for work in this situation to take vacation or other paid leave to cover the full-day’s absence.

What about the pay of a salaried exempt employee if the business is closed? An employer may not make deductions “for absences occasioned by the employer or by the operating requirements of the business.” If the employer closes operations due to weather or other emergency for less than a full workweek, then the employer must pay an exempt employee “the full salary for any week in which the employee performs any work without regard to the number of days or hours worked,” because “deductions may not be made for time when work is not available.” Again, the Wage and Hour Division has ruled that an employer may direct exempt employees to take vacation or other paid leave in this situation, provided the employees receive in payment an amount equal to their guaranteed salary. However, if an exempt employee has no vacation or paid leave, the employee would still receive the full week’s salary in this situation (where the business is closed for less than a week).

Sickness vs. Personal Reasons for Absence

Deductions from a salaried exempt employee’s pay for sickness/disability or personal reasons may only be made as follows:

Employers With a Bona Fide Leave Plan:

  • Exempt-Sickness or Disability-Partial Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet, no reduction in pay is allowed; however, the leave balance may be reduced to the negative.
  • Exempt-Sickness or Disability-Full Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet a full day reduction in pay is allowed (an employer may pay leave time where the balance is zero thereby reducing the leave balance to the negative).
  • Exempt-Personal-Partial Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet, no reduction in pay is allowed; however, the leave balance may be reduced to the negative.
  • Exempt-Personal-Full Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet a full day reduction in pay is allowed (an employer may pay leave time where the balance is zero thereby reducing the leave balance to the negative).

Employers Without a Bona Fide Leave Plan:

  • Exempt-Sickness or Disability-Partial Day- No reduction in pay is allowed.
  • Exempt-Sickness or Disability-Full Day-No reduction in pay is allowed unless the full workweek is not worked.
  • Exempt-Personal-Partial Day-No reduction in pay is allowed.
  • Exempt-Personal-Full Day-Reduction in pay is allowed.

If you are not a retainer client of SESCO Management Consultants, contact them to learn about their services by calling 423-764-4127 or click here.
 

Half of US Adults Skip Common Health Screenings, Including Tests for Certain Diseases, Survey Finds

Fierce Healthcare | By Noah Tong
 
Americans are likely to skip important health screenings, and women have a less positive outlook than men regarding their current and future health prospects, according to a survey released by Aflac.
 
The survey, based on about 2,000 employed adults, examined attitudes, habits and opinions about health and preventive care and found that half of adults have avoided at least one common health screening. These screenings include tests for certain diseases.
 
But for the 51% of respondents who said they have had cancer, that diagnosis came following a routine checkup or screening. For Hispanic survey respondents, 72% of individuals said a diagnosis was discovered at a routine checkup.
 
Skipping regular checkups is common among individuals who feel healthy. One in 4 respondents said they miss routine checkups. Reasons cited include a conflict with work hours, the individuals are “not thinking about it,” a general dislike for going to the doctor’s office, insurance issues, fear of hearing bad news and the time commitment required.
 
Young people were least likely to take advantage of regular checkups. Just 40% of Generation Z respondents (aged 18-24) said they believe preventive care is important to overall health, but that number rose to 49% for millennials. Gen Z also reported they felt least in control of their mental and physical health.  
 
While men had an overall stronger view of their current health status and the ability to control it in the future, only 38% of women had a positive outlook about their weight and BMI. Just 40% of female respondents felt positively about their financial health.
 
"The results of the Wellness Matters survey put a spotlight on the need for individuals to have a more proactive approach to their health care," said Tom Morey, chief actuary of Aflac U.S., in a news release. "That is why Aflac is encouraging policyholders and others to take control of their health by building good health habits early, asking health and insurance providers questions, and prioritizing routine wellness checkups."
 
Among Hispanic survey respondents, 31% reported language is a barrier to accessing preventive care resources, leading to 72% of respondents saying they have avoided a wellness screening. And 61% of Hispanic respondents also agree that healthcare providers and organizations need to better educate the Latino community on why it’s important to be proactive with health and wellness.
 
Internal Aflac data show that its cancer wellness benefit claims dropped in 2022 compared to 2019. For every 1,000 Aflac policyholders, cancer policy wellness claims dropped 11% for those in their 20s and 9% for those in their 30s.

Read Full Article 
 

APTA 2023 House of Delegates Election Results Announced

Elections were held during a July 8 virtual session of the APTA House of Delegates. Click here to view the results. 
 

Predicting Falls in Rehabilitation: A Comparison of Three Instruments Including Hester Davis

Association of Rehabilitation Nurses

A study published in the journal Rehabilitation Nursing evaluated the ability of the Hester Davis Scale (HDS), Section GG, and facility fall risk assessment scores to predict patients who fall during inpatient rehabilitation.

This study was an observational quality improvement project.

Nurses administered the HDS in parallel to the facility's current fall risk assessment and Section GG of the Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument. Receiver operating characteristic curves were compared in 1,645 patients. Relationships of individual scale items to falls were also assessed.

The HDS (area under the curve [AUC] = .680, 95% CI [.626, .734]), facility fall risk assessment (AUC = .688, 95% CI [.637, .740]), and Section GG scores (AUC = .687, 95% CI [.638, .735]) adequately identified patients who fell. AUCs did not significantly differ between assessments. HDS scores of ≥13, facility scores of ≥14, and Section GG scores of ≤51 resulted in the highest sensitivity/specificity balance.

HDS, facility fall risk assessment, and Section GG scores adequately and similarly identified patients of mixed diagnoses at risk of falling in inpatient rehabilitation.

Rehabilitation nurses have several options including the HDS and Section GG to identify patients at greatest risk of falling.

More information: Erin Y. Harmon et al, Predicting Falls in Rehabilitation: A Comparison of Three Instruments Including Hester Davis, Rehabilitation Nursing (2023). DOI: 10.1097/RNJ.0000000000000421
 
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