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- Traumatic Brain Injury and Depression
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- Research Review Apr. 13, 2011
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Executive Summary – Apr. 13, 2011
Traumatic Brain Injury and Depression
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Partly out of date: This report was assessed in August 2016 and some conclusions may not be current.
Table of Contents
We do not know the extent to which depression contributes to long-term disability following traumatic brain injury (TBI), although depression is one of several potential psychiatric illnesses that may be common following TBI. Major depression may be triggered by physical or emotional distress, and it can deplete the mental energy and motivation needed for both recovering from the depression itself and adapting to the physical, social, and emotional consequences of trauma with brain injury. Depression may be masked by other deficits after head injury, such as cognitive changes and flat affect, which may be blamed for lack of progress in post-trauma treatment but actually reflect underlying depression. Clinicians, caregivers, and patients lack formal evidence to guide the timing of depression screening, which tools to use for screening and assessment, treatment choices, and assessment of treatment success.
Importance of Depression
Depression is defined by criteria that likely circumscribe a heterogeneous set of illnesses. While no single feature is seen in all depressed patients, common features include sadness, persistent negative thoughts, apathy, lack of energy, cognitive distortions, nihilism, and inability to enjoy normal events in life. Especially in a first episode, individuals and families may not recognize the changes as part of an illness, making identification and self-reporting of the condition challenging. Active screening is essential to recognition, treatment, and prevention of recurrence.
The most salient consequence of depression is suicide. Suicide is usually impulsive and extremely difficult to predict and prevent. At least half of suicides occur in the context of a mood disorder.1 Depression reduces quality of life, impairs ability to function in social and work roles, and causes self-doubt and difficulty taking action, all of which can delay recovery from TBI. The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, (DSM-IV-TR)2 defines the illness in terms of physiologic disturbances of sleep, appetite, attention and concentration, motor activity, and energy, and of psychological losses of interest in normal activities, hope, and self-worth while ruminating with excessive sadness, guilt, and suicidal thoughts.
The disturbances may also occur following TBI due to other circumstances, such as pain that disrupts sleep, which may mask the recognition that the sleep disturbance is also a part of a burgeoning depression. Depression may be financially costly in undermining physical therapy efforts, treatment compliance in general, and rehabilitation planning and efforts. The need for systematic evaluation of the prevalence and consequences of depression following TBI is imperative, given the potential for mitigating suicide and unnecessary disability.
Importance of TBI
TBI occurs when external force from an event such as a fall, sports injury, assault, motor vehicle accident, or explosive blast injures the brain and causes loss of consciousness or loss of memory.3 TBI can result from direct impact to the head as well as from rapid acceleration or deceleration of brain tissue, which injures the brain by internal impact with the skull. Both mechanisms can cause tissue damage, swelling, inflammation, and internal bleeding.4
TBI is responsible for roughly 1.2 million emergency department visits each year, with 1 in 4 patients requiring hospitalization.5 Because most estimates of TBI rates are based on hospital use, some individuals with TBI are not counted because they do not seek care at all, or they seek care in other settings. The Centers for Disease Control and Prevention estimates that up to 75 percent of TBIs are mild in terms of duration of loss of consciousness and other immediate symptoms, meaning substantial underestimation of the number of individuals affected is likely.
Nonetheless, estimates of direct and indirect costs associated with TBI exceed $56 billion each year.6 Among individuals who sustain a TBI, approximately 50,000 die each year of their injuries and 80,000 to 90,000 will have a long-term disability. More than 5 million survivors of TBI live with chronic disability.
Military service carries a high risk of TBI. Traumatic brain injury is more common in the military than in civilian populations, even in peacetime. Advances in body protection systems have resulted in fewer deaths and a concomitant rise in TBI that is more often moderate to severe than mild.4 The military confirms that more than 50,000 veterans who have returned from current theatres have blast-related TBI.7 As many as 30 percent of those with any injury on active duty have sustained a TBI.8 Because TBI is common, serious, and has high personal and economic costs, understanding potential consequences of injury is crucial.
Relationship of TBI and Depression
TBIs are associated with a range of short- and long-term outcomes, including physical, cognitive, behavioral, and emotional impairment.9 Prior estimates, not derived systematically, of depression among individuals with TBI range widely, from 15 percent to 77 percent.10-12 Depression associated with TBI can manifest shortly after injury or well into the future.13-14 In their review of rehabilitation for TBI patients, Gordon and colleagues identified 74 studies of psychiatric functioning after TBI.15 Their assessment was that TBI is associated with high rates of depression—more than half of cases—and other DSM Axis I and Axis II conditions. Depression was noted to coexist with other psychiatric conditions, including addiction or anxiety. Comorbid psychiatric conditions with depression may complicate screening, diagnosis, and management of depression in multiple ways, including masking depression so it remains undiagnosed or affects the individual's followthrough or adherence to treatment. It is likely that such comorbid conditions complicate treatment response and recovery just as they do in non-TBI depressed patients. However, no systematic examination of this question has been done to date.
Triggers for depression after TBI may include biological, psychological, and social factors,16 and in the post-TBI population, greater attention is often given to biological factors because of the direct injury to the brain. However, many post-TBI patients do not demonstrate radiological or pathological evidence of brain injury,17 and in the context of current understanding of depression as a biopsychosocial entity, researchers and clinicians generally consider all depression to have a complex etiologic basis. Just as in the non-TBI population, the psychological impact of decreased occupational and functional abilities and its potential to affect the likelihood of becoming depressed should not be overlooked.18
Focus of This Systematic Review
In order to compile the literature in a useful fashion, we included publications that provided a clear description of study participants and that used standardized tools and recognized approaches to identifying depression. We did not address penetrating head injury and did not include research about children younger than 16.
Patients, clinical care providers, families, and support organizations need to know the degree to which depression after TBI is a threat so that anticipatory guidance and care planning can incorporate strategies to address risk of depression or prevent onset. Care providers in a variety of settings need to know when and how best to screen TBI patients for depression. When depression is identified, information about likely outcomes of treatment and about whether certain options are superior is key to informed decisionmaking. This review is focused on pragmatic aspects of these concerns.
Key Questions
In preparing this report, we have addressed the following key questions (KQs):
KQ1. What is the prevalence of depression after traumatic brain injury, and does the area of the brain injured, the severity of the injury, the mechanism or context of injury, or time to recognition of the traumatic brain injury or other patient factors influence the probability of developing clinical depression?
KQ2. When should patients who suffer traumatic brain injury be screened for depression, with what tools, and in what setting?
KQ3. Among individuals with TBI and depression, what is the prevalence of concomitant psychiatric/behavioral conditions, including anxiety disorders, post-traumatic stress disorder (PTSD), substance abuse, and major psychiatric disorders?
KQ4. What are the outcomes (short and long term, including harm) of treatment for depression among traumatic brain injury patients utilizing psychotropic medications, individual/group psychotherapy, neuropsychological rehabilitation, community-based rehabilitation, complementary and alternative medicine, neuromodulation therapies, and other therapies?
KQ5. Where head-to-head comparisons are available, which treatment modalities are equivalent or superior with respect to benefits, short- and long-term risks, quality of life, or costs of care?
KQ6. Are the short- and long-term outcomes of treatment for depression after TBI modified by individual characteristics, such as age, preexisting mental health status or medical conditions, functional status, and social support?
Literature search. Our search included examination of results in five databases: PubMed Medline®, the PsycINFO® database of psychological and psychiatric literature, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Published International Literature on Traumatic Stress database. Controlled vocabulary terms served as the foundation of our search in each resource, complemented by additional keyword terms and phrases selected to represent each of the key concepts in the search. We also employed indexing terms when possible to exclude undesired publication types (e.g., reviews, case reports, letters, etc.) and articles published in languages other than English. We hand-searched reference lists of included articles to identify additional citations. We excluded studies that included fewer than 50 participants, included participants younger than 16 years of age, did not include an operational definition of depression, or were unable to be used to answer any key question.
Study selection. Two reviewers separately evaluated abstracts for inclusion or exclusion. If one reviewer concluded the abstract should be included for full review of the article, it was retained. For the full article review, two reviewers read each article and decided whether it met our inclusion criteria. Discordance was resolved by team adjudication.
Quality assessment. The research team used a quality assessment approach that ensured capture of key study characteristics most relevant to our key questions. Quality was assessed by two reviewers independently. They resolved differences through discussion, review of the publications, and arrival at consensus with the team.
Data extraction. All team members shared the task of entering information into the evidence tables. After initial data extraction, another member of the team reviewed the article and checked all table entries for accuracy, completeness, and consistency. The two abstractors reconciled any discordance in information reported in the evidence tables.
Evidence synthesis. We have endeavored to distinguish duplicate populations; however, for a small proportion of publications, the summaries may overrepresent the total number of unique studies available and could doublecount data. In each section, we summarize the yield of the search and key characteristics of the content of the aggregate literature.
We present data in summary tables arranged by key features discussed. Most often this is by the rigor of the TBI definition and depression measurement used in the research. All data extracted is presented in the evidence tables in Appendix C.
In order to characterize estimates of prevalence, and prevalence across time, we calculated weighted averages and reported these as a global aggregate as well as by timing of screening, setting, and severity of injury. If a study included a measurement at more than one time point, the participants in that study contribute to the estimates for each time at which depression was assessed.
Literature search yield. As a result of the search, 2,015 nonduplicate articles were identified. One hundred fifteen articles were included in the review, representing 81 distinct populations, with 112 articles pertaining to KQ1, 113 to KQ2, 9 to KQ3, 2 to KQ4, and none identified for KQ5 or KQ6. Detailed reasons and process for exclusions are described in the full report.
KQ1. Prevalence of Depression After Traumatic Brain Injury
Content of literature. We identified 112 publications7,12-14,18-125 from 79 distinct study populations. Thirty-eight of the 79 were in the United States, 12 in Canada, 12 in Europe, 9 in Australia, and 8 in other countries. The most common sources of study populations were tertiary care centers, identifying participants from emergency department, intensive care, and inpatient admissions (n = 33), including those that specifically noted trauma center status (n = 10), and rehabilitation programs (n = 19). Neuropsychology labs, private neuropsychology practices, prisons, veterans' records, databases, and psychiatric care facilities each contributed three or fewer populations.
Criteria for defining and characterizing those classified as having TBI were varied, with more than half of authors (n = 38) using closed head injury in concert with Glasgow Coma Scores (GCS). American Congress of Rehabilitation Medicine criteria were common (n = 13), as were ad hoc operational definitions (n = 12) and failing to clearly define criteria (n = 12). In total, the majority of the literature provides sufficient detail about inclusion and exclusion criteria and TBI definitions to understand and/or replicate the population studied.
Seventy-three percent of studies provided cross-sectional measures of depression, meaning that depression status was assessed at a single point in time after TBI; the balance were prospective with two or more assessments of depression status over time. Structured clinical interviews, done specifically for the research or in the course of standardized clinical care protocols, were the most common means of assessing depression status (n = 29). Among written or administered tools, the Beck Depression Inventory (BDI; n = 13), Hospital Anxiety and Depression Scale (HADS; n = 11), and Center for Epidemiologic Studies Depression Scale (CES-D; n = 8) were most common. A wide variety of other measures and customized uses of subscales (n = 62) were also used.
Prevalence estimates. We have considered the Structured Clinical Interview for DSM-IV (SCID) and other formal structured clinical interview protocols that map to the DSM and/or International Classification of Diseases codes to be the measures of depression that are most relevant to clinical care. Among studies that used a SCID or other structured protocol to reach a formal diagnosis of depression, the prevalence of depression after TBI ranged from 12.2 percent53 to 76.7 percent.12 If we focus on the subset of studies with both use of the SCID or other clinical interview and clearly operationalized criteria for TBI, the range was 12.2 percent53 to 54.0 percent.96
Across all timeframes and using all depression measures, in studies with clear TBI definitions, the weighted average for prevalence of depression was 31 percent. Among those studies with repeated assessments and/or longer term followup, no clear pattern of expected natural history or peak prevalence emerged. Depression was more common among those with TBI than among normal comparison groups. Household/family members of individuals with TBI may also have increased risk of depression. Results from comparisons to other trauma populations without severe TBI are variable, with some comparison groups also having statistically comparable risk of depression that exceeds expected prevalence in the general population.
Risk factors. Data are sparse to assess whether severity of injury influences risk of depression. Using structured interviews among those studies with mild or mild/moderate TBI populations, the overall prevalence of depression was 20.3 percent compared with 32.5 percent in studies that enrolled or followed up populations of all severity. Too few studies isolated a sufficient number of those with mild TBI compared to those with moderate and/or severe injuries to make valid estimates. Likewise, stratification of prevalence by explanatory factors such as age, gender, area of brain injured, or mechanism of injury is not possible within the current body of literature.
Fourteen studies in 13 distinct study populations report results from multivariate models to identify predictors or risk factors for depression after TBI.13-14,23,38,50,64,78,99,103,118-121,125 Age was reported in a large United States cohort (n = 559) to be an independent risk factor for depression among both those with and without prior depression. In this study, which reflects the full spectrum of severity of TBI, risk decreased with increasing age, such that those age 60 and older were at lowest risk.125 In another study aiming at predicting risk, when age was grouped with other factors, the combination of older age at injury, CT scan with documented intracranial lesion, and higher 1-week CES-D scores, were sensitive (93 percent) though not specific (62 percent) for identifying those with mild TBI who were depressed by 3 months after their injury.50 One group has found that women have higher risk (relative risk [RR] = 1.27; 95 percent confidence interval [CI]: 1.07, 1.52) of new but not recurrent depression after TBI after adjusting for other risk factors.125
Severity of TBI is not clearly linked with risk. In the sole model that assessed GCS scores, coma length, and duration of post-traumatic amnesia, none of the factors were associated with depression or its severity.118 Another group using the Injury Severity Score also found no association between severity and prevalence of depression.121
History of alcohol and substance abuse increase risk.14,64,125 Pain, involvement in litigation related to the injury, and perceived stress have been reported as risk factors among those entering rehabilitation care and in prospective cohorts.23,121 Psychosocial supports were often described in this literature, and data from caregivers, partners, and family members were common. However, few models incorporated social support items. One group reported that "availability of a confidant" reduced risk of depression,78 and another reported that years married were inversely related to risk, while presence and degree of cognitive disability, motor disability, and social aggression elevated risk.99 Concepts related to resilience or personality traits have not been widely investigated, but scores on the Adult Hope Scale (p < 0.005) and the Life Orientation Test-Revised (p < 0.05), a measure of dispositional optimism, are both found to contribute independently to predicting depression and its severity as measured by the BDI in a small Israeli study (n = 65).119 History of depression has been documented as a substantive risk for having depression at followup (RR = 1.54; 95 percent CI: 1.31, 1.82), as was depression at the time of the injury (RR = 1.62; 95 percent CI: 1.37, 1.91).125
A cluster of reports was focused on investigating whether incorporating information about the area of the brain affected by the injury helped to identify those at highest risk. Imaging research about the areas of the brain injured and the relationship to depression risk yields inconsistent results. In aggregate for all those with TBI, onset of major depression within 3 months of injury has been reported to be sevenfold as common (95 percent CI: 1.36 to 43.48) among those with abnormal CT scans after injury compared with normal imaging.50 Focusing on locations of injury, Jorge and colleagues13,103 have replicated their findings in several CT scan-based studies that left anterior lesions involving the left dorsolateral frontal cortex and/or left basal ganglia are associated with increased risk of acute depression (p = 0.006) when injury location is assessed in multivariate regression models. They also note that frontal lesions, whether left, right, or bilateral, are associated with decreased risk of acute depression (p = 0.04). In contrast, delayed-onset major depression was not associated with lesion location. In a subanalysis of depression types, depression alone was related to left hemisphere injury (p = 0.003), while depression associated with anxiety was more common among those with right hemisphere injury (p = 0.003). A specific assessment of the presence or absence of contusions found the type of injury was not predictive and that depression was somewhat more common among those with contusions (71 percent) than among those without (62 percent). Using magnetic resonance imaging (MRI) near the time of injury, the findings from CT scan studies are not supported, and the only lesion type to emerge as a significant predictor was the protective effect of temporal lesions compared to other injury locations (p = 0.028).38 Study size and timing in relation make this literature more exploratory than conclusive in beginning to understand the relationship between pathophysiology related to the brain injury and risk and timing of onset of depression. In a study of political prisoners, up to 50 years after injury, TBI-associated cerebral cortical thinning in the left superior frontal and bilateral superior temporal cortex, as assessed by MRI, was associated with depression, and similar effects were not seen in prisoners without a history of TBI with respect to depression risk.118
Summary. The prevalence of traumatic brain injury is approximately 30 percent across multiple time points up to and beyond a year. Based on structured clinical interviews, on average 27 percent met criteria for depression 3 to 6 months from injury; 32 percent at 6 to 12 months; and 33 percent beyond 12 months. Higher prevalence is reported in many study populations. No strong predictors are available to select a screening window or to advise TBI patients or their providers about risk of depression.
KQ2. Screening for Depression After TBI
Content of literature. We identified 1137,12-14,18-126 publications in 79 distinct populations that provide information about timing of screening or comparison of tools. Overlap is virtually complete with those publications included in KQ1, adding only one publication from the United States. As a result, study characteristics for this literature are nearly identical.
Timing of screening. In all timeframes across all measures, depression is common after TBI. No distinct trend is apparent to suggest a peak time of enhanced risk or a related priority window for screening. In general, the proportion of those assessed as depressed is lower with structured clinical interviews than standardized instruments. Around 1 year and beyond, both categories of assessments converge around 30 percent (27.4 percent with SCID and 33.2 with other tools).
This review cannot distinguish between whether the data suggests that other tools "over-detect" depression relative to structured clinical interviews or whether differences in study design and population create the observed effect. We also cannot distinguish if features unique to a population with TBI make clinical diagnosis more challenging, or whether evaluators in clinical settings are less likely to classify a patient as depressed early after trauma, deferring definitive diagnosis until later in followup as other sequelae of injury subside or stabilize.
Choice of tools for screening. Studies often used more than one instrument, reporting different facets of the scores or evaluation, such as correlations among subscales of separate instruments or relationship of scores by different evaluators. Statistical analyses were generally not intended to directly assess clinical utility. Comparison of diagnostic test characteristics, agreement of classification, and use of expert SCID as a gold standard for comparisons were rare. Five publications compared SCID to candidate tools for assessment of depression, the BDI,90,115 Patient Health Questionnaire (PHQ-9),126 and HADS.28,117 None of the tools reported simultaneous sensitivity and specificity above 90 percent. One study identified different optimal cutoffs of the BDI-II; maximum sensitivity of 87 percent and specificity of 79 percent were obtained with cutoffs of 19 for participants with mild TBI, and 35 for those with moderate or severe TBI. With modification of the scoring algorithm as proposed by the authors, the PHQ-9 achieved a sensitivity of 93 percent, specificity of 89 percent, positive predictive value of 63 percent, and negative predictive value of 99 percent. The BDI had poor sensitivity of 48 percent and 32 percent at specificities of 80 and 90 percent, respectively. The HADS provided 54 percent sensitivity and 76 percent specificity. One team31 reported results of an expert consensus process to select subscale domains of three screening tools (Neurobehavioral Functioning Index , Profile of Mood States Depression Scale, CES-D) that correspond to the DSM-IV criteria for major depressive episode, and found in application that the three tools were highly correlated (r > 0.80) in their identification of depressed individuals. Nonetheless, SCIDs were not actually done in the study.
Summary. Prevalence of depression is high at multiple time points after TBI. No evidence provides a basis for targeting screening to one timeframe over another. Likewise, the literature is insufficient to determine whether tools for detecting depression that have been validated in other populations can accurately identify depression in individuals with TBIs. Nor does the literature support any one tool over the others.
KQ3. Prevalence of Concomitant Psychiatric Conditions
Content of literature. We identified nine publications13,57,59,91,96,98,110,117,125 in eight populations that reported prevalence of concomitant psychiatric conditions within the population of depressed TBI patients,13,96,98,117 or compared rates of comorbid conditions in those with and without depression.57,59,91,110,125 Papers that reported the overall prevalence of psychiatric conditions among the general population of TBI patients with no data on their association with depression were excluded.
Study designs included five prospective cohorts,13,57,59,98,110,125 one retrospective cohort,91 and two cross-sectional studies.96,117 Seven studies were conducted in the United States13,57,59,91,96,98,110,125 and one in Australia.117 One was conducted at an academic medical center,57 one at a rehabilitation center,96 one in the community,91 one at two hospitals within the same state,59 one at a tertiary care center,117 and three at trauma centers.13,98,110,125 The most common condition studied in combination with depression was anxiety.13,59,91,96 Depression was diagnosed via clinical interview in most of the studies.13,57,59,91,96,98
Coexisting psychiatric conditions. Eight percent to 93 percent of depressed participants had one or more concomitant conditions. Anxiety was the most commonly detected coexisting condition. In the studies that compared rates of comorbid anxiety in those with and without depression, it was significantly more common in the depressed group (76.7 percent vs. 20.4 percent in one study; 60 percent vs. 7 percent in the second).59,125
The recruitment phase of a clinical trial for sertraline to treat major depressive disorder was described in the largest study, and included 1-year followup of 599 participants, all of whom had GCS scores of ≤12.125 Depression was assessed with a structured interview based on the PHQ-9, and assessment for anxiety disorders also used modules of the PHQ. The 1-year cumulative incidence of Major Depressive Disorder (MDD) in this population was 53.1 percent. During this first year following injury, individuals with MDD had substantially higher rates of a concomitant anxiety disorder than did participants without MDD (60 percent vs. 7 percent: RR, 8.77; 95 percent CI, 5.56 to 13.83).
Assessing depression with the PHQ-9, and PTSD with the PTSD Checklist-Civilian, 37 percent of individuals who also had depression after TBI had PTSD, compared to none among those who were not depressed.110 Anxiety and aggression outcomes have been investigated among patients with closed head injury and those with multiple trauma but no central nervous system involvement.59 One-third of patients had major depressive disorder (mood disorder with major depressive features). Over the course of followup, 23 of 30 (76.7 percent) patients with major depressive disorder also had anxiety, compared with 9 of 44 (20.4 percent) nondepressed patients. Of note, PTSD was included with anxiety in this study, and was the defining psychiatric feature for 7 of the 23 patients diagnosed with anxiety. Similarly, 17 of 30 (56.7 percent) depressed patients exhibited aggression, compared to 10 of 44 (22.7 percent) without depression.
A cohort of 188 individuals with TBI who were enrolled in a larger study of mood disorders and psychosocial functioning after TBI was assessed twice over 12 months for depression and other psychiatric comorbidities. Individuals were divided into four groups for analysis: no depression at any point, resolved depression (present at entry but not 12 months), late-onset depression (present at 12 months but not study entry) and chronic depression (present throughout the study). At study entry, coexisting psychiatric conditions were most frequent among those individuals who would have late-onset depression (74 percent of late-onset patients) and lowest among those in the chronic depression group (26 percent). At reassessment, the presence of psychiatric conditions had increased in every group except those never diagnosed with depression. Among the psychiatric conditions examined, anxiety was most common at both study entry and at 12 months (19 and 16 percent, respectively).
Summary. When conditions were reported individually, anxiety disorder was most prevalent and affected from 31 to 61 percent of study participants in four papers.13,59,96,125 PTSD, a major anxiety disorder, was observed in 37 percent of depressed patients and in no patients without depression,110 and panic disorder was seen in 15 percent of patients with major depression, but not measured in those without depression.96 Consideration of potential for coexisting psychiatric conditions is warranted.
KQ4. Outcomes of Treatment for Depression After TBI
Content of literature. Only two publications127-128 addressed a treatment for individuals diagnosed with depression after a traumatic brain injury. One of the treatment studies was conducted in the United States127 and the second was in Canada.128 Both were studies of antidepressant efficacy, the first being a randomized controlled trial of sertraline, and the second an open-label case series of the effects of citalopram.
The study on sertraline was a double-blind placebo controlled trial with block randomization, in which treatment was administered for 10 weeks.127 Participants were at least 6 months post-TBI, and TBI included documented loss of consciousness or other evidence, such as pathology or imaging. Diagnosis of depression was established by DSM-IV criteria and a Hamilton Rating Scale for Depression (HAM-D) score higher than 18. Dosage of sertraline was not fixed and could be adjusted at 2-week intervals, with a maximum dosage of 200mg/d. The primary outcome of interest was a change in depression status measured with the HAM-D. A positive response was considered to be a decrease of 50 percent, or a drop below 10 on the HAM-D. Of those who completed the study, 59 percent of the treated group and 32 percent of the control group had a positive response; the difference in response rates between the two groups was not statistically significant (p = 0.08).
The second study128 investigated the effect of citalopram on depressive symptoms after TBI, using an open-label, single-arm (case series) design. The study was limited to individuals with mild to moderate TBI. Mild TBI was defined as loss of consciousness at time of injury of 20 minutes or less, an initial GCS score of 13–15, and post-traumatic amnesia (PTA) of less than 24 hours. Moderate to severe TBI had a GCS score of less than 13, a PTA greater than 24 hours, or an abnormal CT image. The study intended to evaluate the effects of a 6-week course of treatment in 54 patients; however, low response rates resulted in a study extension for 26 participants to 10 weeks. Therefore, although 6-week data were available for all 54 completers, 10-week data were available for 26 participants. The primary outcome measured was a change on the HAM-D score, with an improvement of 50 percent or more designated a positive response and a score of less than 8 defined as remission. In the 6-week data (n = 54), 27.7 percent were classified as responders and 24.1 percent were in remission. Among participants with data at 10 weeks, 46.2 percent were responders and 26.9 were in remission. Of the 11 individuals who dropped out of the study, 6 were in the intended 6-week group and 5 were in the intended 10-week group. Ten of the 11 experienced an adverse event.
The amount of literature about traumatic brain injury is increasing rapidly, with the focus on the relationship between TBI and depression also growing. As is typical of advancing areas of research, early publications about TBI and depression have been predominantly cross-sectional, with little apparent consensus about measures or key covariates and a high degree of variability in quality of publications. Prospective studies of sufficient size to enable multivariate modeling of predictors of outcome or analysis of outcome by factors such as severity are rare. Achieving representative study populations is challenging because enumerating the entire population eligible for followup is hampered by the portion of the population who do not seek care for head injury. While studies in specialized settings like neuropsychiatric clinics or rehabilitation programs can be applicable to estimating risk in those settings, they cannot be generalized to the base population of all those with injuries.
Overall, the content of the current literature is fair to poor, with a preponderance of study designs that do not provide strong evidence. As a result, the strength of the literature is low for understanding the predictors, prevalence, natural history, treatment options, and modifiers of outcomes of depression that follows TBI. Nonetheless, considerable evidence suggests depression after all forms and severity of TBI is common.
We find a concerning lack of high-quality evidence to inform clinical decisionmaking for the 1 to 2 million individuals in the United States who experience traumatic brain injury each year. Lack of treatment studies focused on this population is especially remarkable. Given how common, concerning, and debilitating the combination of TBI and depression can be, a priority on promoting high-quality research in the United States is imperative.
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Full Report
This executive summary is part of the following document: Guillamondegui OD, Montgomery SA, Phibbs FT, McPheeters ML, Alexander PT, Jerome RN, McKoy JN, Seroogy JJ, Eicken JJ, Krishnaswami S, Salomon RM, Hartmann KE. Traumatic Brain Injury and Depression. Comparative Effectiveness Review No. 25. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No. 11-EHC017-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2011.
For More Copies
For more copies of Traumatic Brain Injury and Depression: Executive Summary No. 25 (AHRQ Pub. No. 11-EHC017-1), please call the AHRQ Clearinghouse at 800-358-9295or e-mail firstname.lastname@example.com.


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subset: commoncrawl


text:
I liked this article very much (it seems like most of us did). The part on race studies was the most interesting for me. A number of scientists helped shape the way race was represented. Lombroso's "L'uomo bianco e l'uomo di colore was probably one of the most influential and gave a pseudo-scientific explanation for the superiority of whites. I found this link which is really interesting. As I glanced through the pages I read a part in which he states that even the blood of blacks is different. He says that it coagulated immediately when drawn. Anthropologists today know that race is a social construct and that it's impossible to determine a person's "race" by blood or tissue samples.
I find it paradoxical that northern Europeans viewed Italians with the same prejudice that they used towards the Africans. Sibilla Aleramo reference to Ferrero's book in her novel Una donna surprised me. In Prof. McMenamin's class we read chapters of this book. If the southern man who raped her was a different race (quasi orientale – keeping women secluded harem-style) it was her northern father who forced her to marry him. She was very attached to her father and her education was rather liberal for the day, as a matter of fact she was the first Italian woman to leave her husband and her son.
An excellent article that I will save and do research on many of the people she mentioned!
Link to digital copy of Lombroso's book:


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Forget about President Obama expediting U.S. troop withdrawals from Afghanistan this year. It matters not that some American soldiers are coming apart at the seams, killing innocent Afghans, and burning Qurans, or that President Hamid Karzai of Afghanistan screams to restrict U.S. operations. Nor will polls showing increasing numbers of Americans fed up with the war induce Obama to press the pullout button. Mr. Obama is not going to take the slightest risk that a faster exit might trigger a collapse of the Kabul government and a Taliban takeover after 10 years of sacrificing American blood and treasure. He's not going to give warhawk Republicans a campaign issue. Besides, Obama's aides keep insisting that he still believes in his Afghan goals and strategy. From the day he took office three years ago, Afghanistan became Obama's war. While this reality may not have dawned on most Americans, the president himself knows it all too well.
When Barack Obama stepped into the White House, only some 34,000 U.S. troops patrolled that historic graveyard for foreign invaders and would-be saviors. He upped that number to about 100,000, in addition to more than 40,000 allied troops. Casualties and costs skyrocketed. It was Obama who trumpeted the unachievable goals of defeating the Taliban and ensuring that al Qaeda never returned to Afghan soil to plot another attack on America soil. With this track record and all the sacrifices, he's not going to take big chances. So, he's stuck, and so is the United States.


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Most colorful skyline – closed
Skylines of either a natural or urban setting have always made beautiful gigapans. The potential for capturing a skyline in new and interesting ways is never-ending.
Competition Entries:
This Competition is Closed.
- Entry Name: Zuerifaescht 2010 - Panorama Firework by Balduris
Firework at the "Zürifäscht 2010" - HDR-Panorama taken from "Polyterrasse" Switzerland - Zurich - 2010


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4 days and nothing? Someone has to have pulled the trigger on these
Anyone run these? Looking for feedback on blue tops and yellow tops
4 days and nothing? Someone has to have pulled the trigger on these
I asked the same question bout there hgh in general I got no replies. I'm gonna try a few yellow and have myself tested my wife works in lab so should be easy fast results.
If you can afford pharma, get that. Unfortunately I can't afford them. If you can't afford Rips/comparable product then save your money or spend it on something besides hgh. I spent a great deal of money learning this lesson the hard way.
I like the yellows way more than the blue tops. I think most blues are fake now anyway!!!


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Reality Check: Which Presidential Candidate Leads In Wisconsin Donations?
Most Contributions Come From Milwaukee, Madison
MADISON, Wis. - As the campaigns for president continue, the financial stakes are getting even higher, and some of the campaign contributions are coming from Wisconsin.
VIDEO: Watch The Report
Most primary candidates for president opt out of government funds and fundraise on their own, and much of that funding comes from citizens who donate.
In this "Reality Check," WISC-TV breaks down who is supporting the politicians and their bids for president.
Since the beginning of the 2008 election cycle, the three remaining candidates have raised a staggering amount of money.
John McCain, who is now the Republican nominee, has raised nearly $77 million.
Hillary Rodham Clinton raised just more than $189 million, and Barack Obama raised $234 million.
Overall, Wisconsin ranks 29th in presidential campaign donations out of the 50 states and the District of Columbia.
Wisconsin residents have given just more than $3 million to candidates so far. Milwaukee and Madison are the top donating cities, WISC-TV reported.
Milwaukee residents donated nearly $1.4 million to candidates. Madison contributed nearly $800,000 to campaign coffers, and nearly a quarter of those funds came from the West Side.
Zip code 53705 has given more than $150,000, WISC-TV reported.
Those donation amounts are for all candidates -- those still running and those who have dropped out of the race.
In Wisconsin's primaries, Obama beat Clinton by 17 points and McCain took the Republican race. But who is leading in fundraising in Wisconsin?
In fundraising, Obama is solidly in the lead with more than $1 million from Wisconsin.
Clinton follows Obama with less than half of what he raised, about $558,000.
Third place for the Republicans goes to former-Gov. Tommy Thompson, who raised just short of $500,000. He dropped out after the Iowa straw poll.
McCain comes in fourth with about $317,000.
Wisconsin voters made their decision in the state's primary on Feb. 19, but residents continue to make their voices heard in other primaries by sending money to the candidate of their choice.
A total of more than $624,000 has been donated since Wisconsin's primary.
Obama still leads in the amount raised, with a total of about $337,000, but the gap between Obama and Clinton has gotten much smaller since the primary, with Clinton raising just more than $200,000.
Prior to Wisconsin's primary, Obama had already raised more than $1 million and Clinton has raised $353,000.
Latest Political Headlines
- Republican bill would discipline hecklers at UW speeches
- Records show little GOP feedback to state education plan
- Education accountability bill clears panel, prospects dim
- Gov. Walker hopes Trump's tough talk catches Canada's attention
- Bill would let victims, witnesses block body camera releases
- Abortion coverage restriction bill for state workers advances


text: Your Accommodations Rideout Memorial Hospital offers semi-private (double occupancy) rooms. A few private rooms are available for medical necessity or at the patient's request (for additional fee). We will strive to honor your preference. On occasion, however, alternate arrangements may be necessary due to physicians orders or prevailing conditions. Room transfer requests should be made through nursing staff and will be carried out as soon as possible. Women and Infants Services at Fremont Medical Center offers eighteen spacious private rooms, comfortable chairs, and room for family and couplet care. Hospital Room: We hope you will find your room cheerful and comfortable. When you are admitted, your room, bed, nurse call system and remote control TV will be explained. The Hospital Bed: Your electrically operated hospital bed is probably higher and narrower than your bed at home. The side rails on your bed are there to protect you. Please ask for assistance in lowering them. Nurse Call System: The nurse call system at your bedside alerts our staff by activating a light outside your door and in the nurses' station. Your nurse will assist you as quickly as possible, but please remember he or she may be temporarily occupied with another patient when you ring. Television: In double occupancy rooms, please be considerate so that volume levels do not disturb other patients. Patient Telephone: Making calls: Dial O for hospital operator for assistance. To make a local call, dial 9 and then the telephone number. To access AT&T for credit or collect calls, or third-party billing, dial 8-0 or 8-00. Wireless Internet Service Free wireless internet access for patients is available at both Fremont and Rideout hospitals. Patients must provide their own laptop computer and request the service from a caregiver or the Guest Services Representative at 632-2356. Upon request, the IS Department will provide a temporary account for their stay. Specific security measures are in place to reduce any security or virus threats. Language Services: If a patient should require it, the hospitals have access to interpreters for a number of foreign languages. For more information, contact your nurse. Hearing Impaired: A telecommunications device is available to assist hearing impaired patients communicate with relatives or friends. Arrangements can also be made to have interpreter services, including sign language, to assist a hearing impaired or deaf patient. Televisions with closed captioning are available. Patient Education (TV/ DVD): Health education programs can be viewed on patient TVs or mobile TVs. Topics include nutrition, postnatal care, baby care, diabetes, and other health related subjects. Ask your nurse for more information. Patient Meals: Your diet is prescribed by your doctor and plays a very important role in your therapy. Our registered Dieticians consult with your physician regarding your special nutrition requirements. Your physician or nurse may make arrangements for you to meet with one of our Registered Dieticians during your hospital stay. Outpatient Registered Dietitian Services are available with a physician referral. Most diets include a menu selection delivered with your breakfast tray for the following day. You may return the completed menu to your Nutrition Host or with your breakfast tray. If your family or friends bring outside food for you, please notify your nurse as it may conflict with your physicians prescribed diet order, or your medication. Gourmet meals (for patients on a regular diet) or guest trays for family or friends who wish to dine with you may be purchased at the cafeteria.


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Clinical Research Centers
IAVI recognized early on that to develop effective AIDS vaccines for use throughout the world, it would be essential to build partnerships and bolster capacity to conduct vaccine trials at the highest technical and ethical standards in developing countries, where the need for a vaccine is greatest.
Today, a network of independent but interconnected research centers in five sub-Saharan African countries (Kenya, Rwanda, South Africa, Uganda and Zambia) play a central role in IAVI's vaccine development program, testing HIV vaccine candidates and conducting epidemiological studies that inform the design of candidates and provide baseline information for future efficacy trials. To date, IAVI and its network of partners have:
- Developed and advanced 13 HIV vaccine candidates into early-stage human trials, including the first HIV vaccine trials conducted in Kenya, India, Germany, Zambia and Rwanda
- Conducted 15 observational epidemiological studies
- Provided voluntary testing and counseling to more than 235,000 individuals in Africa
This partnership-based approach emphasizes building capacity by training local researchers and developing the infrastructure required for all such research. Investigators within this network are linked to scientific consortia—such as the Center for HIV/AIDS Vaccine Immunology and the Neutralizing Antibody Consortium—and collaborate closely with IAVI researchers.
To learn more about the clinical trials and epidemiological studies conducted at these clinical research centers, visit the IAVI Studies Database.


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Main Content
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Never worry about your keys falling out of your pocket again with this Ellipse carabiner.
- Officially licensed
- Embossed graphics
- Not intended for climbing key hook
- Reinforced aluminum
- Imported
- Approximately 1.5" x 4"
- Imported
- Brand: Oakley
Special event items are produced by manufacturers only after the outcome of a game or event. These are advanced sale items and will ship immediately after they are received in our warehouse.
Manufacturer direct items are shipped directly from the manufacturer. These items are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite number, and/or designs. Some options may be limited by league rules.


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The Barry House is a London B&B hotel offering family friendly accommodation in central London, close to Hyde Park, Marble Arch and many of London's famous sights. Rated by VisitBritain as Three Star Guest Accommodation.
Highly rated for value, its friendly welcome and efficient service, the Grange Lodge has 14 rooms, most of which have en suite bathroom and all with free wi-fi, TV and tea/coffee making facilities. There's free off street parking on our forecourt.
Tanzania safari in the northern parks with a combination of three most popular national parks.
This walking tour is a must for any and all Harry Potter fans. Explore the exquisitely magical world that Harry and his friends found themselves in, on this amazing 2 hour walk. Use your knowledge of spells to outwit the guide!
Designed to help you get more from your stay, the Amba Hotel Charing Cross offers unlimited, fast, free Wi-Fi in all areas of the hotel, complimentary mini-bars and Nespresso™ machines in all rooms all at no extra charge.
Ideally situated for access to all of London & within minutes of Victoria Coach/Tube/Train (Gatwick Express) & Pimlico Tube Station(s).
Wisteria House is a comfortable guest house located in Stubbington near Fareham in Hampshire. All bedrooms have en-suite bathrooms and are non-smoking. Wisteria House is approximately 1 mile from the beach and 4 miles from Junction 9 of the M27.
The London Lodge Hotel is located in a quiet street in Kensington but only 7 minutes walk from Earls Court underground which leads to the centre of town and Heathrow Airport. 4 museums and Hyde Park are all 20 minutes walk away.
A luxury 7 day chauffeured tour visiting Englands' wonderful Gardens and splendid Country Houses
Chelsea, United Kingdom visitors guide to accommodations, adventure travel, unique tours and rentals. Check out top Chelsea, United Kingdom getaways & destinations. Chelsea, United Kingdom vacations, packages & travel spots. Visit Chelsea, United Kingdom !.


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Because of You April 22 2016 Full Episode Replay
Andrea, masama raw isukat ang wedding gown! Magkatotoo kaya ang pamahiin at maudlot ang kasal? #BOYAndreasGown
SHOW DESCRIPTION: Because of You is an upcoming Philippine Romantic Comedy series to be broadcast by GMA Network starring Gabby Concepcion, Carla Abellana and Rafael Rosell. It is set to premiere November 30, 2015 replacing Beautiful Strangers on the network's GMA Telebabad primetime block, and also aired worldwide via GMA Pinoy TV.
There heartache pain but you know you can overtake but also heartache heart shatter, break-head, and makagunaw-world. That's Andrea felt when he left Oliver. By working. By losing yourself in doing things that will make you see that there's a big, bright world out there without him. Andrea did so in his new job as Executive Assistant to the newly single to Jaime, a clothing line magnate. It was good not only for her but also for the business and, unexpectedly, for James, who found himself falling for her. And the feeling was mutual, for Andrea felt that she was now in love again.
Source: Wikipedia


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Learning Beyond Campus
Princeton strongly encourages students to take advantage of the opportunity to pursue international study and internships. The following programs help connect students to the wealth of openings and funding available to University students and recent alumni.
To learn more about Princeton's global vision and the many international opportunities available, visit the International Princeton website.
International Opportunities & Travel Funding
Office of International Programs
Bridge Year Program
Study Abroad Program
Summer Study Abroad & Intensive Language Programs
Funding Information for Undergraduates
Graduate Study Abroad Fellowships
Graduate Travel Grants
Volunteer & Work Programs
Community-Based Learning Initiative
Funding for Public Service Projects
International Internship Program
Internship Resources at Career Services
Pace Center for Civic Engagement
Student Volunteers Council
International Internships & Postgraduate Funding
Career Services
Postgraduate Fellowships
Princeton in Africa
Princeton in Asia
Princeton in Latin America


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Join me in the chat room for some Calendar Inspiration! We all need a little push to get started and stay on track with our 2013 calendars!!! The designers are loading the boutique with fun new calendar templates all the time so we just need to get using them ladies and gentleman. Hope to see you and bring me some coffee please!!!!
Calendar Chat
Started by tinkerbell11, Oct 30 2012 09:05 PM
6 replies to this topic
Posted 30 October 2012 - 09:05 PM
Posted 31 October 2012 - 05:14 PM
UGH! I thought this was 6 PM!! My eyes missed the am part ... dern.
Posted 31 October 2012 - 06:36 PM
My Java has corrupted or disappeared or something - I can't seem to get it back again! Sigh! I missed the chat!
Posted 31 October 2012 - 07:54 PM
I thought the same thing! 6:00 p.m. I was really looking forward to it, but not at 3:00 A.M. my time.
Posted 31 October 2012 - 08:06 PM
Sorry ladies to miss you ! I will do the next one as an evening time if that is better?
Posted 31 October 2012 - 10:02 PM
No 3 AM chats for me, either!
Posted 02 November 2012 - 06:01 PM
Oh, I am so sorry to have missed this one - was really looking forward to it. Darn hurricane....
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Sitting here in class I have come to realize that fat women bitch VERY loudly. I guess misery loves company.
if I receive head from a fat chick and know one knows is she a supermodel in my story?
"Nonsense, I have not yet begun to defile myself."
2017 Goals:
1) Win the next game.
2) See #1
"The problem with internet quotes lies in verifying their authenticity."
-Abraham Lincoln
"Lucille" is my BanHammer!!!
For years off and on I've been looking for the digitized version of an old cartoon published during the net's formative years where you have an old lady with knee-level sunken boobies and a cig dangling from her mouth typing to an old guy with no hair and a pot belly in a guineaT on the other side of the monitor something to the effect of "Oh, so you're an airline pilot, what a coincidence, I'm a stewardess" or something like that. Epitomized cyber then and now.
Looked again, still couldn't find it, but this one is pretty close in capturing the world of IMs


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STATE HOUSE – Sen. Marc A. Cote is encouraging those interested in legislative issues to take advantage a new bill tracking system that allows people to set up email alerts on the progress of particular legislation pending before the General Assembly.
Cote lauds new online bill tracking system
Woonsocket senator has called for service since 2004
STATE HOUSE – Sen. Marc A. Cote is encouraging those interested in legislative issues to take advantage a new bill tracking system that allows people to set up email alerts on the progress of particular legislation pending before the General Assembly.
Senator Cote had been calling for an online bill tracking system as long ago as 2004, when he introduced a resolution (2004-S 2301aa) that was passed by the Senate asking that the Assembly's information technology staff develop a way for the public to track particular bills' progress online.
"Legislators will appreciate the added convenience of better managing their legislative agendas, and the general public will have a user-friendly system to enable them to better participate in the process by receiving timely notices of committee meetings where they may choose to testify in support or opposition to a specific bill," said Senator Cote in 2004 about the resolution. "That's what open government is all about."
Senator Cote (D-Dist. 24, Woonsocket, North Smithfield) introduced similar legislation in 2006 and 2007 as well.
The recently launched bill tracking system is available at www.rilin.state.ri.us/billtracker, or by clicking on "Bill Tracking" at the bottom of the on the General Assembly's home page, www.rilin.state.ri.us.
Using the new tool, one can search for bills by committee, category, sponsor, range of bill numbers or individual bill numbers. Users will receive email updates regarding the change in status of these bills hourly, daily, or weekly, depending upon their preferred settings. The registration process simply requires an email address and a password. Once registered, members of the public can track up to 50 bills.
"This is a very useful tool for anyone interested in keeping tabs on one or many bills. While the information has always been available online, up to now, tracking a bill meant checking its status frequently and hoping you haven't missed anything since you last checked. Now, citizens can just plug in the bills they'd like to watch, and the information will be emailed directly to them," said Senator Cote, who has been using the system to track his bills since the system launched in mid-May. "Having the information available is good, but making it easier for people to get what they need and delivering it in a way that is useful is much better. I'm glad that Rhode Island now has this system, and I hope that citizens take advantage of it to stay informed about the issues that affect them," said Senator Cote.


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Manufacturer: CAD Manufacturer: Sophia Global 2 Results
CAD NB2 Noise-Canceling Earphones, black
The CAD NB-2 Active noise canceling headphones are professional grade in-ear monitors with superb sound quality. They use a High output 9mm driver with neodymium magnet for clear, robust audio and are Great for travel and music listening in challeng...
Sport MP3 Wireless Wrap-Around Headphones / Headset with Built in 2GB MP3 Player. (Includes USB Cable)
Tired of your MP3 player headphones getting in your way and falling off your head? The sport MP3 player is a perfect workout companion with its wrap around design and wire fee operation it will stay on your head and out of your way. The tight design allows for multiple workout positions including: bench press, sit ups, hard running and aerobics. 2 GB of space stores plenty of songs for...


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As the Managed Care editorial team gathered the names of policy experts to approach for our five-year look forward, we were struck by how quickly we could fill a page with candidates who would have a valuable perspective. After weeks of whittling and editing, we are proud to present these essays from experts who need only the brief introductions provided. The consensus, as noted below by Helen Darling, is that it won't be an easy ride.
Read Next
House Republicans come out with their ACA alternative. A continuous coverage surcharge replaces the individual mandate. But where's the CBO score?
The biosimilar segment of the pharmaceutical industry is on fire. Some 700 biosimilars are at some stage of development, and more than 660 companies are involved in some way in the biosimilars land rush. Still, only a handful may get on the market in the next few years.
No one knows how much of an effect biosimilars will have on oncology expenditures. Pricing and market share are in a large, opaque "to be determined" cloud. But there's certainly potential for a major impact that could lower oncology expenditures by millions, if not billions.
The future of biosimilars in this country is nothing if not uncertain. Most immediately, the U.S. Supreme Court is hearing a case that will determine the timing of the 180-day waiting period before a biosimilar can go on the market. But there are larger and longer-term issues at play as well.
While coupons help individual consumers, they are also having a major impact on the insurance industry and anyone responsible for paying health care bills. Insurers and pharmacy benefit managers complain that they foil formularies and other pricing strategies designed to steer consumers to less-expensive drugs.
The hard truth is that telehealth's future—its size, its contours—will depend a lot on what payers will be willing to pay for. Currently, commercial plans cover only a limited number of services. In addition, research suggests that there may be quality and utilization problems.
Insurers should consider covering new drug-delivery devices that can improve outcomes while lowering disease-specific pharmacy and long-term overall health care costs. Managing these devices in the pharmacy benefit will consolidate volume-based purchasing and capitalize on PBM strategies for improving adherence.
Basaglar is coming on the scene during tumultuous times for insulin products. Manufacturers are under attack for price hikes. There are allegations of backroom rebate deals. And a class-action lawsuit has been brought on behalf of uninsured patients, charging insulin makers with setting artificially high prices.
Evaluating the quality of telemedicine care is about as easy as evaluating the quality of health care, period, and researchers are still ironing out the methodological kinks. That may be one reason research results are all over the place. This article involved reviewing nine such studies, and the findings are a mixed bag.
If millions of Americans lose Medicaid or private health insurance coverage because of the unACAing of American health care, telehealth may seem like a gimmicky sideshow rather than a good-faith effort to bring health care into the digital century.


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I was in Chicago to speak at a conference at the Kellogg School of Management. It was a lot of fun hanging out with Magda and the other NoCal people that were with us. I had a classic Seinfeld Moment on the way back: we were all sitting at the gate, and one of our group went to the bathroom. I was absorbed in a discussion but noticed someone sitting down in her seat, so I turned around and blurbed "Excuse me, but that seat's taken" before I noticed that the friendly-looking lady there was REALLY OLD. She said: "well, I don't see anybody sitting here", in a real friendly way and I was fast getting really embarrassed because she definitely needed to sit down, so I mumbled something like: "It's not a big deal" And she answered: "I'm just waiting for my wheelchair to arrive". Out of the corner of my eye, I noticed Magda jumping up and running away, because she was bursting up laughing. The old lady added: "I can stand up". I mumbled something like "That's OK. Don't worry about it," turned away, stood up, walked away and joined Magda. It was such an embarrassing moment, we both were teared up with laughter for 10 minutes. Then we waited until the old lady had left before we dared rejoin the group.
On the plane back, I finished chapter 4 of the Perl book and DEBUGGED a hangman game. I had a giant headache at the end, but it was fun.
Breakfast at Buck's with Oliver Muoto, a crazy entrepreneur that I rather like. I sat down and noticed a big group of people at the table next to me. Then, Mike Homer walked in - we chatted for a second and he noticed that Simon Perez, Tim Coogle from Yahoo, Andy Grove and Les Vadasz, Jean Louis Gassee, and John Markoff from the NYTimes were all there, including a Secret Service guy. Quite impressive. Oliver is really smart and well-read and claims that his competitive advantage is that he doesn't sleep. In any event, he knew about 10 times as much about Linux as I did, so I was pretty humbled at the end of breakfast.
Went to the newest dermatologist that Susy found for me. No problems, just wanna make sure that the other guy didn't miss anything. This guy has his office at Stanford and he's got himself a regular little business going. He's got top 40 music playing in the waiting room, where there's a bunch of Palo Alto Wives waiting to get their latest skin care lotions. The consultation lasted all of 4 minutes, at the end of which the receptionist sold me $50 worth of lotions. Quite a business. Kind of the exact opposite of the 90-year old guy I saw last month.


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Coconut Sorbet
Coconut Sorbet is a famous island treat, especially around Old San Juan, Puerto Rico where street carts vendors offer frozen scoops of Coco as a refreshing antidote to the tropical heat. But before you book a flight to the Island, try this easy Coconut Sorbet recipe that captures the authentic flavor. The key: two coconut superstars: Coco GOYA® Cream of Coconut, which adds sweet coconut taste and GOYA® Coconut Milk, which imparts creamy- smooth texture. Simply mix, process in your ice cream machine, and take a tropical vacation in your kitchen.
Serves 10
Prep time: less than 5 min.
Total time: 35 min., plus chilling time.
2 cans (13.5 oz.) each GOYA® Coconut Milk
1 can (15 oz.) Coco GOYA® Cream of Coconut
1˝ cup water
˝ cup sweetened flaked coconut, plus more for garnish, if desired.
|Blend coconut milk and cream of coconut in blender until smooth, about 1 minute. Transfer to bowl; stir in water and ˝ cup flaked coconut. Chill until very cold.
|Process cold coconut mixture in 2-qt. ice cream maker, according to manufacturer's instructions; transfer to freezer. Freeze until firm.
|To serve, scoop into dessert bowls and garnish with more flaked coconut, if desired.
No Ice Cream Machine? No problem!
To make this coconut sorbet without an ice cream machine, follow recipe through step 1. Then, transfer coconut mixture to freezer-safe bowl and transfer to freezer. Freeze until frozen, vigorously stirring coconut mixture every 30 minutes, about 3 hours. Then cover and keep frozen until ready to use. Proceed to step 3 of recipe.
Featured Product
Sazón with Coriander and Annatto
Inside this box you'll find the secret to creating the authentic flavors of Latino cuisine. Goya Sazón's special blend of seasonings makes every dish it graces taste truly exceptional.