Too cold may not be so cool: spontaneous hypothermia as a marker of poor outcome after cardiac arrest.

PubMed

Wörner, Jakobea; Oddo, Mauro

2010-01-01

In a recent issue of Critical Care, den Hartog and colleagues show an association between spontaneous hypothermia, defined by an admission body temperature < 35°C, and poor outcome in patients with coma after cardiac arrest (CA) treated with therapeutic hypothermia (TH). Given that TH alters neurological prognostication, studies aiming to identify early markers of injury severity and outcome are welcome, since they may contribute overall to optimize the management of comatose CA patients. This study provides an important message to clinicians involved in post-resuscitation care and raises important questions that need to be taken into account in future studies.

Individual Differences in Anatomy Predict Reading and Oral Language Impairments in Children

ERIC Educational Resources Information Center

Leonard, Christiana; Eckert, Mark; Given, Barbara; Virginia, Berninger; Eden, Guinevere

2006-01-01

Developmental dyslexia (DD) and specific language impairment (SLI) are disorders of language that differ in diagnostic criteria and outcome. DD is defined by isolated reading deficits. SLI is defined by poor receptive and expressive oral language skills. Reading deficits, although prevalent, are not necessary for the diagnosis of SLI. An enduring…

Is Maternal Fatigue Mediating the Relationship between Maternal Depression and Child Outcomes?

ERIC Educational Resources Information Center

White, Carmel Parker; King, Kathleen

2011-01-01

Fatigue, a subjective state that has been defined as a decreased capacity for physical or mental activity, has many behavioral similarities to depression (e.g., weariness, difficulty concentrating, diminished motivation). We hypothesized that fatigue might mediate the relationship between depression and poor child outcomes. A sample of mothers (14…

Is Asymptomatic Vasospasm Associated With Poor Outcome in Subarachnoid Hemorrhage?

PubMed Central

Latorre, Julius Gene S.; Lodi, Yahia; El-Zammar, Ziad; Devasenapathy, Ashok

2011-01-01

Background: Vasospasm occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH), but only half becomes symptomatic. It is unclear whether asymptomatic vasospasm (AV) detected by noninvasive testing affects outcome. Prophylactic hemodilutional, hypertensive, and hypervolemic (HHH) therapy is widely used but the benefit remains unproven. We aim to determine whether AV increases the risk of poor outcome and whether HHH is safe. Methods: A total of 175 consecutive patients with aSAH without clinical vasospasm were included. Patients with sonographic (transcranial doppler) or radiologic (computed tomography [CT] Angiography) vasospasm were assigned to AV group, while those without were assigned to no vasospasm (NV) group. Logistic regression was used to determine the association between AV and HHH on poor outcome, defined as modified Rankin scale (mRS) >3 at discharge or 3 to 6 months' follow-up. Results: In all, 106 patients had NV and 25 received HHH. A total of 69 patients had AV and 54 received HHH. Asymptomatic vasospasm compared to NV was not associated with poor outcome (odds ratio [OR] 2.6, 95% confidence interval [CI]: 0.75-8.9; P = .1). Hemodilutional, hypertensive, and hypervolemic use in patients with AV did not improve the outcome (OR 0.16, 95%CI: 0.009-2.84; P = .2). In patients with NV, HHH use showed trend toward poor outcome after multivariable adjustment (OR 12.6, 95%CI: 1.08-146.5 P = .04). Conclusion: Asymptomatic vasospasm does not appear to be associated with poor outcome in aSAH. Hemodilutional, hypertensive, and hypervolemic therapy in AV was not associated with improved outcome and may be harmful to patients who do not have vasospasm. Further research is needed to validate this finding. PMID:23983851

Epidemiology and outcomes of acute encephalitis.

PubMed

Venkatesan, Arun

2015-06-01

This review seeks to describe recent advances in the epidemiology, outcomes, and prognostic factors in acute encephalitis. Infectious causes continue to account for the largest proportion of encephalitis cases in which a cause is identified, although autoimmune causes are increasingly recognized. Type-A gamma-aminobutyric acid (GABAa) receptor antibodies have been recently identified in encephalitis with refractory seizures, whereas the roles of antibodies to the glycine receptor and dipeptidyl peptidase-like protein 6 have been defined in progressive encephalomyelitis with rigidity and myoclonus. Recent findings in the US cases of encephalomyelitis presenting with acute flaccid paralysis raise the possibility that enterovirus D68, a common respiratory pathogen, may cause central nervous system disease. Mortality from acute encephalitis occurs in about 10% of cases, with a large proportion of survivors suffering from cognitive or physical disability. In addition to delay in institution of appropriate antiviral or immune therapy, several potentially reversible factors associated with poor prognosis have been identified, including cerebral edema, status epilepticus, and thrombocytopenia. Encephalitis imposes a significant worldwide health burden and is associated with poor outcomes. Supportive treatment and early institution of therapy may improve outcomes. Careful neurocognitive assessment of survivors of encephalitis is needed to better define long-term outcomes.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan.

PubMed

Ong, Cheung-Ter; Wong, Yi-Sin; Sung, Sheng-Feng; Wu, Chi-Shun; Hsu, Yung-Chu; Su, Yu-Hsiang; Hung, Ling-Chien

2017-01-01

Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients. A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score. Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF. The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Factors determining poor prognostic outcomes following diabetic hand infections

PubMed Central

Ince, Bilsev; Dadaci, Mehmet; Arslan, Abdullah; Altuntas, Zeynep; Evrenos, Mustafa Kursat; Fatih Karsli, Mehmet

2015-01-01

Background and Objective: Hand ulcers are seen in a small percentage of patients with diabetes. The predisposing factors of diabetic hand varies between different countries. However, the effects of predisposing factors on prognosis are not clear in diabetic hand infections. In this study, our aim was to determine the effects of predisposing factors on poor prognostic outcomes in patients with diabetes mellitus. Methods: Thirty-four patients with diabetes mellitus who were treated and followed up for a hand infection in between 2008 and 2014 were investigated retrospectively. Patients were evaluated according to predisposing factors defined in the literature that included disease period, age, gender, admission time, presence of neuropathy, smoking habits, HbA1c levels at admission time, peripheral vascular disease, end-stage renal disease (ESRD), and trauma. Death and minor/major amputation cases during treatment were defined as poor prognosis. Results: Patients who had ESRD, peripheral neuropathy, or an HbA1c level greater than 10% had significantly higher amputation rates. Conclusions: Peripheral neuropathy, ESRD, and HbA1c levels greater than 10% at the time of admission were determined as poor prognosis criteria for diabetic hand treatment. PMID:26150838

Plasma Vitamin D Deficiency Is Associated with Poor Sleep Quality and Night-Time Eating at Mid-Pregnancy in Singapore

PubMed Central

Cheng, Tuck Seng; Loy, See Ling; Cheung, Yin Bun; Cai, Shirong; Colega, Marjorelee T.; Godfrey, Keith M.; Chong, Yap-Seng; Tan, Kok Hian; Shek, Lynette Pei-Chi; Lee, Yung Seng; Lek, Ngee; Chan, Jerry Kok Yen; Chong, Mary Foong-Fong; Yap, Fabian

2017-01-01

Plasma 25-hydroxyvitamin D (25OHD) deficiency, poor sleep quality, and night-time eating, have been independently associated with adverse pregnancy outcomes, but their inter-relationships are yet to be evaluated. We aimed to investigate the associations between maternal plasma 25OHD status and sleep quality and circadian eating patterns during pregnancy. Data on pregnant women (n = 890) from a prospective cohort (Growing Up in Singapore Towards healthy Outcomes) were analyzed. Plasma 25OHD concentration was measured, while the Pittsburgh sleep quality index (PSQI) and 24-h dietary recall were administered to women at 26–28 weeks’ gestation. Plasma 25OHD status was defined as sufficient (>75 nmol/L), insufficient (50–75 nmol/L), or deficient (<50 nmol/L). Poor sleep quality was defined by a total global PSQI score >5. Predominantly day-time (pDT) and predominantly night-time (pNT) were defined according to consumption of greater proportion of calories (i.e., >50%) from 07:00–18:59 and from 19:00–06:59, respectively. After adjustment for confounders, women with plasma 25OHD deficiency had higher odds of poor sleep quality (odds ratio (OR) 3.49; 95% confidence interval (CI) 1.84–6.63) and pNT eating (OR: 1.85; 95% CI 1.00–3.41) than those who were 25OHD sufficient. Our findings show the association of maternal plasma 25OHD deficiency with poor sleep quality and pNT eating at mid-pregnancy. PMID:28353643

Low free triiodothyronine predicts poor functional outcome after acute ischemic stroke.

PubMed

Suda, Satoshi; Muraga, Kanako; Kanamaru, Takuya; Okubo, Seiji; Abe, Arata; Aoki, Junya; Suzuki, Kentaro; Sakamoto, Yuki; Shimoyama, Takashi; Nito, Chikako; Kimura, Kazumi

2016-09-15

The aim of this study was to investigate the association of admission serum thyroid hormone concentration with clinical characteristics and functional outcomes in patients after acute ischemic stroke. We retrospectively enrolled 398 consecutive patients admitted to our stroke center between July 2010 and April 2012. Serum thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were evaluated upon admission. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) upon admission and the modified Rankin Scale (mRS) upon discharge. Poor outcome was defined as a mRS score of 3-5 or death (mRS score 6). Separate analyses were conducted according to outcome and quartile serum FT3 concentration. In total, 164 patients (41.2%) demonstrated a poor outcome. Age, male gender, blood glucose level, arterial fibrillation, dyslipidemia, smoking, NIHSS score, cardioembolic stroke type, and periventricular hyperintensities, but not FT4 or TSH, were significantly associated with poor functional outcome. Furthermore, poor functional outcome was independently associated with low FT3 (<2.29pg/mL). In comparisons between FT3 quartiles (Q1 [≤2.11pg/mL], Q2 [2.12-2.45pg/mL], Q3 [2.46-2.77pg/mL], Q4 [≥2.78pg/mL]), patients with poor outcomes were more frequent in Q1 than in Q4 after multivariate adjustment. Death was more frequent in Q1 than in Q4 after adjustment for risk factors and comorbidities, but this difference was non-significant after additional adjustment for age and NIHSS score. Our data suggest that a lower FT3 value upon admission may predict a poor functional outcome in patients with acute ischemic stroke. Further large-scale prospective studies are required to clarify the role of thyroid hormone in the acute phase of ischemic stroke. Copyright © 2016 Elsevier B.V. All rights reserved.

New-onset refractory status epilepticus

PubMed Central

Foreman, Brandon P.; Alvarez, Vincent; Cabrera Kang, Christian; Probasco, John C.; Jongeling, Amy C.; Meyers, Emma; Espinera, Alyssa; Haas, Kevin F.; Schmitt, Sarah E.; Gerard, Elizabeth E.; Gofton, Teneille; Kaplan, Peter W.; Lee, Jong W.; Legros, Benjamin; Szaflarski, Jerzy P.; Westover, Brandon M.; LaRoche, Suzette M.; Hirsch, Lawrence J.

2015-01-01

Objectives: The aims of this study were to determine the etiology, clinical features, and predictors of outcome of new-onset refractory status epilepticus. Methods: Retrospective review of patients with refractory status epilepticus without etiology identified within 48 hours of admission between January 1, 2008, and December 31, 2013, in 13 academic medical centers. The primary outcome measure was poor functional outcome at discharge (defined as a score >3 on the modified Rankin Scale). Results: Of 130 cases, 67 (52%) remained cryptogenic. The most common identified etiologies were autoimmune (19%) and paraneoplastic (18%) encephalitis. Full data were available in 125 cases (62 cryptogenic). Poor outcome occurred in 77 of 125 cases (62%), and 28 (22%) died. Predictors of poor outcome included duration of status epilepticus, use of anesthetics, and medical complications. Among the 63 patients with available follow-up data (median 9 months), functional status improved in 36 (57%); 79% had good or fair outcome at last follow-up, but epilepsy developed in 37% with most survivors (92%) remaining on antiseizure medications. Immune therapies were used less frequently in cryptogenic cases, despite a comparable prevalence of inflammatory CSF changes. Conclusions: Autoimmune encephalitis is the most commonly identified cause of new-onset refractory status epilepticus, but half remain cryptogenic. Outcome at discharge is poor but improves during follow-up. Epilepsy develops in most cases. The role of anesthetics and immune therapies warrants further investigation. PMID:26296517

Adverse events associated with poor neurological outcome during targeted temperature management and advanced critical care after out-of-hospital cardiac arrest.

PubMed

Kim, Young-Min; Youn, Chun Song; Kim, Soo Hyun; Lee, Byung Kook; Cho, In Soo; Cho, Gyu Chong; Jeung, Kyung Woon; Oh, Sang Hoon; Choi, Seung Pill; Shin, Jong Hwan; Cha, Kyoung-Chul; Oh, Joo Suk; Yim, Hyeon Woo; Park, Kyu Nam

2015-07-22

The aim of this study was to investigate the association of adverse events (AEs) during targeted temperature management (TTM) and other AEs and concomitant treatments during the advanced critical care period with poor neurological outcome at hospital discharge in adult out-of-hospital cardiac arrest (OHCA) patients. This was a retrospective study using Korean Hypothermia Network registry data of adult OHCA patients treated with TTM in 24 teaching hospitals throughout South Korea from 2007 to 2012. Demographic characteristics, resuscitation and post-resuscitation variables, AEs, and concomitant treatments during TTM and the advanced critical care were collected. The primary outcome was poor neurological outcome, defined as a cerebral performance category (CPC) score of 3-5 at hospital discharge. The AEs and concomitant treatments were individually entered into the best multivariable predictive model of poor neurological outcome to evaluate the associations between each variable and outcome. A total of 930 patients, including 704 for whom a complete dataset of AEs and covariates was available for multivariable modeling, were included in the analysis; 476 of these patients exhibited poor neurological outcome [CPC 3 = 50 (7.1%), CPC 4 = 214 (30.4%), and CPC 5 = 212 (30.1%)]. Common AEs included hyperglycemia (45.6%), hypokalemia (31.3%), arrhythmia (21.3%) and hypotension (29%) during cooling, and hypotension (21.6%) during rewarming. Bleeding (5%) during TTM was a rare AE. Common AEs during the advanced critical care included pneumonia (39.6%), myoclonus (21.9%), seizures (21.7%) and hypoglycemia within 72 hours (23%). After adjusting for independent predictors of outcome, cooling- and rewarming-related AEs were not significantly associated with poor neurological outcome. However, sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care were associated with poor neurological outcome [adjusted odds ratios (95% confidence intervals) of 3.12 (1.40-6.97), 3.72 (1.93-7.16), 4.02 (2.04-7.91), 2.03 (1.09-3.78), and 1.69 (1.03-2.77), respectively]. Alternatively, neuromuscular blocker use was inversely associated with poor neurological outcome (0.48 [0.28-0.84]). Cooling- and rewarming-related AEs were not associated with poor neurological outcome at hospital discharge. Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care period were associated with poor neurological outcome at hospital discharge in our study.

SOCIODEMOGRAPHIC DOMAINS OF DEPRIVATION AND PRETERM BIRTH

EPA Science Inventory

Area-level deprivation is consistently associated with poor health outcomes. Using US census data (2000) and principal components analysis, a priori defined socio-demographic indices of poverty, housing, residential stability, occupation, employment and education were created fo...

Homeostasis model assessment of insulin resistance in relation to the poor functional outcomes in nondiabetic patients with ischemic stroke

PubMed Central

Li, Siou; Yin, Changhao; Zhao, Weina; Zhu, Haifu; Xu, Dan; Xu, Qing; Jiao, Yang; Wang, Xue; Qiao, Hong

2018-01-01

Whether insulin resistance (IR) predicts worse functional outcome in ischemic stroke is still a matter of debate. The aim of the present study is to determine the association between IR and risk of poor outcome in 173 Chinese nondiabetic patients with acute ischemic stroke. This is a prospective, population-based cohort study. Insulin sensitivity, expressed by the homeostasis model assessment (HOMA) of insulin sensitivity (HOMA index = (fasting insulin × fasting glucose)/22.5). IR was defined by HOMA-IR index in the top quartile (Q4). Functional impairment was evaluated at discharge using the modified Rankin scale (mRS). The median (interquartile range) HOMA-IR was 2.14 (1.17–2.83), and Q4 was at least 2.83. There was a significantly positive correlation between HOMA-IR and National Institutes of Health Stroke Scale (r = 0.408; P<0.001). In multivariate analyses, patients in IR group were associated with a higher risk of poor functional outcome (odds ratio (OR) = 3.23; 95% confidence interval (CI) = 1.75–5.08; P=0.001). In multivariate models comparing the third and fourth quartiles against the first quartile of the HOMA-IR, levels of HOMA-IR were associated with poor outcome, and the adjusted risk of poor outcome increased by 207% (OR = 3.05 (95% CI 1.70–4.89), P=0.006) and 429% (5.29 (3.05–9.80), P<0.001). In a receiver operating characteristic curve (ROC) analysis of poor outcome, the area under the curve (AUC) increased from 0.80 to 0.84 (95% CI: 0.79–0.88) by adding HOMA-IR to clinical examination variables (P=0.02). High HOMA-IR index is associated with a poor functional outcome in nondiabetic patients with acute ischemic stroke. PMID:29588341

Analysis of subarachnoid hemorrhage using the Nationwide Inpatient Sample: the NIS-SAH Severity Score and Outcome Measure.

PubMed

Washington, Chad W; Derdeyn, Colin P; Dacey, Ralph G; Dhar, Rajat; Zipfel, Gregory J

2014-08-01

Studies using the Nationwide Inpatient Sample (NIS), a large ICD-9-based (International Classification of Diseases, Ninth Revision) administrative database, to analyze aneurysmal subarachnoid hemorrhage (SAH) have been limited by an inability to control for SAH severity and the use of unverified outcome measures. To address these limitations, the authors developed and validated a surrogate marker for SAH severity, the NIS-SAH Severity Score (NIS-SSS; akin to Hunt and Hess [HH] grade), and a dichotomous measure of SAH outcome, the NIS-SAH Outcome Measure (NIS-SOM; akin to modified Rankin Scale [mRS] score). Three separate and distinct patient cohorts were used to define and then validate the NIS-SSS and NIS-SOM. A cohort (n = 148,958, the "model population") derived from the 1998-2009 NIS was used for developing the NIS-SSS and NIS-SOM models. Diagnoses most likely reflective of SAH severity were entered into a regression model predicting poor outcome; model coefficients of significant factors were used to generate the NIS-SSS. Nationwide Inpatient Sample codes most likely to reflect a poor outcome (for example, discharge disposition, tracheostomy) were used to create the NIS-SOM. Data from 716 patients with SAH (the "validation population") treated at the authors' institution were used to validate the NIS-SSS and NIS-SOM against HH grade and mRS score, respectively. Lastly, 147,395 patients (the "assessment population") from the 1998-2009 NIS, independent of the model population, were used to assess performance of the NIS-SSS in predicting outcome. The ability of the NIS-SSS to predict outcome was compared with other common measures of disease severity (All Patient Refined Diagnosis Related Group [APR-DRG], All Payer Severity-adjusted DRG [APS-DRG], and DRG). RESULTS The NIS-SSS significantly correlated with HH grade, and there was no statistical difference between the abilities of the NIS-SSS and HH grade to predict mRS-based outcomes. As compared with the APR-DRG, APSDRG, and DRG, the NIS-SSS was more accurate in predicting SAH outcome (area under the curve [AUC] = 0.69, 0.71, 0.71, and 0.79, respectively). A strong correlation between NIS-SOM and mRS was found, with an agreement and kappa statistic of 85% and 0.63, respectively, when poor outcome was defined by an mRS score > 2 and 95% and 0.84 when poor outcome was defined by an mRS score > 3. Data in this study indicate that in the analysis of NIS data sets, the NIS-SSS is a valid measure of SAH severity that outperforms previous measures of disease severity and that the NIS-SOM is a valid measure of SAH outcome. It is critically important that outcomes research in SAH using administrative data sets incorporate the NIS-SSS and NIS-SOM to adjust for neurology-specific disease severity.

Prognostic value of serum phosphate level in adult patients resuscitated from cardiac arrest.

PubMed

Jung, Yong Hun; Lee, Byung Kook; Jeung, Kyung Woon; Youn, Chun Song; Lee, Dong Hun; Lee, Sung Min; Heo, Tag; Min, Yong Il

2018-07-01

Several studies have reported increased levels of phosphate after cardiac arrest. Given the relationship between phosphate level and the severity of ischaemic injury reported in previous studies, higher phosphate levels may be associated with worse outcomes. We investigated the prognostic value of phosphate level after the restoration of spontaneous circulation (ROSC) in adult cardiac arrest patients. This study was a retrospective observational study including adult cardiac arrest survivors treated at the Chonnam National University Hospital between January 2014 and June 2017. From medical records, data regarding clinical characteristics, outcome at hospital discharge, and laboratory parameters including phosphate levels after ROSC were collected. The primary outcome was poor outcome at hospital discharge, defined as Cerebral Performance Categories 3-5. Of the 674 included patients, 465 had poor outcome at hospital discharge. Serum phosphate level was significantly higher in patients with poor outcome than in those with good outcome (p < 0.001). Phosphate level was correlated with time to ROSC (r = 0.350, p < 0.001). Receiver operating characteristic curve analysis revealed an area under the curve of 0.805 (95% confidence interval [CI], 0.777-0.838) for phosphate level. In multivariate analysis, a higher phosphate level was independently associated with poor outcome at hospital discharge (odds ratio, 1.432; 95% CI, 1.245-1.626; p < 0.001). A higher phosphate level after ROSC was independently associated with poor outcome at hospital discharge in adult cardiac arrest patients. However, given its modest prognostic performance, phosphate level should be used in combination with other prognostic indicators. Copyright © 2018 Elsevier B.V. All rights reserved.

Therapist strategies early in therapy associated with good or poor outcomes among clients with low proactive agency.

PubMed

von der Lippe, Anna Louise; Oddli, Hanne Weie; Halvorsen, Margrethe Seeger

2017-09-10

Within a mixed methods program of research the present study aimed at expanding knowledge about interactions in the initial therapeutic collaboration by combining focus on client interpersonal style and therapist contribution. The study involves in-depth analyses of therapist-client interactions in the initial two sessions of good and poor outcome therapies. Based on interpersonal theory and previous research, the Inventory of Interpersonal Problems (IIP-64-C) was used to define poor outcome cases, that is, low proactive agency cases. To compare good and poor outcome cases matched on this interpersonal pattern, cases were drawn from two different samples; nine poor outcome cases from a large multi-site outpatient clinic study and nine good outcome cases from a process-outcome study of highly experienced therapists. Qualitative analysis of therapist behaviors resulted in 2 main categories, fostering client's proactive agentic involvement in change work and discouraging client's proactive agentic involvement in change work, 8 categories and 22 sub-categories. The findings revealed distinct and cohesive differences in therapist behaviors between the two outcome groups, and point to the particular therapist role of fostering client agency through engagement in a shared work on change when clients display strong unassertiveness and low readiness for change. Clinical or Methodological Significance Summary: The present analysis combines focus on client interpersonal style, therapist strategies/process and outcome. The categories generated from the present grounded theory analysis may serve as a foundation for identifying interactions that are associated with agentic involvement in future process research and practice, and hence we have formulated principles/strategies that were identified by the analysis.

Artificial neural network classifier predicts neuroblastoma patients' outcome.

PubMed

Cangelosi, Davide; Pelassa, Simone; Morini, Martina; Conte, Massimo; Bosco, Maria Carla; Eva, Alessandra; Sementa, Angela Rita; Varesio, Luigi

2016-11-08

More than fifty percent of neuroblastoma (NB) patients with adverse prognosis do not benefit from treatment making the identification of new potential targets mandatory. Hypoxia is a condition of low oxygen tension, occurring in poorly vascularized tissues, which activates specific genes and contributes to the acquisition of the tumor aggressive phenotype. We defined a gene expression signature (NB-hypo), which measures the hypoxic status of the neuroblastoma tumor. We aimed at developing a classifier predicting neuroblastoma patients' outcome based on the assessment of the adverse effects of tumor hypoxia on the progression of the disease. Multi-layer perceptron (MLP) was trained on the expression values of the 62 probe sets constituting NB-hypo signature to develop a predictive model for neuroblastoma patients' outcome. We utilized the expression data of 100 tumors in a leave-one-out analysis to select and construct the classifier and the expression data of the remaining 82 tumors to test the classifier performance in an external dataset. We utilized the Gene set enrichment analysis (GSEA) to evaluate the enrichment of hypoxia related gene sets in patients predicted with "Poor" or "Good" outcome. We utilized the expression of the 62 probe sets of the NB-Hypo signature in 182 neuroblastoma tumors to develop a MLP classifier predicting patients' outcome (NB-hypo classifier). We trained and validated the classifier in a leave-one-out cross-validation analysis on 100 tumor gene expression profiles. We externally tested the resulting NB-hypo classifier on an independent 82 tumors' set. The NB-hypo classifier predicted the patients' outcome with the remarkable accuracy of 87 %. NB-hypo classifier prediction resulted in 2 % classification error when applied to clinically defined low-intermediate risk neuroblastoma patients. The prediction was 100 % accurate in assessing the death of five low/intermediated risk patients. GSEA of tumor gene expression profile demonstrated the hypoxic status of the tumor in patients with poor prognosis. We developed a robust classifier predicting neuroblastoma patients' outcome with a very low error rate and we provided independent evidence that the poor outcome patients had hypoxic tumors, supporting the potential of using hypoxia as target for neuroblastoma treatment.

The Clinical Features and Surgical Outcomes of Spinal Cord Tanycytic Ependymomas: A Report of 40 Cases.

PubMed

Tao, Xiaogang; Hou, Zonggang; Hao, Shuyu; Zhang, Qi; Wu, Zhen; Zhang, Junting; Liu, Baiyun

2017-10-01

Spinal cord tanycytic ependymomas (TEs) rarely are reported because of extremely low incidence. Understanding of this disease is therefore poor. The aim of this study was to analyze the incidence and clinical, radiologic, pathologic, and prognostic features of spinal cord TEs. Approximately 4000 spinal cord tumors were resected surgically in Beijing Tiantan Hospital between April 2009 and May 2016. We identified all cases of pathologically proved TEs among these patients. TEs accounted for approximately 1% of spinal cord tumors (40 of an estimated 4000). Patients with TE were a mean age of 40.0 years and had no significant sex preference (21 male and 19 female). The median diameter of the maximal tumor was 54.2 mm (range, 16-153 mm). The mean preoperative Japanese Orthopedic Association (JOA) score was 13.0. Radiologically, 47.5% (19/40) cases showed poorly defined tumor border, and 40% (16/40) of them showed preoperative syringomyelia. Gross total resection was achieved in 30 cases, subtotal resection in 8, and partial resection in 2. At the time of discharge, JOA score and neurologic function showed improvement in 26 cases (65%), no change in 12 cases (30%), and worsening in 2 cases (5%). At a median follow-up of 43 months (range, 7-101 months), 1- and 5-year progression-free survival rates were 100.0% and 97.5%, respectively. Only one patient had tumor recurrence which was found 30 months after surgery. No patient died of tumor recurrence. At the latest follow-up, JOA score showed improvement in 30 cases (75%), no change in 8 cases (20%), and worsening in 2 cases (5%). Univariate analysis revealed that tumor size and preoperative JOA score were significantly associated with the short-term outcomes. Meanwhile, age ≥40 years, tumor size ≥50 mm, non-gross total resection, and preoperative JOA score <14 were significantly associated with an increased risk of worsened long-term outcomes. Poorly defined tumor border and preoperative JOA score <14 significantly limited the extent of tumor resection. Spinal cord TE is a rare subtype of ependymomas with low recurrence. Long-term survival can be expected, although poorly defined tumor border is an independent predictor of long-term outcomes. Microsurgical treatment of spinal cord TEs remains a formidable challenge due to the poorly defined border and critical neurovascular structures encasement. It is unnecessary for radical tumor resection at the cost of severe neurologic deficits. Copyright © 2017 Elsevier Inc. All rights reserved.

Defining quality for distal pancreatectomy: does the laparoscopic approach protect patients from poor quality outcomes?

PubMed

Baker, Marshall S; Sherman, Karen L; Stocker, Susan; Hayman, Amanda V; Bentrem, David J; Prinz, Richard A; Talamonti, Mark S

2013-02-01

Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage a complication. Studies using these systems may misrepresent outcomes for the surgical procedures being evaluated. We define a quality outcome for distal pancreatectomy (DP) and use this metric to compare laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP). Records for patients undergoing DP between January 2006 and December 2009 were reviewed. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse--poor quality--postoperative outcomes (SAPOs). II and IIIa complications requiring either significantly prolonged overall lengths of stay including readmissions within 90 days or more than one invasive intervention were also classified as SAPOs. By Clavien-Dindo system alone, 91 % of DP patients had either no complication or a low/moderate grade (I, II, IIIa) complication. Using our reclassification, however, 25 % had a SAPO. Patients undergoing LDP demonstrated a Clavien-Dindo complication profile identical to that for SDP but demonstrated significantly shorter overall lengths of stay, were less likely to require perioperative transfusion, and less likely to have a SAPO. Established systems undergrade the severity of some complications following DP. Using a procedure-specific metric for quality, we demonstrate that LDP affords a higher quality postoperative outcome than ODP.

The ability of intensive care unit physicians to estimate long-term prognosis in survivors of critical illness.

PubMed

Soliman, Ivo W; Cremer, Olaf L; de Lange, Dylan W; Slooter, Arjen J C; van Delden, Johannes Hans J M; van Dijk, Diederik; Peelen, Linda M

2018-02-01

To assess the reliability of physicians' prognoses for intensive care unit (ICU) survivors with respect to long-term survival and health related quality of life (HRQoL). We performed an observational cohort-study in a single mixed tertiary ICU in The Netherlands. ICU survivors with a length of stay >48h were included. At ICU discharge, one-year prognosis was estimated by physicians using the four-option Sabadell score to record their expectations. The outcome of interest was poor outcome, which was defined as dying within one-year follow-up, or surviving with an EuroQoL5D-3L index <0.4. Among 1399 ICU survivors, 1068 (76%) subjects were expected to have a good outcome; 243 (18%) a poor long-term prognosis; 43 (3%) a poor short-term prognosis, and 45 (3%) to die in hospital (i.e. Sabadell score levels). Poor outcome was observed in 38%, 55%, 86%, and 100% of these groups respectively (concomitant c-index: 0.61). The expected prognosis did not match observed outcome in 365 (36%) patients. This was almost exclusively (99%) due to overoptimism. Physician experience did not affect results. Prognoses estimated by physicians incorrectly predicted long-term survival and HRQoL in one-third of ICU survivors. Moreover, inaccurate prognoses were generally the result of overoptimistic expectations of outcome. Copyright © 2017 Elsevier Inc. All rights reserved.

FoxP3 and indoleamine 2,3-dioxygenase immunoreactivity in sentinel nodes from melanoma patients.

PubMed

Ryan, Marisa; Crow, Jennifer; Kahmke, Russel; Fisher, Samuel R; Su, Zuowei; Lee, Walter T

2014-01-01

1) Assess FoxP3/indoleamine 2,3-dioxygenase immunoreactivity in head and neck melanoma sentinel lymph nodes and 2) correlate FoxP3/indoleamine 2,3-dioxygenase with sentinel lymph node metastasis and clinical recurrence. Retrospective cohort study. Patients with sentinel lymph node biopsy for head and neck melanoma between 2004 and 2011 were identified. FoxP3/indoleamine 2,3-dioxygenase prevalence and intensity were determined from the nodes. Poor outcome was defined as local, regional or distant recurrence. The overall immunoreactivity score was correlated with clinical recurrence and sentinel lymph node metastasis using the chi-square test for trend. Fifty-six sentinel lymph nodes were reviewed, with 47 negative and 9 positive for melanoma. Patients with poor outcomes had a statistically significant trend for higher immunoreactivity scores (p=0.03). Positive nodes compared to negative nodes also had a statistically significant trend for higher immunoreactivity scores (p=0.03). Among the negative nodes, there was a statistically significant trend for a poor outcome with higher immunoreactivity scores (p=0.02). FoxP3/indoleamine 2,3-dioxygenase immunoreactivity correlates with sentinel lymph node positivity and poor outcome. Even in negative nodes, higher immunoreactivity correlated with poor outcome. Therefore higher immunoreactivity may portend a worse prognosis even without metastasis in the sentinel lymph node. This could identify a subset of patients that may benefit from future trials and treatment for melanoma through Treg and IDO suppression. Published by Elsevier Inc.

Does Percent Body Fat Predict Outcome in Anorexia Nervosa?

PubMed Central

Mayer, Laurel E.S.; Roberto, Christina A.; Glasofer, Deborah R.; Etu, Sarah Fischer; Gallagher, Dympna; Wang, Jack; Heymsfield, Steven B.; Pierson, Richard N.; Attia, Evelyn; Devlin, Michael J.; Walsh, B. Timothy

2009-01-01

Objective The goal of this study was to investigate the relationship of body composition and neuroendocrine levels with clinical outcome in women with anorexia nervosa in a relapse-prevention trial. Method Body composition and fasting cortisol and leptin levels were assessed before random assignment in 32 weight-recovered subjects with anorexia nervosa from the New York site of the Fluoxetine to Prevent Relapse in Women With Anorexia Nervosa trial. Clinical outcome at the end of study participation was defined using modified Morgan-Russell criteria (full, good, fair, poor), then dichotomized into treatment “success” or “failure.” Results In a binary logistic regression model examining the effect of percent body fat, body mass index, anorexia nervosa subtype, waist-to-hip ratio, and serum cortisol and leptin levels on treatment outcome, only percent body fat was significantly associated with outcome. Conclusions In recently weight-restored women with anorexia nervosa, lower percent body fat was associated with poor long-term outcome. PMID:17541059

The association between patient-therapist MATRIX congruence and treatment outcome.

PubMed

Mendlovic, Shlomo; Saad, Amit; Roll, Uri; Ben Yehuda, Ariel; Tuval-Mashiah, Rivka; Atzil-Slonim, Dana

2018-03-14

The present study aimed to examine the association between patient-therapist micro-level congruence/incongruence ratio and psychotherapeutic outcome. Nine good- and nine poor-outcome psychodynamic treatments (segregated by comparing pre- and post-treatment BDI-II) were analyzed (N = 18) moment by moment using the MATRIX (total number of MATRIX codes analyzed = 11,125). MATRIX congruence was defined as similar adjacent MATRIX codes. the congruence/incongruence ratio tended to increase as the treatment progressed only in good-outcome treatments. Progression of MATRIX codes' congruence/incongruence ratio is associated with good outcome of psychotherapy.

Improved Outcome Prediction Using CT Angiography in Addition to Standard Ischemic Stroke Assessment: Results from the STOPStroke Study

PubMed Central

González, R. Gilberto; Lev, Michael H.; Goldmacher, Gregory V.; Smith, Wade S.; Payabvash, Seyedmehdi; Harris, Gordon J.; Halpern, Elkan F.; Koroshetz, Walter J.; Camargo, Erica C. S.; Dillon, William P.; Furie, Karen L.

2012-01-01

Purpose To improve ischemic stroke outcome prediction using imaging information from a prospective cohort who received admission CT angiography (CTA). Methods In a prospectively designed study, 649 stroke patients diagnosed with acute ischemic stroke had admission NIH stroke scale scores, noncontrast CT (NCCT), CTA, and 6-month outcome assessed using the modified Rankin scale (mRS) scores. Poor outcome was defined as mRS>2. Strokes were classified as “major” by the (1) Alberta Stroke Program Early CT Score (ASPECTS+) if NCCT ASPECTS was≤7; (2) Boston Acute Stroke Imaging Scale (BASIS+) if they were ASPECTS+ or CTA showed occlusion of the distal internal carotid, proximal middle cerebral, or basilar arteries; and (3) NIHSS for scores>10. Results Of 649 patients, 253 (39.0%) had poor outcomes. NIHSS, BASIS, and age, but not ASPECTS, were independent predictors of outcome. BASIS and NIHSS had similar sensitivities, both superior to ASPECTS (p<0.0001). Combining NIHSS with BASIS was highly predictive: 77.6% (114/147) classified as NIHSS>10/BASIS+ had poor outcomes, versus 21.5% (77/358) with NIHSS≤10/BASIS− (p<0.0001), regardless of treatment. The odds ratios for poor outcome is 12.6 (95% CI: 7.9 to 20.0) in patients who are NIHSS>10/BASIS+ compared to patients who are NIHSS≤10/BASIS−; the odds ratio is 5.4 (95% CI: 3.5 to 8.5) when compared to patients who are only NIHSS>10 or BASIS+. Conclusions BASIS and NIHSS are independent outcome predictors. Their combination is stronger than either instrument alone in predicting outcomes. The findings suggest that CTA is a significant clinical tool in routine acute stroke assessment. PMID:22276182

Family-based intervention in adolescent restrictive eating disorders: early treatment response and low weight suppression is associated with favourable one-year outcome.

PubMed

Swenne, Ingemar; Parling, Thomas; Salonen Ros, Helena

2017-09-15

Family-based treatments are first-line treatments for adolescents with restrictive eating disorders (ED) but have to be improved since outcome is poor for some. We have investigated the one-year outcome of a family-based intervention programme with defined and decisive interventions at the start of treatment. Data pertaining 201 adolescents with restrictive ED with features of anorexia nervosa but not fulfilling the weight criterion starting treatment 2010-2015, had a wide range of body mass index (BMI) and of weight loss at presentation, and completed a one-year follow-up was analysed. Recovery from the ED was defined as an Eating Disorder Examination-questionnaire (EDE-Q) score < 2.0 or as not fulfilling criteria for an ED at a clinical interview. By EDE-Q 130 (65%) had recovered at 1 year and by clinical interview 106 (53%). According to the EDE-Q criterion recovery was independently associated with lower EDE-Q score at presentation, higher weight gain after 3 months of treatment and lower weight suppression at follow-up, weight suppression being defined as the difference between premorbid and current BMI. Not fulfilling criteria for an ED was associated with the same factors and also by higher BMI at presentation. The observations that low weight and high ED cognitions confer a poor prognosis but that rapid weight gain at the start of treatment predicts a better prognosis are presently extended to adolescents with restrictive ED with a wide range of BMI at presentation. High weight suppression at follow-up is associated with a poor prognosis and indicates the importance of taking premorbid BMI into account when setting weight targets for treatment.

Status epilepticus severity score (STESS): A useful tool to predict outcome of status epilepticus.

PubMed

Goyal, Manoj Kumar; Chakravarthi, Sudheer; Modi, Manish; Bhalla, Ashish; Lal, Vivek

2015-12-01

The treatment protocols for status epilepticus (SE) range from small doses of intravenous benzodiazepines to induction of coma. The pros and cons of more aggressive treatment regimen remain debatable. The importance of an index need not be overemphasized which can predict outcome of SE and guide the intensity of treatment. We tried to evaluate utility of one such index Status epilepticus severity score (STESS). 44 consecutive patients of SE were enrolled in the study. STESS results were compared with various outcome measures: (a) mortality, (b) final neurological outcome at discharge as defined by functional independence measure (FIM) (good outcome: FIM score 5-7; bad outcome: FIM score 1-4), (c) control of SE within 1h of start of treatment and (d) need for coma induction. A higher STESS score correlated significantly with poor neurological outcome at discharge (p=0.0001), need for coma induction (p=0.0001) and lack of response to treatment within 1h (p=0.001). A STESS of <3 was found to have a negative predictive value of 96.9% for mortality, 96.7% for poor neurological outcome at discharge and 96.7% for need of coma induction, while a STESS of <2 had negative predictive value of 100% for mortality, coma induction and poor neurological outcome at discharge. STESS can reliably predict the outcome of status epilepticus. Further studies on STESS based treatment approach may help in designing better therapeutic regimens for SE. Copyright © 2015 Elsevier B.V. All rights reserved.

Therapeutic hypothermia after cardiac arrest: outcome predictors

PubMed Central

Leão, Rodrigo Nazário; Ávila, Paulo; Cavaco, Raquel; Germano, Nuno; Bento, Luís

2015-01-01

Objective The determination of coma patient prognosis after cardiac arrest has clinical, ethical and social implications. Neurological examination, imaging and biochemical markers are helpful tools accepted as reliable in predicting recovery. With the advent of therapeutic hypothermia, these data need to be reconfirmed. In this study, we attempted to determine the validity of different markers, which can be used in the detection of patients with poor prognosis under hypothermia. Methods Data from adult patients admitted to our intensive care unit for a hypothermia protocol after cardiac arrest were recorded prospectively to generate a descriptive and analytical study analyzing the relationship between clinical, neurophysiological, imaging and biochemical parameters with 6-month outcomes defined according to the Cerebral Performance Categories scale (good 1-2, poor 3-5). Neuron-specific enolase was collected at 72 hours. Imaging and neurophysiologic exams were carried out in the 24 hours after the rewarming period. Results Sixty-seven patients were included in the study, of which 12 had good neurological outcomes. Ventricular fibrillation and electroencephalographic theta activity were associated with increased likelihood of survival and improved neurological outcomes. Patients who had more rapid cooling (mean time of 163 versus 312 minutes), hypoxic-ischemic brain injury on magnetic resonance imaging or neuron-specific enolase > 58ng/mL had poor neurological outcomes (p < 0.05). Conclusion Hypoxic-ischemic brain injury on magnetic resonance imaging and neuron-specific enolase were strong predictors of poor neurological outcomes. Although there is the belief that early achievement of target temperature improves neurological prognoses, in our study, there were increased mortality and worse neurological outcomes with earlier target-temperature achievement. PMID:26761469

High Blood Pressure Increases the Risk of Poor Outcome at Discharge and 12-month Follow-up in Patients with Symptomatic Intracranial Large Artery Stenosis and Occlusions: Subgroup analysis of the CICAS Study.

PubMed

Yu, Dan-Dan; Pu, Yue-Hua; Pan, Yue-Song; Zou, Xin-Ying; Soo, Yannie; Leung, Thomas; Liu, Li-Ping; Wang, David Z; Wong, Ka-Sing; Wang, Yi-Long; Wang, Yong-Jun

2015-06-01

The purpose of this study was to discuss the relationship between blood pressure and prognosis of patients with symptomatic intracranial arterial stenosis. Data on 2426 patients with symptomatic intracranial large artery stenosis and occlusion who participated in the Chinese Intracranial Atherosclerosis (CICAS) study were analyzed. According to the JNC 7 criteria, blood pressure of all patients was classified into one of the four subgroups: normal, prehypertension, hypertension stage I, and hypertension stage II. Poor outcomes were defined as death and functional dependency (mRS 3-5) at discharge or at 1 year. For patients with intracranial stenosis of 70% to 99%, the rate of poor outcome at discharge was 19.3%, 23.5%, 26.8%, and 39.8% (P = 0.001) for each blood pressure subgroup. For patients with intracranial large artery occlusion, the rates were 17.6%, 22.1%, 29.5%, and 49.8%, respectively (P < 0.0001). The rate of poor outcome at 12-month follow-up was 12.6%, 15.3%, 28.5%, and 27.9% (P = 0.0038) in patients with stenosis of 70% to 99% for each blood pressure subgroup and 11.6%, 21.5%, 23.9%, 35.1% (P < 0.0001) in patients with occlusion. For patients with severe intracranial arterial stenosis or occlusion, higher hypertension stages are associated with an increased risk of poor outcome at discharge and 12-month follow-up. © 2015 The Authors. CNS Neuroscience & Therapeutics Published by John Wiley & Sons Ltd.

High glucose variability is associated with poor neurodevelopmental outcomes in neonatal hypoxic ischemic encephalopathy.

PubMed

Al Shafouri, N; Narvey, M; Srinivasan, G; Vallance, J; Hansen, G

2015-01-01

In neonatal hypoxic ischemic encephalopathy (HIE), hypo- and hyperglycemia have been associated with poor outcomes. However, glucose variability has not been reported in this population. To examine the association between serum glucose variability within the first 24 hours and two-year neurodevelopmental outcomes in neonates cooled for HIE. In this retrospective cohort study, glucose, clinical and demographic data were documented from 23 term newborns treated with whole body therapeutic hypothermia. Severe neurodevelopmental outcomes from planned two-year assessments were defined as the presence of any one of the following: Gross Motor Function Classification System levels 3 to 5, Bayley III Motor Standard Score <70, Bayley III Language Score <70 and Bayley III Cognitive Standard Score <70. The neurodevelopmental outcomes from 8 of 23 patients were considered severe, and this group demonstrated a significant increase of mean absolute glucose (MAG) change (-0.28 to -0.03, 95% CI, p = 0.032). There were no significant differences between outcome groups with regards to number of patients with hyperglycemic means, one or multiple hypo- or hyperglycemic measurement(s). There were also no differences between both groups with mean glucose, although mean glucose standard deviation was approaching significance. Poor neurodevelopmental outcomes in whole body cooled HIE neonates are significantly associated with MAG changes. This information may be relevant for prognostication and potential management strategies.

Dose and Effect Thresholds for Early Key Events in a Mode of PPARa-Mediated Action

EPA Science Inventory

ABSTRACT Strategies for predicting adverse health outcomes of environmental chemicals are centered on early key events in toxicity pathways. However, quantitative relationships between early molecular changes in a given pathway and later health effects are often poorly defined. T...

Incidence of delayed seizures, delayed cerebral ischemia and poor outcome with the use of levetiracetam versus phenytoin after aneurysmal subarachnoid hemorrhage.

PubMed

Karamchandani, Rahul Ramesh; Fletcher, Jeffrey James; Pandey, Aditya Swarup; Rajajee, Venkatakrishna

2014-09-01

Current guidelines recommend against the use of phenytoin following aneurysmal subarachnoid hemorrhage (aSAH) but consider other anticonvulsants, such as levetiracetam, acceptable. Our objective was to evaluate the risk of poor functional outcomes, delayed cerebral ischemia (DCI) and delayed seizures in aSAH patients treated with levetiracetam versus phenytoin. Medical records of patients with aSAH admitted between 2005-2012 receiving anticonvulsant prophylaxis with phenytoin or levetiracetam for >72 hours were reviewed. The primary outcome measure was poor functional outcome, defined as modified Rankin Scale (mRS) score >3 at first recorded follow-up. Secondary outcomes measures included DCI and the incidence of delayed seizures. The association between the use of levetiracetam and phenytoin and the outcomes of interest was studied using logistic regression. Medical records of 564 aSAH patients were reviewed and 259 included in the analysis after application of inclusion/exclusion criteria. Phenytoin was used exclusively in 43 (17%), levetiracetam exclusively in 132 (51%) while 84 (32%) patients were switched from phenytoin to levetiracetam. Six (2%) patients had delayed seizures, 94 (36%) developed DCI and 63 (24%) had mRS score >3 at follow-up. On multivariate analysis, only modified Fisher grade and seizure before anticonvulsant administration were associated with DCI while age, Hunt-Hess grade and presence of intraparenchymal hematoma were associated with mRS score >3. Choice of anticonvulsant was not associated with any of the outcomes of interest. There was no difference in the rate of delayed seizures, DCI or poor functional outcome in patients receiving phenytoin versus levetiracetam after aSAH. The high rate of crossover from phenytoin suggests that levetiracetam may be better tolerated. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Temporal profile of body temperature in acute ischemic stroke: relation to infarct size and outcome.

PubMed

Geurts, Marjolein; Scheijmans, Féline E V; van Seeters, Tom; Biessels, Geert J; Kappelle, L Jaap; Velthuis, Birgitta K; van der Worp, H Bart

2016-11-21

High body temperatures after ischemic stroke have been associated with larger infarct size, but the temporal profile of this relation is unknown. We assess the relation between temporal profile of body temperature and infarct size and functional outcome in patients with acute ischemic stroke. In 419 patients with acute ischemic stroke we assessed the relation between body temperature on admission and during the first 3 days with both infarct size and functional outcome. Infarct size was measured in milliliters on CT or MRI after 3 days. Poor functional outcome was defined as a modified Rankin Scale score ≥3 at 3 months. Body temperature on admission was not associated with infarct size or poor outcome in adjusted analyses. By contrast, each additional 1.0 °C in body temperature on day 1 was associated with 0.31 ml larger infarct size (95% confidence interval (CI) 0.04-0.59), on day 2 with 1.13 ml larger infarct size(95% CI, 0.83-1.43), and on day 3 with 0.80 ml larger infarct size (95% CI, 0.48-1.12), in adjusted linear regression analyses. Higher peak body temperatures on days two and three were also associated with poor outcome (adjusted relative risks per additional 1.0 °C in body temperature, 1.52 (95% CI, 1.17-1.99) and 1.47 (95% CI, 1.22-1.77), respectively). Higher peak body temperatures during the first days after ischemic stroke, rather than on admission, are associated with larger infarct size and poor functional outcome. This suggests that prevention of high temperatures may improve outcome if continued for at least 3 days.

Spectrum and Predictors of Refractory Status Epilepticus in a Developing Country.

PubMed

Dubey, Deepanshu; Bhoi, Sanjeev K; Kalita, Jayantee; Misra, Usha K

2017-09-01

Refractory status epilepticus (RSE) can influence the outcome of status epilepticus (SE). In the present study, we report the aetiology and predictors of outcomes of RSE in a developing country. This is a prospective hospital-based study of SE patients (continuous seizures for five minutes or more). Those who had SE persisting after two antiepileptic drugs were defined as having RSE. We present the demographic information, duration, and type of SE, and we note its severity using the status epilepticus severity score (STESS), its aetiology, comorbidities and imaging findings. The outcome of RSE was defined as cessation of seizures and the condition upon discharge, as assessed by the modified Rankin Scale. A total of 35 (42.5%) of our 81 patients had RSE. The median duration of SE before starting treatment was 2 hours (range=0.008-160 h). The most common causes of RSE were stroke in 5 (14.3%), central nervous system (CNS) infections in 12 (34.3%) and metabolic encephalopathies in 13 (37.1%) patients. Some 21 (60%) patients had comorbidities, and the STESS was favourable in 7 (20%) patients. A total of 14 (20%) patients died, but death was directly related to SE in only one of these. Some 10 patients had super-refractory status epilepticus, which was due to CNS infection in 5 (50%) and metabolic encephalopathy in 3 (30%). On multivariate analysis, an unfavourable STESS (p=0.05) and duration of SE before treatment (p=0.01) predicted RSE. Metabolic aetiology (p=0.05), mechanical ventilation (p60 years (p=0.003) were predictors of poor outcomes. RSE was common (42.5%) among patients with SE in a tertiary care center in India. It was associated with high mortality and poor outcomes. Age above 60 years and metabolic aetiology were found to be predictors of poor outcomes.

Perinatal brain injury, visual motor function and poor school outcome of regional low birth weight survivors at age nine.

PubMed

Zhang, Jun; Mahoney, Ashley Darcy; Pinto-Martin, Jennifer A

2013-08-01

To explore the relationship between perinatal brain injury, visual motor function (VMF) and poor school outcome. Little is known about the status and underlying mechanism of poor school outcome as experienced by low birth weight survivors. This is a secondary data analysis. The parental study recruited 1104 low birth weight (LBW) infants weighing ≤ 2000 g from three medical centres of Central New Jersey between 1984 and 1987. Seven hundred and seventy-seven infants survived the neonatal period, and their developmental outcomes had been following up regularly until now. The development data of the survivors were used to achieve the research aims. Initial school outcome assessment was carried out in 9-year-old, using the Woodcock-Johnson Academic Achievement Scale. The severity and range of perinatal brain injury was determined by repeated neonatal cranial ultrasound results obtained at 4 hours, 24 hours and 7 days of life. Seventeen and a half per cent of the sample experienced poor school performance at age 9 as defined by lower than one standard deviation (SD) of average performance score. Children with the most severe injury, PL/VE, had the lowest mathematics (F = 14·54, p = 0·000) and reading (anova results: F = 11·56, p = 0·000) performances. Visual motor function had a significant effect on children's overall school performance (Hotelling's trace value was 0·028, F = 3·414, p = 0·018), as well as subtest scores for reading (p = 0·006) and mathematics (p = 0·036). However, visual motor function was not a mediator in the association of perinatal brain injury and school outcome. Perinatal brain injury had a significant long-term effect on school outcome. Low birth weight infants with history of perinatal brain injury need be closely monitored to substantially reduce the rates of poor school outcome and other neurodevelopmental disabilities. © 2012 Blackwell Publishing Ltd.

[Thyroid carcinoma--differentiated, poorly differentiated and anaplastic carcinoma].

PubMed

Kakudo, Kennichi; Bai, Yanhua; Li, Yaqiong; Wakasa, Tomoko; Mori, Ichiro

2007-11-01

The poorly differentiated carcinoma was first added as a new member in the lists of classification of thyroid carcinomas in the WHO 2004 edition. However its histological criteria include necrosis and increased mitoses in addition to the original definition by Sakamoto's proposal, solid, trabecular and schirrhous growth. This modification creates a significant change in the incidence and prognosis of this carcinoma. This carcinoma, defined by the new WHO classification, is about 1-5% of all thyroid malignancy and has more aggressive outcome than the previous definition.

Serum tenascin-C predicts severity and outcome of acute intracerebral hemorrhage.

PubMed

Wang, Lin-Guo; Huangfu, Xue-Qin; Tao, Bo; Zhong, Guan-Jin; Le, Zhou-Di

2018-06-01

Tenascin-C is a matricellular protein related to brain injury. We studied serum tenascin-C in acute intracerebral hemorrhage (ICH) and examined the associations with severity and outcome following the acute event. Tenascin-C samples were obtained from 162 patients with acute hemorrhagic stroke and 162 healthy controls. Poor 90-day functional outcome was defined as modified Rankin Scale score > 2. Early neurological deterioration (END) and hematoma growth (HG) were recorded at 24 h. Patients had higher tenascin-C levels than controls. Tenascin-C levels were positively correlated with hematoma volume or National Institutes of Health Stroke Scale score at baseline. Elevated tenascin-C levels were independently associated with END, HG, 90-day mortality and poor functional outcome. Moreover, tenascin-C levels significantly predicted END, HG and 90-day outcomes under receiver operating characteristic curves. An increase in serum tenascin-C level is associated with an adverse outcome in ICH patients, supporting the potential role of serum tenascin-C as a prognostic biomarker for hemorrhagic stroke. Copyright © 2018 Elsevier B.V. All rights reserved.

Self-Rated Estimates of Multiple Intelligences Based on Approaches to Learning

ERIC Educational Resources Information Center

Bowles, Terry

2008-01-01

To date questionnaires that measure Multiple Intelligences (MIs) have typically not been systematically developed, have poor psychometric properties, and relatively low reliability. The aim of this research was to define the factor structure, and reliability of nine talents which are the behavioural outcomes of MIs, using items representing…

Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

PubMed

Hartzler, Robert U; Steen, Brandon M; Hussey, Michael M; Cusick, Michael C; Cottrell, Benjamin J; Clark, Rachel E; Frankle, Mark A

2015-11-01

Some patients unexpectedly have poor functional improvement after reverse shoulder arthroplasty (RSA) for massive rotator cuff tear without glenohumeral arthritis. Our aim was to identify risk factors for this outcome. We also assessed the value of RSA for cases with poor functional improvement vs. The study was a retrospective case-control analysis for primary RSA performed for massive rotator cuff tear without glenohumeral arthritis with minimum 2-year follow-up. Cases were defined as Simple Shoulder Test (SST) score improvement of ≤1, whereas controls improved SST score ≥2. Risk factors were chosen on the basis of previous association with poor outcomes after shoulder arthroplasty. Latissimus dorsi tendon transfer results were analyzed as a subgroup. Value was defined as improvement in American Shoulder and Elbow Surgeons (ASES) score per $10,000 hospital cost. In a multivariate binomial logistic regression analysis, neurologic dysfunction (P = .006), age <60 years (P = .02), and high preoperative SST score (P = .03) were independently associated with poor functional improvement. Latissimus dorsi tendon transfer patients significantly improved in active external rotation (-0.3° to 38.7°; P < .01). The value of RSA (ΔASES/$10,000 cost) for cases was 0.8 compared with 17.5 for controls (P < .0001). Young age, high preoperative function, and neurologic dysfunction were associated with poor functional improvement. Surgeons should consider these associations in counseling and selection of patients. Concurrent latissimus dorsi transfer was successful in restoring active external rotation in a subgroup of patients. The critical economic importance of improved patient selection is emphasized by the very low value of the procedure in the case group. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Emotional and Financial Experiences of Kidney Donors over the Past 50 Years: The RELIVE Study.

PubMed

Jacobs, Cheryl L; Gross, Cynthia R; Messersmith, Emily E; Hong, Barry A; Gillespie, Brenda W; Hill-Callahan, Peg; Taler, Sandra J; Jowsey, Sheila G; Beebe, Tim J; Matas, Arthur J; Odim, Jonah; Ibrahim, Hassan N

2015-12-07

Most kidney donors view their experience positively, but some may experience psychosocial and financial burdens. We hypothesized that certain donor characteristics, poor outcome of the recipient, negative perceptions of care, and lack of support may be associated with poor psychosocial outcomes for donors. The Renal and Lung Living Donors Evaluation Study (RELIVE) examined long-term medical and psychosocial outcomes for kidney donors (at three U.S. transplant centers) who donated between 1963 and 2005. Standardized questionnaires evaluated donor perspectives, recovery time, social support, motivation, financial impact, insurability after donation, and current psychological status. Questionnaires were mailed to 6909 donors. Questionnaires were returned by 2455 donors, who had donated 17 ± 10 years earlier (range, 5-48 years), a response rate of 36%. Most (95%) rated their overall donation experience as good to excellent. Rating the overall donor experience more negatively was associated with donor complications, psychological difficulties, recipient graft failure, and longer time since donation. Nine percent (n=231) reported one or more of the following poor psychosocial outcomes: fair or poor overall donor experience, financial burden, regret or discomfort with decision to donate, or psychological difficulties since donation. Recipient graft failure was the only predictor for reporting one or more of these poor psychosocial outcomes (odds ratio, 1.77; 95% confidence interval, 1.33 to 2.34). Donors with lower educational attainment experienced greater financial burden. One of five employed donors took unpaid leave; 2% reported health and life insurability concerns. Although the majority of donors viewed their overall donation experience positively, almost 1 in 10 donors reported at least one negative consequence related to donation. Recipient graft failure was associated with poor psychosocial outcome, defined as one or more of these negative consequences. Some donors were financially disadvantaged, and some experienced insurance difficulties. Interventions to avoid negative psychosocial and financial consequences are warranted. Copyright © 2015 by the American Society of Nephrology.

High Dietary Glycemic Load is Associated with Poor Functional Outcome in Patients with Acute Cerebral Infarction.

PubMed

Song, Tae Jin; Chang, Yoonkyung; Chun, Min Young; Lee, Chan Young; Kim, A Ram; Kim, Yuri; Kim, Yong Jae

2018-04-01

Elevated postprandial blood glucose is a critical risk factor for stroke. The dietary glycemic load (GL) and glycemic index (GI) are frequently used as markers of the postprandial blood glucose response to estimate the overall glycemic effect of diets. We hypothesized that high dietary GL, GI, or total carbohydrate intake is associated with a poor functional outcome in patients with acute ischemic stroke. We prospectively included 263 first-ever ischemic stroke patients who completed a semiquantitative food-frequency questionnaire. The dietary GL, GI, and total carbohydrate intake were investigated by examining the average frequency of intake during the previous year based on reference amounts for various food items. Poor functional outcome was defined as a score on the modified Rankin Scale (mRS) of ≥3 at 3 months after stroke. The patients were aged 65.4±11.7 years (mean±standard deviation), and 58.2% of them were male. A multivariate analysis adjusted for age, sex, marital status, prestroke mRS score, diabetes mellitus, hyperlipidemia, body mass index, triglycerides, low-density lipoprotein, hemoglobin A1c, stroke classification, and National Institutes of Health Stroke Scale score, early neurological deterioration, and high-grade white-matter hyperintensities revealed that the dietary GL and total carbohydrate intake were associated with a poor functional outcome, with odds ratios for the top quartile relative to the bottom quartile of 28.93 (95% confidence interval=2.82-296.04) and 36.84 (95% confidence interval=2.99-453.42), respectively (p for trend=0.002 and 0.002, respectively). In contrast, high dietary GI was not associated with a poor functional outcome (p for trend=0.481). Increased dietary GL and carbohydrate intake were associated with a poor short-term functional outcome after an acute ischemic stroke. Copyright © 2018 Korean Neurological Association.

Emotional and Financial Experiences of Kidney Donors over the Past 50 Years: The RELIVE Study

PubMed Central

Gross, Cynthia R.; Messersmith, Emily E.; Hong, Barry A.; Gillespie, Brenda W.; Hill-Callahan, Peg; Taler, Sandra J.; Jowsey, Sheila G.; Beebe, Tim J.; Matas, Arthur J.; Odim, Jonah; Ibrahim, Hassan N.

2015-01-01

Background and objectives Most kidney donors view their experience positively, but some may experience psychosocial and financial burdens. We hypothesized that certain donor characteristics, poor outcome of the recipient, negative perceptions of care, and lack of support may be associated with poor psychosocial outcomes for donors. Design, setting, participants, & measurements The Renal and Lung Living Donors Evaluation Study (RELIVE) examined long-term medical and psychosocial outcomes for kidney donors (at three U.S. transplant centers) who donated between 1963 and 2005. Standardized questionnaires evaluated donor perspectives, recovery time, social support, motivation, financial impact, insurability after donation, and current psychological status. Questionnaires were mailed to 6909 donors. Results Questionnaires were returned by 2455 donors, who had donated 17±10 years earlier (range, 5–48 years), a response rate of 36%. Most (95%) rated their overall donation experience as good to excellent. Rating the overall donor experience more negatively was associated with donor complications, psychological difficulties, recipient graft failure, and longer time since donation. Nine percent (n=231) reported one or more of the following poor psychosocial outcomes: fair or poor overall donor experience, financial burden, regret or discomfort with decision to donate, or psychological difficulties since donation. Recipient graft failure was the only predictor for reporting one or more of these poor psychosocial outcomes (odds ratio, 1.77; 95% confidence interval, 1.33 to 2.34). Donors with lower educational attainment experienced greater financial burden. One of five employed donors took unpaid leave; 2% reported health and life insurability concerns. Conclusions Although the majority of donors viewed their overall donation experience positively, almost 1 in 10 donors reported at least one negative consequence related to donation. Recipient graft failure was associated with poor psychosocial outcome, defined as one or more of these negative consequences. Some donors were financially disadvantaged, and some experienced insurance difficulties. Interventions to avoid negative psychosocial and financial consequences are warranted. PMID:26463883

Allogeneic hematopoietic cell transplantation in first remission abrogates poor outcomes associated with high-risk pediatric acute myeloid leukemia.

PubMed

Burke, Michael J; Wagner, John E; Cao, Qing; Ustun, Celalettin; Verneris, Michael R

2013-07-01

Despite remission rates of approximately 85% for children diagnosed with acute myeloid leukemia (AML), greater than 40% will die from relapsed disease. Patients with poor-risk molecular/cytogenetics and/or inadequate response to up-front therapy are typically considered high-risk (HR) and historically have poor outcomes with chemotherapy alone. We investigated whether allogeneic hematopoietic cell transplantation (allo-HCT) with best available donor in first remission (CR1) would abrogate the poor outcomes associated with HR AML in children and young adults treated with chemotherapy. We reviewed the outcomes of 50 consecutive children and young adults (ages 0 to 30 years) with AML who received a myeloablative allo-HCT between 2001 and 2010. Thirty-six patients (72%) were HR, defined as having FLT3-ITD mutations, 11q23 MLL rearrangements, chromosome 5 or 7 abnormalities, induction failure, and/or having persistent disease. The majority of patients received cyclophosphamide and total body irradiation conditioning, and graft-versus-host-disease (GVHD) prophylaxis was cyclosporine based. Transplantation outcomes for HR patients were compared to standard-risk patients, with no significant differences observed in overall survival (72% versus 78%, P = .72), leukemia-free survival (69% versus 79%, P = .62), relapse (11% versus 7%, P = .71), or treatment-related mortality (17% versus 14%, P = .89). Children and young adults with HR-AML have comparable outcomes to standard-risk patients following allo-HCT in CR1. Copyright © 2013 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Barriers to the routine collection of health outcome data in an Australian community care organization.

PubMed

Nancarrow, Susan A

2013-01-01

For over a decade, organizations have attempted to include the measurement and reporting of health outcome data in contractual agreements between funders and health service providers, but few have succeeded. This research explores the utility of collecting health outcomes data that could be included in funding contracts for an Australian Community Care Organisation (CCO). An action-research methodology was used to trial the implementation of outcome measurement in six diverse projects within the CCO using a taxonomy of interventions based on the International Classification of Function. The findings from the six projects are presented as vignettes to illustrate the issues around the routine collection of health outcomes in each case. Data collection and analyses were structured around Donabedian's structure-process-outcome triad. Health outcomes are commonly defined as a change in health status that is attributable to an intervention. This definition assumes that a change in health status can be defined and measured objectively; the intervention can be defined; the change in health status is attributable to the intervention; and that the health outcomes data are accessible. This study found flaws with all of these assumptions that seriously undermine the ability of community-based organizations to introduce routine health outcome measurement. Challenges were identified across all stages of the Donabedian triad, including poor adherence to minimum dataset requirements; difficulties standardizing processes or defining interventions; low rates of use of outcome tools; lack of value of the tools to the service provider; difficulties defining or identifying the end point of an intervention; technical and ethical barriers to accessing data; a lack of standardized processes; and time lags for the collection of data. In no case was the use of outcome measures sustained by any of the teams, although some quality-assurance measures were introduced as a result of the project.

Using a modification of the Clavien-Dindo system accounting for readmissions and multiple interventions: defining quality for pancreaticoduodenectomy.

PubMed

Baker, Marshall S; Sherman, Karen L; Stocker, Susan J; Hayman, Amanda V; Bentrem, David J; Prinz, Richard A; Talamonti, Mark S

2014-09-01

The Clavien-Dindo system (CD) does not change the grade assigned a complication when multiple readmissions or interventions are required to manage a complication. We apply a modification of CD accounting for readmissions and interventions to pancreaticoduodenectomy (PD). PDs done between 1999 and 2009 were reviewed. CD grade IIIa complications requiring more than one intervention and II and IIIa complications requiring significantly prolonged lengths of stay including all 90-day readmissions were classified severe-adverse-postoperative-outcomes (SAPO). CD IIIb, IV, and V complications were also classified SAPOs. All other complications were considered minor-adverse-postoperative-outcomes (MAPO). Four-hundred forty three of 490 PD patients (90.4%) had either no complication or a complication of low to moderate CD grade (I, II, IIIa). When reclassified by the new metric, 92 patient-outcomes (19%) were upgraded from CD II or IIIa to SAPO. One-hundred thirty nine patients (28.4%) had a SAPO. Multivariable regression identified age >75 years, pylorus preservation and operative blood loss >1,500 ml as predictors of SAPO. Age was not associated with poor outcome using the unmodified CD system. Established systems may under-grade the severity of some complications following PD. We define a procedure-specific modification of CD accounting for readmissions and multiple interventions. Using this modification, advanced age, pylorus preservation, and significant blood loss are associated with poor outcome. © 2014 Wiley Periodicals, Inc.

Insulin resistance is associated with a poor response to intravenous thrombolysis in acute ischemic stroke.

PubMed

Calleja, Ana I; García-Bermejo, Pablo; Cortijo, Elisa; Bustamante, Rosa; Rojo Martínez, Esther; González Sarmiento, Enrique; Fernández-Herranz, Rosa; Arenillas, Juan F

2011-11-01

Insulin resistance (IR) may not only increase stroke risk, but could also contribute to aggravate stroke prognosis. Mainly through a derangement in endogenous fibrinolysis, IR could affect the response to intravenous thrombolysis, currently the only therapy proved to be efficacious for acute ischemic stroke. We hypothesized that high IR is associated with more persistent arterial occlusions and poorer long-term outcome after stroke thrombolysis. We performed a prospective, observational, longitudinal study in consecutive acute ischemic stroke patients presenting with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis. Patients with acute hyperglycemia (≥155 mg/dL) receiving insulin were excluded. IR was determined during admission by the homeostatic model assessment index (HOMA-IR). Poor long-term outcome, as defined by a day 90 modified Rankin scale score ≥ 3, was considered the primary outcome variable. Transcranial Duplex-assessed resistance to MCA recanalization and symptomatic hemorrhagic transformation were considered secondary end points. A total of 109 thrombolysed MCA ischemic stroke patients were included (43.1% women, mean age 71 years). The HOMA-IR was higher in the group of patients with poor outcome (P = 0.02). The probability of good outcome decreased gradually with increasing HOMA-IR tertiles (80.6%, 1st tertile; 71.4%, 2nd tertile; and 55.3%, upper tertile). A HOMA-IR in the upper tertile was independently associated with poor outcome when compared with the lower tertile (odds ratio [OR] 8.54 [95% CI 1.67-43.55]; P = 0.01) and was associated with more persistent MCA occlusions (OR 8.2 [1.23-54.44]; P = 0.029). High IR may be associated with more persistent arterial occlusions and worse long-term outcome after acute ischemic stroke thrombolysis.

Insulin Resistance Is Associated With a Poor Response to Intravenous Thrombolysis in Acute Ischemic Stroke

PubMed Central

Calleja, Ana I.; García-Bermejo, Pablo; Cortijo, Elisa; Bustamante, Rosa; Rojo Martínez, Esther; González Sarmiento, Enrique; Fernández-Herranz, Rosa; Arenillas, Juan F.

2011-01-01

OBJECTIVE Insulin resistance (IR) may not only increase stroke risk, but could also contribute to aggravate stroke prognosis. Mainly through a derangement in endogenous fibrinolysis, IR could affect the response to intravenous thrombolysis, currently the only therapy proved to be efficacious for acute ischemic stroke. We hypothesized that high IR is associated with more persistent arterial occlusions and poorer long-term outcome after stroke thrombolysis. RESEARCH DESIGN AND METHODS We performed a prospective, observational, longitudinal study in consecutive acute ischemic stroke patients presenting with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis. Patients with acute hyperglycemia (≥155 mg/dL) receiving insulin were excluded. IR was determined during admission by the homeostatic model assessment index (HOMA-IR). Poor long-term outcome, as defined by a day 90 modified Rankin scale score ≥3, was considered the primary outcome variable. Transcranial Duplex-assessed resistance to MCA recanalization and symptomatic hemorrhagic transformation were considered secondary end points. RESULTS A total of 109 thrombolysed MCA ischemic stroke patients were included (43.1% women, mean age 71 years). The HOMA-IR was higher in the group of patients with poor outcome (P = 0.02). The probability of good outcome decreased gradually with increasing HOMA-IR tertiles (80.6%, 1st tertile; 71.4%, 2nd tertile; and 55.3%, upper tertile). A HOMA-IR in the upper tertile was independently associated with poor outcome when compared with the lower tertile (odds ratio [OR] 8.54 [95% CI 1.67–43.55]; P = 0.01) and was associated with more persistent MCA occlusions (OR 8.2 [1.23–54.44]; P = 0.029). CONCLUSIONS High IR may be associated with more persistent arterial occlusions and worse long-term outcome after acute ischemic stroke thrombolysis. PMID:21911778

Maternal predictors of neonatal outcomes after emergency cesarean section: a retrospective study in three rural district hospitals in Rwanda.

PubMed

Nyirahabimana, Naome; Ufashingabire, Christine Minani; Lin, Yihan; Hedt-Gauthier, Bethany; Riviello, Robert; Odhiambo, Jackline; Mubiligi, Joel; Macharia, Martin; Rulisa, Stephen; Uwicyeza, Illuminee; Ngamije, Patient; Nkikabahizi, Fulgence; Nkurunziza, Theoneste

2017-01-01

In sub-Saharan Africa, neonatal mortality post-cesarean delivery is higher than the global average. In this region, most emergency cesarean sections are performed at district hospitals. This study assesses maternal predictors for poor neonatal outcomes post-emergency cesarean delivery in three rural district hospitals in Rwanda. This retrospective study includes a random sample of 441 neonates from Butaro, Kirehe and Rwinkwavu District Hospitals, born between 01 January and 31 December 2015. We described the demographic and clinical characteristics of the mothers of these neonates using frequencies and proportions. We assessed the association between maternal characteristics with poor neonatal outcomes, defined as death within 24 h or APGAR < 7 at 5 min after birth, using Fisher's exact test. Factors significant at α = 0.20 significance level were considered for the multivariate logistic regression model, built using a backwards stepwise process. We stopped when all the factors were significant at the α = 0.05 level. For all 441 neonates included in this study, 40 (9.0%) had poor outcomes. In the final model, three factors were significantly associated with poor neonatal outcomes. Neonates born to mothers who had four or more prior pregnancies were more likely to have poor outcomes (OR = 3.01, 95%CI:1.23,7.35, p  = 0.015). Neonates whose mothers came from health centers with ambulance travel times of more than 30 min to the district hospital had greater odds of having poor outcomes (for 30-60 min: OR = 3.80, 95%CI:1.07,13.40, p  = 0.012; for 60+ minutes: OR = 5.82, 95%CI:1.47,23.05, p  = 0.012). Neonates whose mothers presented with very severe indications for cesarean section had twice odds of having a poor outcome (95% CI: 1.11,4.52, p  = 0.023). Longer travel time to the district hospital was a leading predictor of poor neonatal outcomes post cesarean delivery. Improving referral systems, ambulance availability, number of equipped hospitals per district, and road networks may lessen travel delays for women in labor. Boosting the diagnostic capacity of labor conditions at the health center level through facilities and staff training can improve early identification of very severe indications for cesarean delivery for early referral and intervention.

Usefulness of Midregional Proadrenomedullin to Predict Poor Outcome in Patients with Community Acquired Pneumonia

PubMed Central

Gordo-Remartínez, Susana; Sevillano-Fernández, José A.; Álvarez-Sala, Luis A.; Andueza-Lillo, Juan A.; de Miguel-Yanes, José M.

2015-01-01

Background midregional proadrenomedullin (MR-proADM) is a prognostic biomarker in patients with community-acquired pneumonia (CAP). We sought to confirm whether MR-proADM added to Pneumonia Severity Index (PSI) improves the potential prognostic value of PSI alone, and tested to what extent this combination could be useful in predicting poor outcome of patients with CAP in an Emergency Department (ED). Methods Consecutive patients diagnosed with CAP were enrolled in this prospective, single-centre, observational study. We analyzed the ability of MR-proADM added to PSI to predict poor outcome using receiver operating characteristic (ROC) curves, logistic regression and risk reclassification and comparing it with the ability of PSI alone. The primary outcome was “poor outcome”, defined as the incidence of an adverse event (ICU admission, hospital readmission, or mortality at 30 days after CAP diagnosis). Results 226 patients were included; 33 patients (14.6%) reached primary outcome. To predict primary outcome the highest area under curve (AUC) was found for PSI (0.74 [0.64-0.85]), which was not significantly higher than for MR-proADM (AUC 0.72 [0.63-0.81, p > 0.05]). The combination of PSI and MR-proADM failed to improve the predictive potential of PSI alone (AUC 0.75 [0.65-0.85, p=0.56]). Ten patients were appropriately reclassified when the combined PSI and MR-proADM model was used as compared with the model of PSI alone. Net reclassification improvement (NRI) index was statistically significant (7.69%, p = 0.03) with an improvement percentage of 3.03% (p = 0.32) for adverse event, and 4.66% (P = 0.02) for no adverse event. Conclusion MR-proADM in combination with PSI may be helpful in individual risk stratification for short-term poor outcome of CAP patients, allowing a better reclassification of patients compared with PSI alone. PMID:26030588

Targeting the Poor: Evidence from a Field Experiment in Indonesia

PubMed Central

Alatas, Vivi; Banerjee, Abhijit; Hanna, Rema; Olken, Benjamin A.; Tobias, Julia

2014-01-01

This paper reports an experiment in 640 Indonesian villages on three approaches to target the poor: proxy-means tests (PMT), where assets are used to predict consumption; community targeting, where villagers rank everyone from richest to poorest; and a hybrid. Defining poverty based on PPP$2 per-capita consumption, community targeting and the hybrid perform somewhat worse in identifying the poor than PMT, though not by enough to significantly affect poverty outcomes for a typical program. Elite capture does not explain these results. Instead, communities appear to apply a different concept of poverty. Consistent with this finding, community targeting results in higher satisfaction. PMID:25197099

Adverse Influence of Pre-Stroke Dementia on Short-Term Functional Outcomes in Patients with Acute Ischemic Stroke: The Fukuoka Stroke Registry.

PubMed

Wakisaka, Yoshinobu; Matsuo, Ryu; Hata, Jun; Kuroda, Junya; Kitazono, Takanari; Kamouchi, Masahiro; Ago, Tetsuro

2017-01-01

Dementia and stroke are major causes of disability in the elderly. However, the association between pre-stroke dementia and functional outcome after stoke remains unresolved. We aimed to determine this association in patients with acute ischemic stroke. Among patients registered in the Fukuoka Stroke Registry from June 2007 to May 2015, 4,237 patients with ischemic stroke within 24 h of onset, who were functionally independent before the onset, were enrolled in this study. Pre-stroke dementia was defined as any type of dementia that was present prior to the index stroke. Primary and secondary study outcomes were poor functional outcome (modified Rankin Scale 3-6) at 3 months after the stroke onset and neurological deterioration (≥2-point increases on the National Institutes of Health Stroke Scale score during hospitalization), respectively. For propensity score (PS)-matched cohort study to control confounding variables for pre-stroke dementia, 318 pairs of patients with and without pre-stroke dementia were also selected on the basis of 1:1 matching. Multivariable logistic regression models and conditional logistic regression analysis were used to quantify associations between pre-stroke dementia and study outcomes. Of all 4,237 participants, 347 (8.2%) had pre-stroke dementia. The frequencies of neurological deterioration and poor functional outcome were significantly higher in patients with pre-stroke dementia than in those without pre-stroke dementia (neurological deterioration, 16.1 vs. 7.1%, p < 0.01; poor functional outcome, 63.7 vs. 27.1%, p < 0.01). Multivariable analysis showed that pre-stroke dementia was significantly associated with neurological deterioration (OR 1.67; 95% CI 1.14-2.41; p < 0.01) and poor functional outcome (OR 2.91; 95% CI 2.17-3.91; p < 0.01). In the PS-matched cohort study, the same trends were observed between the pre-stroke dementia and neurological deterioration (OR 2.60; 95% CI 1.17-5.78; p < 0.01) and between the dementia and poor functional outcome (OR 3.62; 95% CI 1.89-6.95; p < 0.01). Pre-stroke dementia was significantly associated with higher risks for poor functional outcome at 3 months after stroke onset as well as for neurological deterioration during hospitalization in patients with acute ischemic stroke. © 2016 S. Karger AG, Basel.

Hypnotic Relaxation and Yoga to Improve Sleep and School Functioning

ERIC Educational Resources Information Center

Perfect, Michelle M.; Smith, Bradley

2016-01-01

Sleep insufficiency, defined as inadequate sleep duration, poor sleep quality, and daytime sleepiness, has been linked with students' learning and behavioral outcomes at school. However, there is limited research on interventions designed to improve the sleep of school-age children. In order to promote more interest on this critical topic, we…

Evaluation of functional outcome of the floating knee injury using multivariate analysis.

PubMed

Yokoyama, Kazuhiko; Tsukamoto, Tatsuro; Aoki, Shinichi; Wakita, Ryuji; Uchino, Masataka; Noumi, Takashi; Fukushima, Nobuaki; Itoman, Moritoshi

2002-11-01

The objective of this study is to evaluate significant contributing factors affecting the functional prognosis of floating knee injuries using multivariate analysis. A total of 68 floating knee injuries (67 patients) were treated at Kitasato University Hospital from 1986 to 1999. Both the femoral fractures and the tibial fractures were managed surgically by various methods. The functional results of these injuries were evaluated using the grading system of Karlström and Olerud. Follow-up periods ranged from 2 to 19 years (mean 50.2 months) after the original injury. We defined satisfactory (S) outcomes as those cases with excellent or good results and unsatisfactory (US) outcomes as those cases with acceptable or poor results. Logistic regression analysis was used as a multivariate analysis, and the dependent variables were defined as a satisfactory outcome or as an unsatisfactory outcome. The explanatory variables were predicting factors influencing the functional outcome such as age at trauma, gender, severity of soft-tissue injury in the femur and the tibia, AO fracture grade in the femur and the tibia, Fraser type (type I or type II), Injury Severity Score (ISS), and fixation time after injury (less than 1 week or more than 1 week) in the femur and the tibia. The final functional results were as follows: 25 cases had excellent results, 15 cases good results, 16 cases acceptable results, and 12 cases poor results. The predictive logistic regression equation was as follows: Log 1-p/p = 3.12-1.52 x Fraser type - 1.65 x severity of soft-tissue injury in the tibia - 1.31 x fixation time after injury in the tibia - 0.821 x AO fracture grade in the tibia + 1.025 x fixation time after injury in the femur - 0.687 x AO fracture grade in the femur ( p=0.01). Among the variables, Fraser type and the severity of soft-tissue injury in the tibia were significantly related to the final result. The multivariate analysis showed that both the involvement of the knee joint and the severity grade of soft-tissue injury in the tibia represented significant risk factors of poor outcome in floating knee injuries in this study.

A 5-year audit of cataract surgery outcomes after posterior capsule rupture and risk factors affecting visual acuity.

PubMed

Ti, Seng-Ei; Yang, You-Nian; Lang, Stephanie S; Chee, Soon Phaik

2014-01-01

To describe the posterior capsule rupture rates and visual outcomes after phacoemulsification, analyze risk factors for poor vision, and compare results of faculty (F) and residents (R). Retrospective audit study. Visual success of all capsule ruptures (2006-2010) was analyzed and compared to uneventful cases. Rupture rates of faculty and residents were compared (χ², P < .05). Success was defined as % best-corrected visual acuity (BCVA) ≥20/40 at 3 months (excluding poor-prognosis eyes) and studied in relation to age, sex, surgeon type, stage of surgery, vitreous loss, dropped nucleus, and other complications (eg, retinal detachment, corneal decompensation, dislocated intraocular lens [IOL]). Final risk factors were identified using multivariate logistic regression analysis. From 2006 to 2010, there were 887 capsule ruptures in 48 377 phacoemulsification cases (rate 1.8%). Uneventful cases had significantly better visual outcomes than capsule ruptures (98.5% vs 93.9%; P < .01). Faculty rupture rates were lower (F = 1.4%) than residents' (R = 3.4%; P < .01), but visual outcomes were similar (F = 93.8%, R = 93.7%; P > .05). Ruptures most frequently occurred during phacoemulsification (59.6%) and irrigation and aspiration (24.8%) stages. Risk factors for poor outcomes included age >65 years, dropped nuclei, and other complications. The overall capsule rupture rate was 1.8%. Although residents had higher rates, visual success matched faculty's, possibly attributable to case mix and close supervision. Associated risk factors for poor vision included age >65 years, dropped nuclei, and postoperative retinal, corneal, and IOL complications. Copyright © 2014 Elsevier Inc. All rights reserved.

Thai venous stroke prognostic score: TV-SPSS.

PubMed

Poungvarin, Niphon; Prayoonwiwat, Naraporn; Ratanakorn, Disya; Towanabut, Somchai; Tantirittisak, Tassanee; Suwanwela, Nijasri; Phanthumchinda, Kamman; Tiamkoa, Somsak; Chankrachang, Siwaporn; Nidhinandana, Samart; Laptikultham, Somsak; Limsoontarakul, Sansern; Udomphanthuruk, Suthipol

2009-11-01

Prognosis of cerebral venous sinus thrombosis (CVST) has never been studied in Thailand. A simple prognostic score to predict poor prognosis of CVST has also never been reported. The authors are aiming to establish a simple and reliable prognostic score for this condition. The medical records of CVST patients from eight neurological training centers in Thailand who received between April 1993 and September 2005 were reviewed as part of this retrospective study. Clinical features included headache, seizure, stroke risk factors, Glasgow coma scale (GCS), blood pressure on arrival, papilledema, hemiparesis, meningeal irritation sign, location of occluded venous sinuses, hemorrhagic infarction, cerebrospinal fluid opening pressure, treatment options, length of stay, and other complications were analyzed to determine the outcome using modified Rankin scale (mRS). Poor prognosis (defined as mRS of 3-6) was determined on the discharge date. One hundred ninety four patients' records, 127 females (65.5%) and mean age of 36.6 +/- 14.4 years, were analyzed Fifty-one patients (26.3%) were in the poor outcome group (mRS 3-6). Overall mortality was 8.4%. Univariate analysis and then multivariate analysis using SPSS version 11.5 revealed only four statistically significant predictors influencing outcome of CVST They were underlying malignancy, low GCS, presence of hemorrhagic infarction (for poor outcome), and involvement of lateral sinus (for good outcome). Thai venous stroke prognostic score (TV-SPSS) was derived from these four factors using a multiple logistic model. A simple and pragmatic prognostic score for CVST outcome has been developed with high sensitivity (93%), yet low specificity (33%). The next study should focus on the validation of this score in other prospective populations.

The Association Between Spontaneous Hyperventilation, Delayed Cerebral Ischemia, and Poor Neurological Outcome in Patients with Subarachnoid Hemorrhage.

PubMed

Williamson, Craig A; Sheehan, Kyle M; Tipirneni, Renuka; Roark, Christopher D; Pandey, Aditya S; Thompson, B Gregory; Rajajee, Venkatakrishna

2015-12-01

The frequency and associations of spontaneous hyperventilation in subarachnoid hemorrhage (SAH) are unknown. Because hyperventilation decreases cerebral blood flow, it may exacerbate delayed cerebral ischemia (DCI) and worsen neurological outcome. This is a retrospective analysis of data from a prospectively collected cohort of SAH patients at an academic medical center. Spontaneous hyperventilation was defined by PaCO2 <35 mmHg and pH >7.45 and subdivided into moderate and severe groups. Clinical and demographic characteristics of patients with and without spontaneous hyperventilation were compared using χ (2) or t tests. Bivariate and multivariable logistic regression analyses were conducted to examine the association of moderate and severe hyperventilation with DCI and discharge neurological outcome. Of 207 patients, 113 (55 %) had spontaneous hyperventilation. Spontaneously hyperventilating patients had greater illness severity as measured by the Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), and SAH sum scores. They were also more likely to develop the following complications: pneumonia, neurogenic myocardial injury, systemic inflammatory response syndrome (SIRS), radiographic vasospasm, DCI, and poor neurological outcome. In a multivariable logistic regression model including age, gender, WFNS, SAH sum score, pneumonia, neurogenic myocardial injury, etiology, and SIRS, only moderate [odds ratio (OR) 2.49, 95 % confidence interval (CI) 1.10-5.62] and severe (OR 3.12, 95 % CI 1.30-7.49) spontaneous hyperventilation were associated with DCI. Severe spontaneous hyperventilation (OR 4.52, 95 % CI 1.37-14.89) was also significantly associated with poor discharge outcome in multivariable logistic regression analysis. Spontaneous hyperventilation is common in SAH and is associated with DCI and poor neurological outcome.

Black Hole Sign Predicts Poor Outcome in Patients with Intracerebral Hemorrhage.

PubMed

Li, Qi; Yang, Wen-Song; Chen, Sheng-Li; Lv, Fu-Rong; Lv, Fa-Jin; Hu, Xi; Zhu, Dan; Cao, Du; Wang, Xing-Chen; Li, Rui; Yuan, Liang; Qin, Xin-Yue; Xie, Peng

2018-01-01

In spontaneous intracerebral hemorrhage (ICH), black hole sign has been proposed as a promising imaging marker that predicts hematoma expansion in patients with ICH. The aim of our study was to investigate whether admission CT black hole sign predicts hematoma growth in patients with ICH. From July 2011 till February 2016, patients with spontaneous ICH who underwent baseline CT scan within 6 h of symptoms onset and follow-up CT scan were recruited into the study. The presence of black hole sign on admission non-enhanced CT was independently assessed by 2 readers. The functional outcome was assessed using the modified Rankin Scale (mRS) at 90 days. Univariate and multivariable logistic regression analyses were performed to assess the association between the presence of the black hole sign and functional outcome. A total of 225 patients (67.6% male, mean age 60.3 years) were included in our study. Black hole sign was identified in 32 of 225 (14.2%) patients on admission CT scan. The multivariate logistic regression analysis demonstrated that age, intraventricular hemorrhage, baseline ICH volume, admission Glasgow Coma Scale score, and presence of black hole sign on baseline CT independently predict poor functional outcome at 90 days. There are significantly more patients with a poor functional outcome (defined as mRS ≥4) among patients with black hole sign than those without (84.4 vs. 32.1%, p < 0.001; OR 8.19, p = 0.001). The CT black hole sign independently predicts poor outcome in patients with ICH. Early identification of black hole sign is useful in prognostic stratification and may serve as a potential therapeutic target for anti-expansion clinical trials. © 2018 S. Karger AG, Basel.

External validation of the MRI-DRAGON score: early prediction of stroke outcome after intravenous thrombolysis.

PubMed

Turc, Guillaume; Aguettaz, Pierre; Ponchelle-Dequatre, Nelly; Hénon, Hilde; Naggara, Olivier; Leclerc, Xavier; Cordonnier, Charlotte; Leys, Didier; Mas, Jean-Louis; Oppenheim, Catherine

2014-01-01

The aim of our study was to validate in an independent cohort the MRI-DRAGON score, an adaptation of the (CT-) DRAGON score to predict 3-month outcome in acute ischemic stroke patients undergoing MRI before intravenous thrombolysis (IV-tPA). We reviewed consecutive (2009-2013) anterior circulation stroke patients treated within 4.5 hours by IV-tPA in the Lille stroke unit (France), where MRI is the first-line pretherapeutic work-up. We assessed the discrimination and calibration of the MRI-DRAGON score to predict poor 3-month outcome, defined as modified Rankin Score >2, using c-statistic and the Hosmer-Lemeshow test, respectively. We included 230 patients (mean ±SD age 70.4±16.0 years, median [IQR] baseline NIHSS 8 [5]-[14]; poor outcome in 78(34%) patients). The c-statistic was 0.81 (95%CI 0.75-0.87), and the Hosmer-Lemeshow test was not significant (p = 0.54). The MRI-DRAGON score showed good prognostic performance in the external validation cohort. It could therefore be used to inform the patient's relatives about long-term prognosis and help to identify poor responders to IV-tPA alone, who may be candidates for additional therapeutic strategies, if they are otherwise eligible for such procedures based on the institutional criteria.

Effect of diabetes on tuberculosis presentation and outcomes in Kiribati.

PubMed

Cavanaugh, J; Viney, K; Kienene, T; Harley, D; Kelly, P M; Sleigh, A; O'Connor, J; Mase, S

2015-05-01

To determine the association between diabetes and the clinical features and treatment outcomes of TB in Kiribati. We enrolled consecutive patients with TB who presented from August 2010 to February 2012 and compared clinical features and TB treatment outcomes for patients with and without diabetes, as measured by haemoglobin A1c assay. Poor outcome was defined as death, default or treatment failure, and good outcome as treatment success or cure. Two hundred and seventy-five eligible persons with TB disease were enrolled; 101 (37%) had diabetes. TB patients with diabetes were more likely to have acid-fast bacilli (AFB) seen on sputum smear microscopy (RR: 1.3; 95% CI: 1.03-1.62). The risk of poor outcome did not differ between patients with or without diabetes (RR: 1.1; 95% CI: 0.5-2.7). TB patients with diabetes are more likely than those without to have sputum with AFB on microscopy. This could increase transmission in the community. Early detection of TB by screening patients with diabetes, and the converse, could be important public health interventions where diabetes and TB are prevalent. © 2015 John Wiley & Sons Ltd.

Association Between Blood Glucose and Functional Outcome in Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis.

PubMed

Zheng, Jun; Yu, Zhiyuan; Ma, Lu; Guo, Rui; Lin, Sen; You, Chao; Li, Hao

2018-03-16

Intracerebral hemorrhage (ICH) is a devastating subtype of stroke. Patients with ICH have poor functional outcomes. The association between blood glucose level and functional outcome in ICH remains unclear. This systematic review and meta-analysis aimed to investigate the association between blood glucose level and functional outcomes in patients with ICH. Literature was searched systemically in PubMed, EMBASE, Web of Science, and Cochrane Library. Published cohort studies evaluating the association between blood glucose and functional outcome in patients with ICH were included. This meta-analysis was performed using odds ratios (ORs) and 95% confidence intervals (CIs). A total of 16 studies were included in our meta-analysis. Our data show that hyperglycemia defined by cutoff values was significantly associated with unfavorable functional outcome (OR, 1.80; 95% CI, 1.36-2.39; P < 0.001). Our analysis also suggested a significant association between increased blood glucose levels and functional outcomes (OR, 1.05; 95% CI, 1.03-1.07; P < 0.001). High blood glucose level is significantly associated with poor functional outcome in ICH. Further studies with larger sample sizes, more time points, and longer follow-up times are necessary to confirm this association. Copyright © 2018 Elsevier Inc. All rights reserved.

Cycle cancellation and pregnancy after luteal estradiol priming in women defined as poor responders: a systematic review and meta-analysis

PubMed Central

Reynolds, Kasey A.; Omurtag, Kenan R.; Jimenez, Patricia T.; Rhee, Julie S.; Tuuli, Method G.; Jungheim, Emily S.

2013-01-01

STUDY QUESTION Does a luteal estradiol (LE) stimulation protocol improve outcomes in poor responders to IVF? SUMMARY ANSWER LE priming is associated with decreased cycle cancellation and increased chance of clinical pregnancy in poor responders WHAT IS KNOWN ALREADY Poor responders to IVF are one of the most challenging patient populations to treat. Many standard protocols currently exist for stimulating these patients but all have failed to improve outcomes. STUDY DESIGN, SIZE, DURATION Systematic review and meta-analysis including eight published studies comparing assisted reproduction technology (ART) outcomes in poor responders exposed to controlled ovarian hyperstimulation with and without LE priming. A search of the databases MEDLINE, EMBASE and PUBMED was carried out for studies in the English language published up to January 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS Studies evaluating women defined as poor responders to ART were evaluated. These studies were identified following a systematic review of the literature and data were analyzed using the DerSimonian–Laird random effects model. The main outcomes of interest were cycle cancellation rate and clinical pregnancy. Although the definition of clinical pregnancy varied between studies, the principal definition included fetal cardiac activity as assessed by transvaginal ultrasonography after 5 weeks of gestation. MAIN RESULTS AND THE ROLE OF CHANCE A total of 2249 publications were identified from the initial search, and the bibliographies, abstracts and other sources yielded 11 more. After excluding duplications, 1227 studies remained and 8 ultimately met the inclusion criteria. Compared with women undergoing non-LE primed protocols (n = 621), women exposed to LE priming (n = 468) had a lower risk of cycle cancellation [relative risk (RR): 0.60, 95% confidence interval (CI): 0.45–0.78] and an improved chance of clinical pregnancy (RR: 1.33, 95% CI: 1.02–1.72). There was no significant improvement in the number of mature oocytes obtained or number of zygotes obtained per cycle. LIMITATIONS, REASONS FOR CAUTION These findings are limited by the body of literature currently available. As the poor responder lacks a concrete definition, there is some heterogeneity to these results, which merits caution when applying our findings to individual patients. Furthermore, the increased clinical pregnancy rate demonstrated when using the LE protocol may be principally related to the decreased cycle cancellation rate. WIDER IMPLICATIONS OF THE FINDINGS The LE protocol may be of some utility in the poor responder to IVF and may increase clinical pregnancy rates in this population by improving stimulation and thereby decreasing cycle cancellation. STUDY FUNDING/COMPETING INTERESTS NIH K12 HD063086 (ESJ, MGT), NIH T32 HD0040135-11 (KAR), F32 HD040135-10 NIH (KRO), 5K12HD000849-25 (PTJ). No competing interests. PMID:23887073

Outcome at 3 years of age in a population-based cohort of extremely preterm infants.

PubMed

De Groote, Isabel; Vanhaesebrouck, Piet; Bruneel, Els; Dom, Lina; Durein, Isabelle; Hasaerts, Danielle; Laroche, Sabine; Oostra, Ann; Ortibus, Els; Roeyers, Herbert; van Mol, Christine

2007-10-01

To assess health and neurodevelopmental outcome at 3 years of age in neonatal intensive care unit (NICU)-surviving children who were born at 26 or fewer weeks of gestation in a geographically defined region of Belgium from 1999 through 2000. The study included a clinical examination and a standardized neurologic and developmental assessment. Disabilities were defined by international criteria. In 97% (92 of 95) of the children, accurate information on the presence of overall disability could be collected. Thirty-six percent (95% confidence interval [CI] 25-47%) of the formally assessed children (28 of 77) had deficient neuromotor development, with 5% of them showing severe sensory-communicative impairment. Mean (+/-standard deviation) scores on the Mental Developmental Index and Psychomotor Developmental Index were 81.2 (18.8) and 73.2 (17.8), respectively. Seventy percent (95% CI 60-80%) had a mental (Mental Developmental Index) or psychomotor (Psychomotor Developmental Index) impairment or both, assessed to be more than 1 standard deviation below the population mean. Mental and psychomotor outcome did not differ significantly when compared according to either gestational age, gender, or multiple birth (all P>.05). When either minor central dysfunction or cerebral palsy was not taken into account, normal mental development was recorded in 62% of the subjects. The cumulative of poor outcome (ie, disability- or prematurity-related death) among the 95 infants discharged alive was estimated to be 58% (95% CI 48-68%), representing 25 (26%) mildly-to-moderately disabled and 28 (29%) severely disabled toddlers, including two infants whose postdischarge deaths were directly related to prematurity. The average developmental outcome is poor in children born as extremely preterm infants. Finding early predictors of adverse outcome is a major challenge.

Early Absent Pupillary Light Reflexes After Cardiac Arrest in Patients Treated with Therapeutic Hypothermia.

PubMed

Dhakal, Laxmi P; Sen, Ayan; Stanko, Carlene M; Rawal, Bhupendra; Heckman, Michael G; Hoyne, Jonathan B; Dimberg, Elliot L; Freeman, Michelle L; Ng, Lauren K; Rabinstein, Alejandro A; Freeman, William D

2016-08-01

Loss of pupillary light reactivity is one recognized indicator of poor prognosis after cardiopulmonary resuscitation (CPR). However, drug overdose, low cardiac output, and/or resuscitation drugs can lead to impaired pupillary light reflex. To investigate pupillary light reflex status before therapeutic hypothermia (TH) in relation to neurological outcome, we retrospectively reviewed the data of a prospectively implemented TH protocol in patients with cardiac arrest (CA) at Mayo Clinic in Jacksonville, Florida (January 2006-January 2012), and Mayo Clinic in Scottsdale, Arizona (August 2010-March 2014). During this period, all CA patients who underwent hypothermia were included. These patients were selected from an institutional database and hypothermia data set. The Cerebral Performance Category (CPC) at time of discharge was our primary outcome measure. A CPC of 1 to 2 was defined as good outcome and a CPC from 3 to 5 was defined as poor outcome. We identified 99 patients who had CA treated with TH. Twenty-nine patients (29%) had pupils that were nonreactive to light on admission examination before TH, eight of whom later had return of pupil reactivity by day 3. Two of these 29 patients (6.9%) had good outcome, compared to 24 of 70 patients (34.3%) with pupils that were reactive to light (p = 0.005). Both of these patients had CA after illicit drug overdose. Early nonreactive pupils occurred in almost a third of patients after CPR and before TH in our patient population. Recovery of pupillary light reactivity is possible, and in a small minority of those cases (particularly when CA is preceded by the use of illicit drugs), a good outcome can be achieved.

Prognostic implications of aspiration pneumonia in patients with community acquired pneumonia: A systematic review with meta-analysis

PubMed Central

Komiya, Kosaku; Rubin, Bruce K.; Kadota, Jun-ichi; Mukae, Hiroshi; Akaba, Tomohiro; Moro, Hiroshi; Aoki, Nobumasa; Tsukada, Hiroki; Noguchi, Shingo; Shime, Nobuaki; Takahashi, Osamu; Kohno, Shigeru

2016-01-01

Aspiration pneumonia is thought to be associated with a poor outcome in patients with community acquired pneumonia (CAP). However, there has been no systematic review regarding the impact of aspiration pneumonia on the outcomes in patients with CAP. This review was conducted using the MOOSE guidelines: Patients: patients defined CAP. Exposure: aspiration pneumonia defined as pneumonia in patients who have aspiration risk. Comparison: confirmed pneumonia in patients who were not considered to be at high risk for oral aspiration. Outcomes: mortality, hospital readmission or recurrent pneumonia. Three investigators independently identified published cohort studies from PubMed, CENTRAL database, and EMBASE. Nineteen studies were included for this systematic review. Aspiration pneumonia increased in-hospital mortality (relative risk, 3.62; 95% CI, 2.65–4.96; P < 0.001, seven studies) and 30-day mortality (3.57; 2.18–5.86; P < 0.001, five studies). In contrast, aspiration pneumonia was associated with decreased ICU mortality (relative risk, 0.40; 95% CI, 0.26–0.60; P < 0.00001, four studies). Although there are insufficient data to perform a meta-analysis on long-term mortality, recurrent pneumonia, and hospital readmission, the few reported studies suggest that aspiration pneumonia is also associated with these poor outcomes. In conclusion, aspiration pneumonia was associated with both higher in-hospital and 30-day mortality in patients with CAP outside ICU settings. PMID:27924871

Outcome of treatment after first relapse in younger adults with acute myeloid leukemia initially treated by the ALFA-9802 trial.

PubMed

Thomas, Xavier; Raffoux, Emmanuel; Renneville, Aline; Pautas, Cécile; de Botton, Stéphane; de Revel, Thierry; Reman, Oumedaly; Terré, Christine; Gardin, Claude; Chelghoum, Youcef; Boissel, Nicolas; Quesnel, Bruno; Cordonnier, Catherine; Bourhis, Jean-Henri; Elhamri, Mohamed; Fenaux, Pierre; Preudhomme, Claude; Socié, Gérard; Michallet, Mauricette; Castaigne, Sylvie; Dombret, Hervé

2012-09-01

Forty-seven percent of adults with acute myeloid leukemia (AML) who entered the ALFA-9802 trial and achieved a first complete remission (CR) experienced a first relapse. We examined the outcome of these 190 adult patients. Eighty-four patients (44%) achieved a second CR. The median overall survival (OS) after relapse was 8.9 months with a 2-year OS at 25%. Factors predicting a better outcome after relapse were stem cell transplant (SCT) performed in second CR and a first CR duration >1 year. Risk groups defined at the time of diagnosis and treatment received in first CR also influenced the outcome after relapse. The best results were obtained in patients with core binding factor (CBF)-AML, while patients initially defined as favorable intermediate risk showed a similar outcome after relapse than those initially entering the poor risk group. We conclude that most adult patients with recurring AML could not be rescued using current available therapies, although allogeneic SCT remains the best therapeutic option at this stage of the disease. Copyright © 2012 Elsevier Ltd. All rights reserved.

Treatment outcomes of multidrug-resistant tuberculosis patients in Zhejiang, China, 2009-2013.

PubMed

Zhang, L; Meng, Q; Chen, S; Zhang, M; Chen, B; Wu, B; Yan, G; Wang, X; Jia, Z

2018-04-01

To examine treatment outcomes and factors associated with poor outcome of multidrug-resistant (MDR) tuberculosis (TB) in China. We conducted a prospective observational cohort study including consecutive patients with MDR-TB between 2009 and 2013 in six regions of Zhejiang province. Patients were prescribed treatments by infectious disease specialists, and treatment outcomes were recorded. Sociodemographic characteristics were obtained through a structured questionnaire. The primary endpoint was poor treatment outcomes, defined as treatment failure based on microbiologic persistence, default (lost to follow-up) or death at 24 months. We assessed risk factors for poor treatment outcomes using a Cox proportional hazards model. A total of 820 MDR-TB patients were observed, and 537 with known treatment outcomes were included in our study. Overall, the treatment success rate was 40.2 per 100 years (374/537 participants, 69.6%), while treatment failure, death and default rates were 10.0 per 100 years (101 participants, 18.8%), 3.4 per 100 years (36 participants, 6.7%) and 2.7 per 100 years (26 participants, 4.8%) respectively. Independent predictors of poor treatment outcomes included age >60 years (hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.2), patients registered as experiencing relapse (HR 2.2, 95% CI 1.1-4.4), patients registered as receiving treatment after failure (HR 2.4, 95% CI 1.2-4.9), use of standardized MDR-TB regimens (HR 0.6, 95% CI 0.4-1.0), cavitary disease (HR 4.9, 95% CI 2.8-8.6) and adverse events (HR 2.5, 95% CI 1.2-5.5). Under well-designed treatment and management scheme, high treatment success rates were achieved in a high-MDR-TB-burden country. Antimicrobial susceptibility testing for all second-line drugs should be conducted to further assist in the treatment of MDR-TB. Copyright © 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Magnetic Resonance Imaging-DRAGON score: 3-month outcome prediction after intravenous thrombolysis for anterior circulation stroke.

PubMed

Turc, Guillaume; Apoil, Marion; Naggara, Olivier; Calvet, David; Lamy, Catherine; Tataru, Alina M; Méder, Jean-François; Mas, Jean-Louis; Baron, Jean-Claude; Oppenheim, Catherine; Touzé, Emmanuel

2013-05-01

The DRAGON score, which includes clinical and computed tomographic scan parameters, showed a high specificity to predict 3-month outcome in patients with acute ischemic stroke treated by intravenous tissue plasminogen activator. We adapted the score for patients undergoing MRI as the first-line diagnostic tool. We reviewed patients with consecutive anterior circulation ischemic stroke treated ≤ 4.5 hour by intravenous tissue plasminogen activator between 2003 and 2012 in our center, where MRI is systematically implemented as first-line diagnostic work-up. We derived the MRI-DRAGON score keeping all clinical parameters of computed tomography-DRAGON (age, initial National Institutes of Health Stroke Scale and glucose level, prestroke handicap, onset to treatment time), and considering the following radiological variables: proximal middle cerebral artery occlusion on MR angiography instead of hyperdense middle cerebral artery sign, and diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI ASPECTS) ≤ 5 instead of early infarct signs on computed tomography. Poor 3-month outcome was defined as modified Rankin scale >2. We calculated c-statistics as a measure of predictive ability and performed an internal cross-validation. Two hundred twenty-eight patients were included. Poor outcome was observed in 98 (43%) patients and was significantly associated with all parameters of the MRI-DRAGON score in multivariate analysis, except for onset to treatment time (nonsignificant trend). The c-statistic was 0.83 (95% confidence interval, 0.78-0.88) for poor outcome prediction. All patients with a MRI-DRAGON score ≤ 2 (n=22) had a good outcome, whereas all patients with a score ≥ 8 (n=11) had a poor outcome. The MRI-DRAGON score is a simple tool to predict 3-month outcome in acute stroke patients screened by MRI then treated by intravenous tissue plasminogen activator and may help for therapeutic decision.

Social Contributors to Glycemic Control in Gestational Diabetes Mellitus.

PubMed

Colicchia, Laura C; Parviainen, Kristiina; Chang, Judy C

2016-12-01

To evaluate the association of social factors with glycemic control in women with gestational diabetes mellitus (GDM). A survey instrument assessing social support, access to healthy food, cooking and meal preparation, chaotic lifestyle, employer support, and physical and emotional responses to food was developed and administered to women with GDM at maternal-fetal medicine office visits. Validated scales were used to measure social support and life chaos (defined as organization, instability, and the ability to plan and prepare for the future). Glycemic control and pregnancy outcome were ascertained by chart review. Multivariable logistic regression was used to quantify the association of these factors with the primary outcome of satisfactory glycemic control, defined as greater than 70% of blood sugars within goal. We approached 145 women, of whom 111 agreed to participate (76.5%). Seventy-seven percent of patients (86/111) achieved satisfactory glycemic control. Chaotic lifestyle (Confusion, Hubbub and Order Scale score 12.5±2.9 for those with good control, 16.3±3.9 for poor control; odds ratio [OR] 0.71, 95% confidence interval [CI] 0.59-0.85) and receipt of food stamps (11/86 [12.9%] for good control and 10/25 [40%] for poor control; OR 0.22, 95% CI 0.08-0.62) were associated with decreased likelihood of achieving glycemic control. Being married (67/86 [77.9%] for good control and 12/25 [48.0%] for poor control; OR 3.82, 95% CI 1.49-9.74) and regular exercise (49/86 [57.0%] for good control and 5/25 [20.0%] for poor control; OR 5.03, 95% CI 1.72-14.72) increased the likelihood of achieving glycemic control. Transportation time to food stores, home cooking, and social support were not associated with glycemic control or pregnancy outcomes. Social factors are associated with glycemic control in GDM and may be modifiable to improve glucose control.

Contribution of Revised International Prognostic Scoring System Cytogenetics to Predict Outcome After Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes: A Study From the French Society of Bone Marrow Transplantation and Cellular Therapy.

PubMed

Gauthier, Jordan; Damaj, Gandhi; Langlois, Carole; Robin, Marie; Michallet, Mauricette; Chevallier, Patrice; Beguin, Yves; N'guyen, Stéphanie; Bories, Pierre; Blaise, Didier; Cornillon, Jérôme; Clavert, Aline; Mohty, Mohamad; Huynh, Anne; Thiébaut-Bertrand, Anne; Vigouroux, Stéphane; Duhamel, Alain; Yakoub-Agha, Ibrahim

2015-08-01

The prognosis of myelodysplastic syndromes (MDS) after allogeneic stem cell transplantation is critically determined by cytogenetic abnormalities, as previously defined by International Prognostic Scoring System (IPSS) cytogenetics. It has been shown that a new cytogenetic classification, included in the IPSS-R (cytogenetic-IPSS-R [C-IPSS-R]), can better predict the outcome of untreated MDS patients. In this study, we assessed the impact of the IPSS-R cytogenetic score (C-IPSS-R) on the outcome of 367 MDS patients transplanted from HLA-identical siblings or HLA allele-matched unrelated donors. According to the C-IPSS-R, 178 patients (48%) fell in the good risk, 102 (28%) in the intermediate risk, 77 (21%) in the poor risk, and 10 (3%) in the very poor risk group. In multivariate analysis, after a median follow-up of 4 years, the poor and very poor-risk categories correlated with shorter overall survival (OS) (4-year OS, 32%; hazard ratio [HR], 1.59; P = 0.009 and OS, 10%; HR, 3.18; P = 0.002, respectively) and higher cumulative incidence of relapse (CIR) (CIR, 52%; HR, 1.82; P = 0.004 and CIR, 60%; HR, 2.44; P = 0.060, respectively). Overall, the C-IPSS-R changed the IPSS cytogenetic risk only in 8% of cases but identified a new risk group, the very poor C-IPSS-R category, with dismal outcome after allogeneic stem cell transplantation (10% 4-year OS, 60% 4-year CIR). Posttransplantation maintenance therapy should be investigated in prospective trials for patients with high-risk C-IPSS-R karyotypes.

Live birth rates in the different combinations of the Bologna criteria poor ovarian responders: a validation study.

PubMed

La Marca, Antonio; Grisendi, Valentina; Giulini, Simone; Sighinolfi, Giovanna; Tirelli, Alessandra; Argento, Cindy; Re, Claudia; Tagliasacchi, Daniela; Marsella, Tiziana; Sunkara, Sesh Kamal

2015-06-01

to compare the baseline characteristics and chance of live birth in the different categories of poor responders identified by the combinations of the Bologna criteria and establish whether these groups comprise a homogenous population. database containing clinical and laboratory information on IVF treatment cycles carried out at the Mother-Infant Department of the University Hospital of Modena between year 2007 and 2011 was analysed. This data was collected prospectively and recorded in the registered database of the fertility centre. Eight hundred and thirty women fulfilled the inclusion/ exclusion criteria of the study and 210 women fulfilled the Bologna criteria definition for poor ovarian response (POR). Five categories of poor responders were identified by different combinations of the Bologna criteria. There were no significant differences in female age, AFC, AMH, cycle cancellation rate and number of retrieved oocytes between the five groups. The live birth rate ranged between 5.5 and 7.4 % and was not statistically different in the five different categories of women defined as poor responders according to the Bologna criteria. The study demonstrates that the different groups of poor responders based on the Bologna criteria have similar IVF outcomes. This information validates the Bologna criteria definition as women having a uniform poor prognosis and also demonstrates that the Bologna criteria poor responders in the various subgroups represent a homogenous population with similar pre-clinical and clinical outcomes.

Effects of platelet and plasma transfusion on outcome in traumatic brain injury patients with moderate bleeding diatheses.

PubMed

Anglin, Catherine O; Spence, Jeffrey S; Warner, Matthew A; Paliotta, Christopher; Harper, Caryn; Moore, Carol; Sarode, Ravi; Madden, Christopher; Diaz-Arrastia, Ramon

2013-03-01

Object Coagulopathy and thrombocytopenia are common after traumatic brain injury (TBI), yet transfusion thresholds for mildly to moderately abnormal ranges of international normalized ratio and platelet count remain controversial. This study evaluates associations between fresh frozen plasma (FFP) and platelet transfusions with long-term functional outcome and survival in TBI patients with moderate hemostatic laboratory abnormalities. Methods This study is a retrospective review of prospectively collected data of patients with mild to severe TBI. Data include patient demographics, several initial injury severity metrics, daily laboratory values, Glasgow Outcome Score- Extended (GOSE) scores, Functional Status Examination (FSE) scores, and survival to 6 months. Correlations were evaluated between these variables and transfusion of FFP, platelets, packed red blood cells (RBCs), cryoprecipitate, recombinant factor VIIa, and albumin. Ordinal regression was performed to account for potential confounding variables to further define relationships between transfusion status and long-term outcome. By analyzing collected data, mild to moderate coagulopathy was defined as an international normalized ratio 1.4-2.0, moderate thrombocytopenia as platelet count 50 × 10(9)/L to 107 × 10(9)/L, and moderate anemia as 21%-30% hematocrit. Results In patients with mild to moderate laboratory hematological abnormalities, univariate analysis shows significant correlations between poor outcome scores and FFP, platelet, or packed RBC transfusion; the volume of FFP or packed RBCs transfused also correlated with poor outcome. Several measures of initial injury and laboratory abnormalities also correlated with poor outcome. Patient age, initial Glasgow Coma Scale score, and highest recorded serum sodium were included in the ordinal regression model using backward variable selection. In the moderate coagulopathy subgroup, patients transfused with FFP were more likely to have a lower GOSE score relative to those who did not receive a transfusion (OR 5.20 [95% CI 1.72-15.73]). Patients with moderate coagulopathy who received FFP and packed RBCs were even more likely to be have a lower GOSE score (OR 7.17 [95% CI 2.12-24.12]). Moderately anemic patients who received packed RBCs alone were more likely to have a worse long-term functional outcome as determined by GOSE and FSE scores (GOSE: OR 2.41 [95% CI 1.51-3.85]; and FSE: OR 3.27 [95% CI 2.00-5.35]). No transfusion types or combinations were noted to significantly correlate with the 6-month mortality in ordinal regression. Conclusions In TBI patients with moderate coagulopathy, FFP transfusions alone or a combination of FFP and packed RBCs were associated with poorer long-term functional outcomes as measured by the GOSE. Red blood cell transfusions were associated with poor long-term functional outcome in TBI patients with moderate anemia. Platelet transfusion in patients with moderate thrombocytopenia was not significantly associated with outcome. Although transfusion is beneficial to many patients with severe hematological abnormalities, it is not without risk, and the indications for transfusion should be carefully considered in patients with moderate hematological abnormalities.

Glucose in prediabetic and diabetic range and outcome after stroke.

PubMed

Osei, E; Fonville, S; Zandbergen, A A M; Koudstaal, P J; Dippel, D W J; den Hertog, H M

2017-02-01

Newly diagnosed disturbed glucose metabolism is highly prevalent in patients with stroke. Limited data are available on their prognostic value on outcome after stroke. We aimed to assess the association of glucose in the prediabetic and diabetic range with unfavourable short-term outcome after stroke. We included 839 consecutive patients with ischemic stroke and 168 patients with intracerebral haemorrhage. In all nondiabetic patients, fasting glucose levels were determined on day 2-4. Prediabetic range was defined as fasting glucose of 5.6-6.9 mmol/L, diabetic range as ≥7.0 mmol/L, pre-existent diabetes as the use of anti-diabetic medication prior to admission. Outcome measures were poor functional outcome or death defined as modified Rankin Scale (mRS) score >2 and discharge not to home. The association of prediabetic range, diabetic range and pre-existent diabetes (versus normal glucose) with unfavourable outcome was expressed as odds ratios, estimated with multiple logistic regression, with adjustment for prognostic factors. Compared with normal glucose, prediabetic range (aOR 1.8; 95%CI 1.1-2.8), diabetic range (aOR 2.5; 95%CI 1.3-4.9) and pre-existent diabetes (aOR 2.6; 95%CI 1.6-4.0) were associated with poor functional outcome or death. Patients in the prediabetic range (aOR 0.6; 95%CI 0.4-0.9), diabetic range (aOR 0.4; 95%CI 0.2-0.9) and pre-existent diabetes (aOR 0.6; 95%CI 0.4-0.9) were more likely not to be discharged to home. Patients with glucose in the prediabetic and diabetic range have an increased risk of unfavourable short-term outcome after stroke. These findings illustrate the potential impact of early detection and treatment of these patients. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Outcome scores in spinal surgery quantified: excellent, good, fair and poor in terms of patient-completed tools.

PubMed

Tafazal, Suhayl I; Sell, Philip J

2006-11-01

Outcome scores are very useful tools in the field of spinal surgery as they allow us to assess a patient's progress and the effect of various treatments. The clinical importance of a score change is not so clear. Although previous studies have looked at the minimum clinically important score change, the degree of score change varies considerably. Our study is a prospective cohort study of 193 patients undergoing discectomy, decompression and fusion procedures with minimum 2-year follow-up. We have used three standard outcome measures in common usage, the oswestry disability index (ODI), the low back outcome score (LBOS) and the visual analogue score (VAS). We have defined each of these scores according to a global measure of outcome graded by the patient as excellent, good, fair or poor. We have also graded patient perception and classified excellent and good as success and fair and poor as failure. Our results suggest that a median 24-point change in the ODI equates with a good outcome or is the minimum change needed for success. We have also found that different surgical disorders have very different minimal clinically important differences as perceived by patient perception. We found that for a discectomy a minimum 27-point change in the ODI would be classed as a success, for a decompression the change in ODI needed to class it as a success would be 16 points, whereas for a fusion the change in the ODI would be only 13 points. We believe that patient-rated global measures of outcome are of value and we have quantified them in terms of the standard outcome measures used in spinal surgery.

Endovascular therapy versus thrombolysis in patients with large vessel occlusions within the anterior circulation aged ≥80 years.

PubMed

Kastrup, Andreas; Brunner, Freimuth; Hildebrandt, Helmut; Roth, Christian; Winterhalter, Michael; Papanagiotou, Panagiotis

2018-03-16

In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, the effectiveness of ET in elderly patients is uncertain. Using our stroke database, we compared the rates of good outcome (modified Rankin scale (mRS) ≤2), excellent outcome (mRS 0-1), poor outcome (mRS 5-6) at discharge, in-hospital death, infarct size, and symptomatic intracranial hemorrhage (SICH) in patients aged ≥80 years with distal intracranial carotid artery, M1 and M2 occlusions during two time periods. From January 2008 to October 2012, 217 patients were treated with IVT and, from November 2012 to October 2017, 209 patients received ET with stent retrievers (with or without IVT). Significantly more patients in the ET group than in the IVT group had a good outcome (25% vs 16%, P<0.05), as well as an excellent outcome (12% vs 4%, P<0.01). Significantly fewer patients in the ET group than in the IVT group died (14% vs 22%, P<0.05) or had a poor outcome (35% vs 52%, P<001). The SICH rates were lower after ET than after IVT (1% vs 6%, P<0.01), and the infarct sizes were smaller after ET than after IVT. Compared with IVT, the routine use of ET significantly improved the early clinical and radiological outcome in patients with anterior circulation large vessel occlusions aged ≥80 years. Nevertheless, poor outcome rates were high so the role of ET needs to be defined further in this population. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Ultraearly hematoma growth in active intracerebral hemorrhage

PubMed Central

Coscojuela, Pilar; Rubiera, Marta; Hill, Michael D.; Dowlatshahi, Dar; Aviv, Richard I.; Silva, Yolanda; Dzialowski, Imanuel; Lum, Cheemun; Czlonkowska, Anna; Boulanger, Jean-Martin; Kase, Carlos S.; Gubitz, Gord; Bhatia, Rohit; Padma, Vasantha; Roy, Jayanta; Tomasello, Alejandro; Demchuk, Andrew M.; Molina, Carlos A.

2016-01-01

Objective: To determine the association of ultraearly hematoma growth (uHG) with the CT angiography (CTA) spot sign, hematoma expansion, and clinical outcomes in patients with acute intracerebral hemorrhage (ICH). Methods: We analyzed data from 231 patients enrolled in the multicenter Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT study. uHG was defined as baseline ICH volume/onset-to-CT time (mL/h). The spot sign was used as marker of active hemorrhage. Outcome parameters included significant hematoma expansion (>33% or >6 mL, primary outcome), rate of hematoma expansion, early neurologic deterioration, 90-day mortality, and poor outcome. Results: uHG was higher in spot sign patients (p < 0.001) and in patients scanned earlier (p < 0.001). Both uHG >4.7 mL/h (p = 0.002) and the CTA spot sign (p = 0.030) showed effects on rate of hematoma expansion but not its interaction (2-way analysis of variance, p = 0.477). uHG >4.7 mL/h improved the sensitivity of the spot sign in the prediction of significant hematoma expansion (73.9% vs 46.4%), early neurologic deterioration (67.6% vs 35.3%), 90-day mortality (81.6% vs 44.9%), and poor outcome (72.8% vs 29.8%), respectively. uHG was independently related to significant hematoma expansion (odds ratio 1.06, 95% confidence interval 1.03–1.10) and clinical outcomes. Conclusions: uHG is a useful predictor of hematoma expansion and poor clinical outcomes in patients with acute ICH. The combination of high uHG and the spot sign is associated with a higher rate of hematoma expansion, highlighting the need for very fast treatment in ICH patients. PMID:27343067

Association between PTGS1 polymorphisms and functional outcomes in Chinese patients with stroke during aspirin therapy: Interaction with smoking.

PubMed

Cai, Huan; Cai, Biyang; Sun, Lingli; Zhang, Hao; Zhou, Shuyu; Cao, Liping; Guo, Hongquan; Sun, Wen; Yan, Bernard; Davis, Stephen M; Zhang, Zhizhong; Liu, Xinfeng

2017-05-15

Prostaglandin-Endoperoxide Synthase 1 (PTGS1) and smoking may play important roles in aspirin nonresponsiveness, but the effect of their interaction on stroke outcomes remains largely unknown. We examined the effects of PTGS1 polymorphisms, smoking status, and their interaction on functional outcomes in a cohort of Chinese Han patients with stroke during aspirin therapy. A total of 617 ischemic stroke patients taking aspirin were enrolled. Three single nucleotide polymorphisms (SNPs) rs1330344, rs3842788, and rs5788 in PTGS1 were determined for genotyping. Poor functional outcomes were defined as a modified Rankin Scale (mRS) of 3-6 at 90-day follow-up. The influence of PTGS1 gene-smoking interaction on functional outcomes was examined. Poor functional outcomes occurred in 145 (23.5%) patients. When adjusting multiple factors by logistic regression, CC genotype of rs1330344 was associated with poor functional outcomes (risk ratio [RR]=1.73; 95% confidence interval [CI]: 1.17-2.37). A similar connection was found in the CGC haplotype (RR=1.40; 95% CI: 1.08-1.77). Furthermore, we found a significant interaction between rs1330344 and smoking status (P interaction =0.018); the interaction effect between the PTGS1 haplotype and smoking also showed statistical significance (P interaction =0.040). In Chinese Han stroke patients with aspirin therapy, the adverse effect of PTGS1 polymorphisms on functional outcomes may be modulated by the smoking status. PTGS1 gene-smoking interaction might in part reflect the heterogeneity in the prognosis of patients treated with aspirin. Copyright © 2017 Elsevier B.V. All rights reserved.

Status epilepticus in the elderly: Prognostic implications of rhythmic and periodic patterns in electroencephalography and hyperintensities on diffusion-weighted imaging.

PubMed

Yoshimura, Hajime; Matsumoto, Riki; Ueda, Hiroyuki; Ariyoshi, Koichi; Kawamoto, Michi; Ishii, Junko; Ikeda, Akio; Takahashi, Ryosuke; Kohara, Nobuo

2016-11-15

To delineate the clinical characteristics and functional outcome of status epilepticus (SE) in elderly people, and elucidate prognostic implications of SE-associated rhythmic and periodic patterns (RPPs) in electroencephalography and hyperintensities on diffusion-weighted imaging. We retrospectively investigated 107 consecutive patients with SE aged≥65years in a comprehensive community hospital. RPPs were classified using the 2012 American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology. Poor outcome was defined as an increase in modified Rankin Scale (mRS) score at discharge compared with that at baseline, including death. Median age of patients was 80.0years. Median mRS score at baseline was 3. Thirty-four patients (31.8%) had a previous diagnosis of epilepsy. Cerebrovascular disease and dementia were major etiologies. Poor outcome occurred in 41 (38.3%). In electroencephalography, periodic discharges (PDs) were present in 21.0% (22/105), rhythmic delta activity (RDA) in 10.5% (11/105), and conventional seizure patterns in 9.5% (10/105). Diffusion-weighted hyperintensities associated with SE were observed in 28.0% (26/93). With univariate analysis, poor outcome was significantly associated with no previous diagnosis of epilepsy, etiology, refractory SE, specific electroencephalographic patterns (PDs and conventional seizure patterns, but not RDA), and diffusion-weighted hyperintensities. With multivariate logistic regression analysis, diffusion-weighted hyperintensities (OR 6.13 [95% CI 1.72-21.9]) and refractory SE (OR 5.36 [95% CI 1.28-22.4]) were independently associated with poor outcome. SE often occurred as the first seizure in already disabled elderly people, further worsening their functional disabilities. Diffusion-weighted hyperintensities and refractory SE, but not RPPs in electroencephalography, were independent functional prognostic factors. Copyright © 2016 Elsevier B.V. All rights reserved.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

PubMed

Yeo, L L L; Paliwal, P; Teoh, H L; Seet, R C; Chan, B P; Ting, E; Venketasubramanian, N; Leow, W K; Wakerley, B; Kusama, Y; Rathakrishnan, R; Sharma, V K

2015-02-01

Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals. © 2015 by American Journal of Neuroradiology.

Why is control of hypertension in sub-Saharan Africa poor?

PubMed Central

Seedat, YK

2015-01-01

In sub-Saharan Africa (SSA) in 2010, hypertension (defined as systolic blood pressure ≥ 115 mmHg) was the leading cause of death, increasing 67% since 1990. It was also the sixth leading cause of disability, contributing more than 11 million adjusted life years. In SSA, stroke was the main outcome of uncontrolled hypertension. Poverty is the major underlying factor for hypertension and cardiovascular disease. This article analyses the causes of poor compliance in the treatment of hypertension in SSA and provides suggestions on the treatment of hypertension in a poverty-stricken continent. PMID:26407222

Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru.

PubMed

Wingfield, Tom; Boccia, Delia; Tovar, Marco; Gavino, Arquímedes; Zevallos, Karine; Montoya, Rosario; Lönnroth, Knut; Evans, Carlton A

2014-07-01

Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed "catastrophic" but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs. From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain "dis-saving" variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients. Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.

Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial.

PubMed

Farris, Reid W D; Weiss, Noel S; Zimmerman, Jerry J

2013-11-01

To evaluate risk factors for poor functional outcome in 28-day survivors after an episode of severe sepsis. Retrospective cohort study examining data from the Researching Severe Sepsis and Organ Dysfunction in Children: A Global Perspective trial (NCT00049764). One hundred and four pediatric centers in 18 countries. Children with severe sepsis who required both vasoactive-inotropic infusions and mechanical ventilation and who survived to 28 days (n = 384). None. Poor functional outcome was defined as a Pediatric Overall Performance Category score greater than or equal to 3 and an increase from baseline when measured 28 days after trial enrollment. Median Pediatric Overall Performance Category at enrollment was 1 (interquartile range, 1-2). Median Pediatric Overall Performance Category at 28 days was 2 (interquartile range, 1-4). Thirty-four percent of survivors had decline in their functional status at 28 days, and 18% were determined to have a "poor" functional outcome. Hispanic ethnicity was associated with poor functional outcome compared to the white referent group (risk ratio = 1.9; 95% CI: 1.0-3.0). Clinical factors associated with increased risk of poor outcome included CNS and intra-abdominal infection sources compared to the lung infection referent category (risk ratio = 3.3; 95% CI: 1.4-5.6 and 2.4; 95% CI: 1.0-4.5, respectively); a history of recent trauma (risk ratio = 3.9; 95% CI: 1.4-5.4); receipt of cardiopulmonary resuscitation prior to enrollment (risk ratio = 5.1; 95% CI: 2.9-5.7); and baseline Pediatric Risk of Mortality III score of 20-29 (risk ratio = 2.8; 95% CI: 1.2-5.2) and Pediatric Risk of Mortality III greater than or equal to 30 (risk ratio = 4.5; 95% CI: 1.6-8.0) compared to the referent group with Pediatric Risk of Mortality III scores of 0-9. In this sample of 28-day survivors of pediatric severe sepsis diminished functional status was common. This analysis provides evidence that particular patient characteristics and aspects of an individual's clinical course are associated with poor functional outcome 28 days after onset of severe sepsis. These characteristics may provide opportunity for intervention in order to improve functional outcome in pediatric patients with severe sepsis. Decline in functional status 28 days after onset of severe sepsis is a frequent and potentially clinically meaningful event. Utilization of functional status as the primary outcome in future pediatric sepsis clinical trials should be considered.

Clinical outcomes of neonatal onset proximal versus distal urea cycle disorders do not differ.

PubMed

Ah Mew, Nicholas; Krivitzky, Lauren; McCarter, Robert; Batshaw, Mark; Tuchman, Mendel

2013-02-01

To compare the clinical course and outcome of patients diagnosed with one of 4 neonatal-onset urea cycle disorders (UCDs): deficiency of carbamyl phosphate synthase 1 (CPSD), ornithine transcarbamylase (OTCD), argininosuccinate synthase (ASD), or argininosuccinate lyase (ALD). Clinical, biochemical, and neuropsychological data from 103 subjects with neonatal-onset UCDs were derived from the Longitudinal Study of Urea Cycle Disorders, an observational protocol of the Urea Cycle Disorders Consortium, one of the Rare Disease Clinical Research Networks. Some 88% of the subjects presented clinically by age 7 days. Peak ammonia level was 963 μM in patients with proximal UCDs (CPSD or OTCD), compared with 589 μM in ASD and 573 μM in ALD. Roughly 25% of subjects with CPSD or OTCD, 18% of those with ASD, and 67% of those with ALD had a "honeymoon period," defined as the time interval from discharge from initial admission to subsequent admission for hyperammonemia, greater than 1 year. The proportion of patients with a poor outcome (IQ/Developmental Quotient <70) was greatest in ALD (68%), followed by ASD (54%) and CPSD/OTCD (47%). This trend was not significant, but was observed in both patients aged <4 years and those aged ≥ 4 years. Poor cognitive outcome was not correlated with peak ammonia level or duration of initial admission. Neurocognitive outcomes do not differ between patients with proximal UCDs and those with distal UCDs. Factors other than hyperammonemia may contribute to poor neurocognitive outcome in the distal UCDs. Copyright © 2013 Mosby, Inc. All rights reserved.

Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial.

PubMed

Geurts, Marjolein; van der Worp, H Bart; Kappelle, L Jaap; Amelink, G Johan; Algra, Ale; Hofmeijer, Jeannette

2013-09-01

We assessed whether the effects of surgical decompression for space-occupying hemispheric infarction, observed at 1 year, are sustained at 3 years. Patients with space-occupying hemispheric infarction, who were enrolled in the Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial within 4 days after stroke onset, were followed up at 3 years. Outcome measures included functional outcome (modified Rankin Scale), death, quality of life, and place of residence. Poor functional outcome was defined as modified Rankin Scale >3. Of 64 included patients, 32 were randomized to decompressive surgery and 32 to best medical treatment. Just as at 1 year, surgery had no effect on the risk of poor functional outcome at 3 years (absolute risk reduction, 1%; 95% confidence interval, -21 to 22), but it reduced case fatality (absolute risk reduction, 37%; 95% confidence interval, 14-60). Sixteen surgically treated patients and 8 controls lived at home (absolute risk reduction, 27%; 95% confidence interval, 4-50). Quality of life improved between 1 and 3 years in patients treated with surgery. In patients with space-occupying hemispheric infarction, the effects of decompressive surgery on case fatality and functional outcome observed at 1 year are sustained at 3 years. http://www.controlled-trials.com. Unique identifier: ISRCTN94237756.

The Need for Core Outcome Reporting in Autologous Fat Grafting for Breast Reconstruction.

PubMed

Agha, Riaz A; Fowler, Alexander J; Pidgeon, Thomas E; Wellstead, Georgina; Orgill, Dennis P

2016-11-01

There is growing interest in autologous fat grafting (AFG) for breast reconstruction. This systematic review examines the range of outcomes used across studies of AFG, their definitions and whether there is a need for a core outcome set to aid reporting. Following the protocol of our systematic review, a search of 20 databases (1986 to March 2014) returned 35 studies which met the inclusion criteria. These were assessed independently by two authors. Disagreements were resolved by consensus. Of the 35 studies, 27 (77%) were case series, 5 (14.3%) were cohort studies, and 3 (8.6%) were case reports. A total of 51 different outcomes were reported. These studies each reported a median of five separate outcomes (range, 2-14), of which a median of 3 outcomes were defined (range, 0-14). A median of 2 outcomes per paper were prespecified in the study methods (range, 0-12) and a median of only 2 outcomes per paper (range, 0-12) were both defined and prespecified. The most commonly reported outcome in studies of AFG was that of "operative details," reported by 26 studies, and eight different outcome definitions were used. "Cancer recurrence" was reported by 20 studies, with the use of 10 different outcome definitions. Overall, there was a poor proportion of defined and prespecified outcomes that employed a wide range of different outcome definitions. In addition only 14/35 studies stated the number of patients lost to follow-up. There is a need for a core outcomes set for AFG to the breast to minimise outcome and reporting bias and aid evidence synthesis. Our future research will focus in this direction, titled VOGUE or Valid Outcomes for the Grafting of AUtologous Fat to the BrEast study. We invite all those interested to get in touch with the lead author.

Brainstem leukoaraiosis independently predicts poor outcome after ischemic stroke.

PubMed

Giralt-Steinhauer, E; Medrano, S; Soriano-Tárraga, C; Mola-Caminal, M; Rasal, R; Cuadrado-Godia, E; Rodríguez-Campello, A; Ois, A; Capellades, J; Jimenez-Conde, J; Roquer, J

2018-04-16

Increased supratentorial white matter hyperintensities volume (S-WMHV) has been reported to be a predictor of worse outcome in patients with acute ischemic stroke (AIS). However, few studies have focused on less common locations, such as brainstem white matter hyperintensities (B-WMH), and their relationship to S-WMHV. This study aimed to examine whether B-WMH affect clinical outcome after AIS or transient ischemic attack (TIA). Based on magnetic resonance imaging evidence, B-WMH were evaluated in 313 prospectively identified patients with AIS/TIA and registered as absent or present. Standardized S-WMHV was quantified using a validated volumetric image analysis and natural log-transformed (Log_S-WMHV). Poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months after the index event. Brainstem white matter hyperintensities were detected in 57 (18.2%) patients. In unadjusted analyses for outcome, the presence of B-WMH was associated with worse outcome, compared with patients without B-WMH (P = 0.034). In multivariate analysis controlling for age, atrial fibrillation, stroke severity, reperfusion therapies and Log_S-WMHV, only B-WMH [odds ratio (OR), 2.46; P = 0.021] and stroke severity (OR, 1.23; P < 0.001) remained independently associated with unfavourable 90-day modified Rankin Scale score. Patients with B-WMH were older (OR, 1.06; P < 0.001) and tended to have more hyperlipidaemia (OR, 2.21; P = 0.023) and peripheral arterial disease (OR, 2.57; P = 0.031). Brainstem white matter hyperintensities are an independent predictor of poor outcome after AIS/TIA and this relationship persists after adjustment for important prognostic factors. Our results also show that leukoaraiosis in this location identifies patients with a specific risk factor profile, suggesting differences in the underlying pathogenesis. © 2018 EAN.

Hyperchloremia Is Associated With Complicated Course and Mortality in Pediatric Patients With Septic Shock.

PubMed

Stenson, Erin K; Cvijanovich, Natalie Z; Anas, Nick; Allen, Geoffrey L; Thomas, Neal J; Bigham, Michael T; Weiss, Scott L; Fitzgerald, Julie C; Checchia, Paul A; Meyer, Keith; Quasney, Michael; Hall, Mark; Gedeit, Rainer; Freishtat, Robert J; Nowak, Jeffrey; Raj, Shekhar S; Gertz, Shira; Grunwell, Jocelyn R; Wong, Hector R

2018-02-01

Hyperchloremia is associated with poor outcome among critically ill adults, but it is unknown if a similar association exists among critically ill children. We determined if hyperchloremia is associated with poor outcomes in children with septic shock. Retrospective analysis of a pediatric septic shock database. Twenty-nine PICUs in the United States. Eight hundred ninety children 10 years and younger with septic shock. None. We considered the minimum, maximum, and mean chloride values during the initial 7 days of septic shock for each study subject as separate hyperchloremia variables. Within each category, we considered hyperchloremia as a dichotomous variable defined as a serum concentration greater than or equal to 110 mmol/L. We used multivariable logistic regression to determine the association between the hyperchloremia variables and outcome, adjusted for illness severity. We considered all cause 28-day mortality and complicated course as the primary outcome variables. Complicated course was defined as mortality by 28 days or persistence of greater than or equal to two organ failures at day 7 of septic shock. Secondarily, we conducted a stratified analysis using a biomarker-based mortality risk stratification tool. There were 226 patients (25%) with a complicated course and 93 mortalities (10%). Seventy patients had a minimum chloride greater than or equal to 110 mmol/L, 179 had a mean chloride greater than or equal to 110 mmol/L, and 514 had a maximum chloride greater than or equal to 110 mmol/L. A minimum chloride greater than or equal to 110 mmol/L was associated with increased odds of complicated course (odds ratio, 1.9; 95% CI, 1.1-3.2; p = 0.023) and mortality (odds ratio, 3.7; 95% CI, 2.0-6.8; p < 0.001). A mean chloride greater than or equal to 110 mmol/L was also associated with increased odds of mortality (odds ratio, 2.1; 95% CI, 1.3-3.5; p = 0.002). The secondary analysis yielded similar results. Hyperchloremia is independently associated with poor outcomes among children with septic shock.

Prospective Predictors of Suicidal Behavior in BPD at 6 Year Follow-up

PubMed Central

Soloff, Paul H.; Chiappetta, Laurel

2012-01-01

Objective Recurrent suicidal behavior is a defining characteristic of BPD. Although most patients achieve remission of suicidal behaviors over time, 3% to 10% die by suicide, raising the question of whether there is a high risk suicidal subtype in BPD. We are conducting the first longitudinal study of suicidal behavior in BPD to identify prospective predictors of suicide attempts, and characterize BPD patients at highest risk for suicide completion. Method Demographic, diagnostic, clinical and psychosocial risk factors assessed at baseline were examined for predictive association with medically significant suicide attempts using Cox proportional hazards models. Prospective predictors were defined for subjects completing 6 or more years in the study and compared to earlier intervals. Results Among 90 subjects, 25 (27.8%) made at least one suicide attempt in the interval, most occurring in the first two years. Risk of attempt was increased by: a.) low socioeconomic status, b.) poor psychosocial adjustment, c.) a family history of suicide d.) prior psychiatric hospitalization; e.) absence of any outpatient treatment prior to the attempt. Higher global functioning at baseline decreased risk. Conclusion Risk factors predictive of suicide attempts change over time. Acute stressors such as MDD were predictive only in the short term (12 mos.), while poor psychosocial functioning had persistent and long term effects on suicide risk. Half of BPD patients have poor psychosocial outcomes despite symptomatic improvement. A social and vocational rehabilitation model of treatment is needed to decrease suicide risk and optimize long term outcomes in BPD. PMID:22549208

The Ethics of Internationalisation in Higher Education: Hospitality, Self-Presence and "Being Late"

ERIC Educational Resources Information Center

Hughes-Warrington, Marnie

2012-01-01

While the concept of internationalization plays a key role in contemporary discussions on the activities and outcomes sought by universities, it is commonly argued that it is poorly understood or realised in practice. This has led some to argue that more work is needed to define the dimensions of the concept, or even to plot out stages of its…

Acute kidney injury subphenotypes based on creatinine trajectory identifies patients at increased risk of death.

PubMed

Bhatraju, Pavan K; Mukherjee, Paramita; Robinson-Cohen, Cassianne; O'Keefe, Grant E; Frank, Angela J; Christie, Jason D; Meyer, Nuala J; Liu, Kathleen D; Matthay, Michael A; Calfee, Carolyn S; Christiani, David C; Himmelfarb, Jonathan; Wurfel, Mark M

2016-11-17

Acute kidney injury (AKI) is common among intensive care unit (ICU) patients. AKI is highly heterogeneous, with variable links to poor outcomes. Current approaches to classify AKI severity and identify patients at highest risk for poor outcomes focus on the maximum change in serum creatinine (SCr) values. However, these scores are hampered by the need for a reliable baseline SCr value and the absence of a component differentiating transient from persistent rises in SCr. We hypothesized that identification of resolving or nonresolving AKI subphenotypes based on the early trajectory of SCr values in the ICU would better differentiate patients at risk of hospital mortality. We performed a secondary analysis of two prospective studies of ICU patients admitted to a trauma ICU (group 1; n = 1914) or general medical-surgical ICUs (group 2; n = 1867). In group 1, we tested definitions for resolving and nonresolving AKI subphenotypes and selected the definitions resulting in subphenotypes with the greatest separation in risk of death relative to non-AKI controls. We applied this definition to group 2 and tested whether the subphenotypes were independently associated with hospital mortality after adjustment for AKI severity. AKI occurred in 46% and 69% of patients in groups 1 and 2, respectively. In group 1, a resolving AKI subphenotype (defined as a decrease in SCr of 0.3 mg/dl or 25% from maximum in the first 72 h of study enrollment) was associated with a low risk of death. A nonresolving AKI subphenotype (defined as all AKI cases not meeting the "resolving" definition) was associated with a high risk of death. In group 2, the resolving AKI subphenotype was not associated with increased mortality (relative risk [RR] 0.86, 95% CI 0.63-1.17), whereas the nonresolving AKI subphenotype was associated with higher mortality (RR 1.68, 95% CI 1.15-2.44) even after adjustment for AKI severity stage. The trajectory of SCr levels identifies AKI subphenotypes with different risks for death, even among AKI cases of similar severity. These AKI subphenotypes might better define the patients at risk for poor outcomes who might benefit from novel interventions.

Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage.

PubMed

Badjatia, Neeraj; Monahan, Aimee; Carpenter, Amanda; Zimmerman, Jacqueline; Schmidt, J Michael; Claassen, Jan; Connolly, E Sander; Mayer, Stephan A; Karmally, Wahida; Seres, David

2015-02-17

To analyze the impact of inflammation and negative nitrogen balance (NBAL) on nutritional status and outcomes after subarachnoid hemorrhage (SAH). This was a prospective observational study of SAH patients admitted between May 2008 and June 2012. Measurements of C-reactive protein (CRP), transthyretin (TTR), resting energy expenditure (REE), and NBAL (g/day) were performed over 4 preset time periods during the first 14 postbleed days (PBD) in addition to daily caloric intake. Factors associated with REE and NBAL were analyzed with multivariable linear regression. Hospital-acquired infections (HAI) were tracked daily for time-to-event analyses. Poor outcome at 3 months was defined as a modified Rankin Scale score ≥ 4 and assessed by multivariable logistic regression. There were 229 patients with an average age of 55 ± 15 years. Higher REE was associated with younger age (p = 0.02), male sex (p < 0.001), higher Hunt Hess grade (p = 0.001), and higher modified Fisher score (p = 0.01). Negative NBAL was associated with lower caloric intake (p < 0.001), higher body mass index (p < 0.001), aneurysm clipping (p = 0.03), and higher CRP:TTR ratio (p = 0.03). HAIs developed in 53 (23%) patients on mean PBD 8 ± 3. Older age (p = 0.002), higher Hunt Hess (p < 0.001), lower caloric intake (p = 0.001), and negative NBAL (p = 0.04) predicted time to first HAI. Poor outcome at 3 months was associated with higher Hunt Hess grade (p < 0.001), older age (p < 0.001), negative NBAL (p = 0.01), HAI (p = 0.03), higher CRP:TTR ratio (p = 0.04), higher body mass index (p = 0.03), and delayed cerebral ischemia (p = 0.04). Negative NBAL after SAH is influenced by inflammation and associated with an increased risk of HAI and poor outcome. Underfeeding and systemic inflammation are potential modifiable risk factors for negative NBAL and poor outcome after SAH. © 2015 American Academy of Neurology.

Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage

PubMed Central

Monahan, Aimee; Carpenter, Amanda; Zimmerman, Jacqueline; Schmidt, J. Michael; Claassen, Jan; Connolly, E. Sander; Mayer, Stephan A.; Karmally, Wahida; Seres, David

2015-01-01

Objective: To analyze the impact of inflammation and negative nitrogen balance (NBAL) on nutritional status and outcomes after subarachnoid hemorrhage (SAH). Methods: This was a prospective observational study of SAH patients admitted between May 2008 and June 2012. Measurements of C-reactive protein (CRP), transthyretin (TTR), resting energy expenditure (REE), and NBAL (g/day) were performed over 4 preset time periods during the first 14 postbleed days (PBD) in addition to daily caloric intake. Factors associated with REE and NBAL were analyzed with multivariable linear regression. Hospital-acquired infections (HAI) were tracked daily for time-to-event analyses. Poor outcome at 3 months was defined as a modified Rankin Scale score ≥4 and assessed by multivariable logistic regression. Results: There were 229 patients with an average age of 55 ± 15 years. Higher REE was associated with younger age (p = 0.02), male sex (p < 0.001), higher Hunt Hess grade (p = 0.001), and higher modified Fisher score (p = 0.01). Negative NBAL was associated with lower caloric intake (p < 0.001), higher body mass index (p < 0.001), aneurysm clipping (p = 0.03), and higher CRP:TTR ratio (p = 0.03). HAIs developed in 53 (23%) patients on mean PBD 8 ± 3. Older age (p = 0.002), higher Hunt Hess (p < 0.001), lower caloric intake (p = 0.001), and negative NBAL (p = 0.04) predicted time to first HAI. Poor outcome at 3 months was associated with higher Hunt Hess grade (p < 0.001), older age (p < 0.001), negative NBAL (p = 0.01), HAI (p = 0.03), higher CRP:TTR ratio (p = 0.04), higher body mass index (p = 0.03), and delayed cerebral ischemia (p = 0.04). Conclusions: Negative NBAL after SAH is influenced by inflammation and associated with an increased risk of HAI and poor outcome. Underfeeding and systemic inflammation are potential modifiable risk factors for negative NBAL and poor outcome after SAH. PMID:25596503

Brain Natriuretic Peptide Is a Powerful Predictor of Outcome in Stroke Patients with Atrial Fibrillation

PubMed Central

Maruyama, Kenji; Uchiyama, Shinichiro; Shiga, Tsuyoshi; Iijima, Mutsumi; Ishizuka, Kentaro; Hoshino, Takao; Kitagawa, Kazuo

2017-01-01

Background Since stroke patients with nonvalvular atrial fibrillation (NVAF) have poor outcomes in general, the prediction of outcomes following discharge is of utmost concern for these patients. We previously reported that brain natriuretic peptide (BNP) levels were significantly higher in NVAF patients with larger infarcts, higher modified Rankin Scale (mRS) score, and higher CHADS2 score. In the present study, we evaluated an array of variables, including BNP, in order to determine significant predictors for functional outcome in patients with NVAF after acute ischemic stroke (AIS). Methods A total of 615 consecutive patients with AIS within 48 h of symptom onset, admitted to our hospital between April 2010 and October 2015, were retrospectively searched. Among these patients, we enrolled consecutive patients with NVAF. We evaluated the mRS score 3 months after onset of stroke and investigated associations between mRS score and the following clinical and echocardiographic variables. Categorical variables included male sex, current smoking, alcohol intake, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, peripheral artery disease, use of antiplatelet drugs, anticoagulants, or tissue plasminogen activator (tPA), and infarct size. Continuous variables included age, systolic blood pressure (SBP), diastolic blood pressure, hemoglobin, creatinine, D-dimer, brain natriuretic peptide (BNP), left atrial diameter, left ventricular ejection fraction (EF), and early mitral inflow velocity/diastolic mitral annular velocity (E/e’). We also analyzed the association of prestroke CHADS2, CHA2DS2-VASc, and R2CHADS2 scores, and National Institutes of Health Stroke Scale (NIHSS) score on admission with mRS score 3 months after the onset of stroke. Patients were classified into 2 groups according to mRS score: an mRS score ≤2 was defined as good outcome, an mRS score ≥3 was defined as poor outcome. To clarify the correlations between categorical or continuous variables and mRS score, uni- and multivariate logistic regression models using the stepwise variable selection method were applied. Results Among 157 patients with NVAF after AIS, 63.7% were male and the mean age was 75.9 years. In univariate regression analysis, poor outcome (mRS score ≥3) was associated with use of tPA, infarct size, age, SBP, BNP, EF, and NIHSS score. In multivariate regression analysis, BNP levels (odds ratio [OR] 6.40; 95% confidence interval [CI] 1.26–32.43; p = 0.0235) and NIHSS score (OR 2.87; 95% CI 1.84–4.47; p < 0.001) were significantly associated with poor outcome (mRS score ≥3) after adjusting for use of tPA, infarct size, age, BNP, EF, and NIHSS score. Conclusions Apart from NIHSS score, BNP was a very useful predictor for long-term outcomes of patients with NVAF after AIS. PMID:28253498

Sarcopenia Screened by the SARC-F Questionnaire and Physical Performances of Elderly Women: A Cross-Sectional Study.

PubMed

Rolland, Yves; Dupuy, Charlotte; Abellan Van Kan, Gabor; Cesari, Matteo; Vellas, Bruno; Faruch, Marie; Dray, Cedric; de Souto Barreto, Philipe

2017-10-01

Screening for sarcopenia in daily practice can be challenging. Our objective was to explore whether the SARC-F questionnaire is a valid screening tool for sarcopenia (defined by the Foundation for the National Institutes of Health [FNIH] criteria). Moreover, we evaluated the physical performance of older women according to the SARC-F questionnaire. Cross-sectional study. Data from the Toulouse and Lyon EPIDémiologie de l'OStéoporose study (EPIDOS) on 3025 women living in the community (mean age: 80.5 ± 3.9 years), without a previous history of hip fracture, were assessed. The SARC-F self-report questionnaire score ranges from 0 to 10: a score ≥4 defines sarcopenia. The FNIH criteria uses handgrip strength (GS) and appendicular lean mass (ALM; assessed by DXA) divided by body mass index (BMI) to define sarcopenia. Outcome measures were the following performance-based tests: knee-extension strength, 6-m gait speed, and a repeated chair-stand test. The associations of sarcopenia with performance-based tests was examined using bootstrap multiple linear-regression models; adjusted R 2 determined the percentage variation for each outcome explained by the model. Prevalence of sarcopenia was 16.7% (n = 504) according to the SARC-F questionnaire and 1.8% (n = 49) using the FNIH criteria. Sensibility and specificity of the SARC-F to diagnose sarcopenia (defined by FNIH criteria) were 34% and 85%, respectively. Sarcopenic women defined by SARC-F had significantly lower physical performance than nonsarcopenic women. The SARC-F improved the ability to predict poor physical performance. The validity of the SARC-F questionnaire to screen for sarcopenia, when compared with the FNIH criteria, was limited. However, sarcopenia defined by the SARC-F questionnaire substantially improved the predictive value of clinical characteristics of patients to predict poor physical performance. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Tactical lighting in special operations medicine: survey of current preferences.

PubMed

Calvano, Christopher J; Enzenauer, Robert W; Eisnor, Derek L; Laporta, Anthony J

2013-01-01

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings. 2013.

Extracorporeal Ultrafiltration for Fluid Overload in Heart Failure

PubMed Central

Costanzo, Maria Rosa; Ronco, Claudio; Abraham, William T.; Agostoni, Piergiuseppe; Barasch, Jonathan; Fonarow, Gregg C.; Gottlieb, Stephen S.; Jaski, Brian E.; Kazory, Amir; Levin, Allison P.; Levin, Howard R.; Marenzi, Giancarlo; Mullens, Wilfried; Negoianu, Dan; Redfield, Margaret M.; Tang, W.H. Wilson; Testani, Jeffrey M.; Voors, Adriaan A.

2017-01-01

More than 1 million heart failure hospitalizations occur annually, and congestion is the predominant cause. Rehospitalizations for recurrent congestion portend poor outcomes independently of age and renal function. Persistent congestion trumps serum creatinine increases in predicting adverse heart failure outcomes. No decongestive pharmacological therapy has reduced these harmful consequences. Simplified ultrafiltration devices permit fluid removal in lower-acuity hospital settings, but with conflicting results regarding safety and efficacy. Ultrafiltration performed at fixed rates after onset of therapy-induced increased serum creatinine was not superior to standard care and resulted in more complications. In contrast, compared with diuretic agents, some data suggest that adjustment of ultrafiltration rates to patients’ vital signs and renal function may be associated with more effective decongestion and fewer heart failure events. Essential aspects of ultrafiltration remain poorly defined. Further research is urgently needed, given the burden of congestion and data suggesting sustained benefits of early and adjustable ultrafiltration. PMID:28494980

Heart failure services in the United Kingdom: rethinking the machine bureaucracy.

PubMed

Hawkins, Nathaniel M; Wright, David J; Capewell, Simon

2013-01-20

Poor outcomes and poor uptake of evidence based therapies persist for patients with heart failure in the United Kingdom. We offer a strategic analysis of services, defining the context, organization and objectives of the service, before focusing on implementation and performance. Critical flaws in past service development and performance are apparent, a consequence of failed performance management, policy and political initiative. The barriers to change and potential solutions are common to many health care systems. Integration, information, financing, incentives, innovation and values: all must be challenged and improved if heart failure services are to succeed. Modern healthcare requires open adaptive systems, continually learning and improving. The system also needs controls. Performance indicators should be simple, clinically relevant, and outcome focused. Heart failure presents one of the greatest opportunities to improve symptoms and survival with existing technology. To do so, heart failure services require radical reorganization. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Epidemiologic research using probabilistic outcome definitions.

PubMed

Cai, Bing; Hennessy, Sean; Lo Re, Vincent; Small, Dylan S

2015-01-01

Epidemiologic studies using electronic healthcare data often define the presence or absence of binary clinical outcomes by using algorithms with imperfect specificity, sensitivity, and positive predictive value. This results in misclassification and bias in study results. We describe and evaluate a new method called probabilistic outcome definition (POD) that uses logistic regression to estimate the probability of a clinical outcome using multiple potential algorithms and then uses multiple imputation to make valid inferences about the risk ratio or other epidemiologic parameters of interest. We conducted a simulation to evaluate the performance of the POD method with two variables that can predict the true outcome and compared the POD method with the conventional method. The simulation results showed that when the true risk ratio is equal to 1.0 (null), the conventional method based on a binary outcome provides unbiased estimates. However, when the risk ratio is not equal to 1.0, the traditional method, either using one predictive variable or both predictive variables to define the outcome, is biased when the positive predictive value is <100%, and the bias is very severe when the sensitivity or positive predictive value is poor (less than 0.75 in our simulation). In contrast, the POD method provides unbiased estimates of the risk ratio both when this measure of effect is equal to 1.0 and not equal to 1.0. Even when the sensitivity and positive predictive value are low, the POD method continues to provide unbiased estimates of the risk ratio. The POD method provides an improved way to define outcomes in database research. This method has a major advantage over the conventional method in that it provided unbiased estimates of risk ratios and it is easy to use. Copyright © 2014 John Wiley & Sons, Ltd.

Lack of Early Improvement Predicts Poor Outcome Following Acute Intracerebral Hemorrhage.

PubMed

Yogendrakumar, Vignan; Smith, Eric E; Demchuk, Andrew M; Aviv, Richard I; Rodriguez-Luna, David; Molina, Carlos A; Silva Blas, Yolanda; Dzialowski, Imanuel; Kobayashi, Adam; Boulanger, Jean-Martin; Lum, Cheemun; Gubitz, Gord; Padma, Vasantha; Roy, Jayanta; Kase, Carlos S; Bhatia, Rohit; Ali, Myzoon; Lyden, Patrick; Hill, Michael D; Dowlatshahi, Dar

2018-04-01

There are limited data as to what degree of early neurologic change best relates to outcome in acute intracerebral hemorrhage. We aimed to derive and validate a threshold for early postintracerebral hemorrhage change that best predicts 90-day outcomes. Derivation: retrospective analysis of collated clinical stroke trial data (Virtual International Stroke Trials Archive). retrospective analysis of a prospective multicenter cohort study (Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign [PREDICT]). Neurocritical and ICUs. Patients with acute intracerebral hemorrhage presenting less than 6 hours. Derivation: 552 patients; validation: 275 patients. None. We generated a receiver operating characteristic curve for the association between 24-hour National Institutes of Health Stroke Scale change and clinical outcome. The primary outcome was a modified Rankin Scale score of 4-6 at 90 days; secondary outcomes were other modified Rankin Scale score ranges (modified Rankin Scale, 2-6, 3-6, 5-6, 6). We employed Youden's J Index to select optimal cut points and calculated sensitivity, specificity, and predictive values. We determined independent predictors via multivariable logistic regression. The derived definitions were validated in the PREDICT cohort. Twenty-four-hour National Institutes of Health Stroke Scale change was strongly associated with 90-day outcome with an area under the receiver operating characteristic curve of 0.75. Youden's method showed an optimum cut point at -0.5, corresponding to National Institutes of Health Stroke Scale change of greater than or equal to 0 (a lack of clinical improvement), which was seen in 46%. Early neurologic change accurately predicted poor outcome when defined as greater than or equal to 0 (sensitivity, 65%; specificity, 73%; positive predictive value, 70%; adjusted odds ratio, 5.05 [CI, 3.25-7.85]) or greater than or equal to 4 (sensitivity, 19%; specificity, 98%; positive predictive value, 91%; adjusted odds ratio, 12.24 [CI, 4.08-36.66]). All definitions reproduced well in the validation cohort. Lack of clinical improvement at 24 hours robustly predicted poor outcome and showed good discrimination for individual patients who would do poorly. These findings are useful for prognostication and may also present as a potential early surrogate outcome for future intracerebral hemorrhage treatment trials.

When Care is a "Systematic Route of Torture": Conceptualizing the Violence of Medical Negligence in Resource-Poor Settings.

PubMed

Heckert, Carina

2016-12-01

Descriptions of patient mistreatment fill ethnographic accounts of healthcare in resource-poor settings. Often, anthropologists point to structural factors and the ways that the global political economy produces substandard care. This approach makes it difficult to hold parties accountable when there is blatant disregard for human life on the part of individuals providing care. In this article, I draw on the illness narrative of Magaly Chacón, the first HIV positive individual in Bolivia to file charges of medical negligence after failing to receive care to prevent mother-to-child transmission. Magaly's narrative demonstrates how structural conditions are often used to explain away poor patient outcomes, shifting attention away from and normalizing the symbolic violence that also perpetuates substandard care of marginalized patients. I use Magaly's accusations to interrogate how defining acts of mistreatment as medical negligence can be a productive exercise, even when it is difficult to disentangle structural constraints from blatant acts of negligence. Defining who is negligent in resource-poor settings is not easy, as Magaly's case demonstrates. However, Magaly's case also demonstrates that accusations of negligence themselves can demand accountability and force changes within the local structures that contribute to the systematic mistreatment of marginalized patients.

Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): A multidisciplinary position statement.

PubMed

Stewart, Simon; Riegel, Barbara; Boyd, Cynthia; Ahamed, Yasmin; Thompson, David R; Burrell, Louise M; Carrington, Melinda J; Coats, Andrew; Granger, Bradi B; Hides, Julie; Weintraub, William S; Moser, Debra K; Dickson, Victoria Vaughan; McDermott, Cressida J; Keates, Ashley K; Rich, Michael W

2016-06-01

Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide. To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population. We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol - adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals. We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF. Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.

Defining Catastrophic Costs and Comparing Their Importance for Adverse Tuberculosis Outcome with Multi-Drug Resistance: A Prospective Cohort Study, Peru

PubMed Central

Wingfield, Tom; Boccia, Delia; Tovar, Marco; Gavino, Arquímedes; Zevallos, Karine; Montoya, Rosario; Lönnroth, Knut; Evans, Carlton A.

2014-01-01

Background Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed “catastrophic” but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs. Methods and Findings From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2–4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%–43%) in the least-poor houses versus 48% (95% CI = 36%–50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%–61%] versus 38% [95% CI = 34%–41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7–15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3–3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00–1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1–2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%–28%), similar to that of MDR TB (20% [95% CI = 14%–25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain “dis-saving” variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients. Conclusions Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary PMID:25025331

Work disability prevention in rural healthcare workers.

PubMed

Franche, Renée L; Murray, Eleanor J; Ostry, Aleck; Ratner, Pamela A; Wagner, Shannon L; Harder, Henry G

2010-01-01

Approximately 20% of healthcare workers in high-income countries such as Australia, Canada and the USA work in rural areas. Healthcare workers are known to be vulnerable to occupational injury and poor work disability outcomes; given their rural-urban distribution, it is possible to compare work disability prevention in rural and urban areas. However, little attention has been paid to work disability prevention issues specific to rural workers, including rural healthcare workers. A comprehensive review of the literature was conducted to identify rural-urban differences in work disability outcomes (defined as the incidence of occupational injury and the duration of associated work absence), as well as risk factors for poor work disability outcomes in rural healthcare workers. The databases MEDLINE, CINAHL, and EMBASE were searched, as were relevant research centers and government agencies, to identify all quantitative and qualitative English-language studies published between 1 January 2000 and 6 October 2009 that discussed occupational injury, work absence duration, work disability management, or risk factors for poor work disability outcomes, for rural workers specifically, or in comparison with urban workers. To ensure inclusion of studies of healthcare workers as a distinct group among other sector-specific groups, a broad search for literature related to all industrial sectors was conducted. Of 860 references identified, 5 discussed work disability outcomes and 25 discussed known risk factors. Known risk factors were defined as factors firmly established to be associated with poor work disability outcomes in the general worker population based on systematic reviews, well-established conceptual models of work disability prevention, and public health literature. Although somewhat conflicting, the evidence suggests that rural healthcare workers experience higher rates of occupational injury compared with urban healthcare workers, within occupational categories. Rural workers also appear to be more vulnerable to prolonged work absence although the data are limited. No studies directly compared risk factors for work disability prevention outcomes between rural and urban healthcare workers. However, potential risk factors were identified at the level of the environment, worker, job, organization, worker compensation system and healthcare access. Important methodological limitations were noted, including unclear definitions of rurality, inadequate methods of urban-rural comparisons such as comparing samples from different countries, and a paucity of studies applying longitudinal or multivariate designs. There is a notable lack of evidence about work disability prevention issues for healthcare workers in rural areas. Available evidence supports the hypothesis that rural healthcare workers are vulnerable to occupational injury, and suggests they are vulnerable to prolonged work absence. They may be particularly vulnerable to poor work disability prevention outcomes due to complex patient needs in the context of risk factors such as heavy workloads, long hours, heavy on-call demands, high stress levels, limited support and workplace violence. Additional vulnerability may occur because their work conditions are managed in distant urban administrative centers, and due to barriers in their own healthcare access. Although rural healthcare workers seem generally at greater risk of injury, one study suggests that urban emergency medical service workers experience a high vulnerability to injury that may outweigh the effects of rurality. Additional research is needed to document rural-urban disparities in work disability outcomes and to identify associated sources and risk factors. Other issues to address are access to and quality of healthcare for rural healthcare workers, streamlining the compensation system, the unique needs of Aboriginal healthcare workers, and the management of prolonged work absence. Finally, occupational injury and work absence duration programs should be tailored to meet the needs of rural workers.

Risk predictors for adverse outcome in pediatric febrile neutropenia: Single center experience from a low and middle-income country.

PubMed

Prasad, M; Chinnaswamy, G; Arora, B; Vora, T; Hawaldar, R; Banavali, S

2014-01-01

Risk stratification of patients with febrile neutropenia (FN) into those at "High Risk" and "Low Risk" of developing complications helps in making decisions regarding optimal treatment, such as whether to treat with oral or intravenous antibiotics, whether to treat as inpatient or outpatient and how long to treat. Risk predictors obtained from Western studies on pediatric FN are unlikely to be relevant to low middle-income country (LMICs). Our study aimed to identify clinical and laboratory parameters predictive of poor outcomes in children with chemotherapy-induced FN in a LMIC. Two hundred and fifty consecutive episodes of chemotherapy-induced FN in pediatric (<15 years) patients were analyzed prospectively. Adverse outcomes were defined as per SPOG 2003 FN study as serious medical complications (SMC) due to infection, microbiologically defined infection, and radiologically defined pneumonia (RDP). Variables found to be significant for adverse outcome (P < 0.05) on univariate analysis were selected for multivariate analysis. Five factors that were found to independently predict adverse outcome were (a) previously documented infection in the past 6 months, (b) presence of significant focus of infection, (c) absolute phagocyte count <100/mm3, (d) peak temperature more than 39°C in this episode of FN, and (e) fever lasting more than 5 days during this episode of FN. Identifying the risk factors for adverse outcome in pediatric FN, which are objective and applicable across LMICs would contribute in developing guidelines for the management of FN in a resource-limited setting.

Effect of regional cerebral oximetry to estimate neurologic prognostic outcomes in patients administered targeted temperature management.

PubMed

Sarıtaş, Aykut; Çinleti, Burcu Acar; Zincircioğlu, Çiler; Uzun, Uğur; Köse, Işıl; Şenoğlu, Nimet

2018-04-09

The aim of our study is to research the role and efficacy of cerebral oximetry in predicting neurologic prognosis when applied during TTM to patients experiencing coma after CA. This study was performed on surviving adult comatose patients after CA treated with TTM. The average scores of rSO 2 was measured at 6h intervals for the first 2days and once a day for the following 3days with a NIRS device during TTM. The CPC scale was used to define the neurologic outcomes of patients. We compared the correlations of rSO 2 values between good (CPC 1-2) and poor (CPC 3-5) neurologic outcomes in CA patients. There was no statistically significant difference identified between the prognosis groups in terms of rSO 2 , CPR durations, hemoglobin values and admission body temperature (p>0.05). When the variation in rSO 2 values over time is investigated, though there was no significant difference between the good and poor prognosis groups, it appeared to fall in the first 6h in both prognosis groups. The median NT-proBNP and lactate values were observed to be higher in the poor prognosis group. There is no significant correlation between rSO 2 values and neurologic outcomes. Multimodal monitoring methods may be useful and further studies with a larger patient population are necessary in this area. Copyright © 2018. Published by Elsevier Inc.

Patients With Failed Prior Two-Stage Exchange Have Poor Outcomes After Further Surgical Intervention.

PubMed

Kheir, Michael M; Tan, Timothy L; Gomez, Miguel M; Chen, Antonia F; Parvizi, Javad

2017-04-01

Failure of 2-stage exchange arthroplasty for the management of periprosthetic joint infection (PJI) poses a major clinical challenge. There is a paucity of information regarding the outcomes of further surgical intervention in these patients. Thus, we aim to report the clinical outcomes of subsequent surgery for a failed prior 2-stage exchange arthroplasty. Our institutional database was used to identify 60 patients (42 knees and 18 hips), with a failed prior 2-stage exchange, who underwent further surgical intervention between 1998 and 2012, and had a minimum 2-year follow-up. A retrospective review was performed to extract relevant clinical information, including mortality, microbiology, and subsequent surgeries. Musculoskeletal Infection Society criteria were used to define PJI, and treatment success was defined using Delphi criteria. Irrigation and debridement (I&D) was performed after a failed 2-stage exchange in 61.7% of patients; 56.8% subsequently failed. Forty patients underwent an intended second 2-stage exchange; 6 cases required a spacer exchange. Reimplantation occurred only in 65% of cases, and 61.6% had infection controlled. The 14 cases that were not reimplanted resulted in 6 retained spacers, 5 amputations, 2 PJI-related mortalities, and 1 arthrodesis. Further surgical intervention after a failed prior 2-stage exchange arthroplasty has poor outcomes. Although I&D has a high failure rate, many patients who are deemed candidates for a second 2-stage exchange either do not undergo reimplantation or fail after reimplantation. The management of PJI clearly remains imperfect, and there is a dire need for further innovations that may improve the care of these patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Poor clinical outcomes among pneumonia patients with depressive disorder.

PubMed

Kao, Li-Ting; Liu, Shih-Ping; Lin, Herng-Ching; Lee, Hsin-Chien; Tsai, Ming-Chieh; Chung, Shiu-Dong

2014-01-01

Some studies suggested that psychological stress may be associated with the severity and duration of infectious diseases. In this population-based study, we investigated associations between depressive disorder (DD) and pneumonia outcomes in Taiwan with a large-scale database from the National Health Insurance. Our study defined 112,198 patients who were hospitalized with a principal diagnosis of pneumonia. We defined their admission date for treatment of pneumonia as the index date. Subsequently, we selected 2,394 patients with DD within 3 years prior to their index date and 11,970 matched patients without DD. We carried out separate conditional logistic regressions to explore the association of clinical pneumonia treatment outcome (ICU admission, use of mechanical ventilation, acute respiratory failure and in-hospital death) with previously diagnosed DD. Patients with DD had a significantly higher probability of an intensive care unit admission (18.1% vs. 12.9%; p<0.001), need for mechanical ventilation (21.9% vs. 18.1%; p<0.001) and in-hospital death (10.4% vs. 9.0%; p = 0.025) than patients without DD. The study showed that pneumonia patients with DD were respectively 1.41- (95% CI: 1.25∼1.59, p<0.001), 1.28- (95% CI: 1.14∼1.43, p<0.001), and 1.17- times (95% CI: 1.01∼1.36, p = 0.039) greater odds of being admitted to the ICU, need for mechanical ventilation, and in-hospital death than patients without DD after adjusting for monthly income, urbanization level, geographic region and Charlson Comorbidity Index score. In conclusion, we found that pneumonia patients with DD were associated with poor treatment outcomes compared to patients without DD.

Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine.

PubMed

Lipton, Richard B; Fanning, Kristina M; Serrano, Daniel; Reed, Michael L; Cady, Roger; Buse, Dawn C

2015-02-17

To test the hypothesis that ineffective acute treatment of episodic migraine (EM) is associated with an increased risk for the subsequent onset of chronic migraine (CM). In the American Migraine Prevalence and Prevention Study, respondents with EM in 2006 who completed the Migraine Treatment Optimization Questionnaire (mTOQ-4) and provided outcome data in 2007 were eligible for analyses. The mTOQ-4 is a validated questionnaire that assesses treatment efficacy based on 4 aspects of response to acute treatment. Total mTOQ-4 scores were used to define categories of acute treatment response: very poor, poor, moderate, and maximum treatment efficacy. Logistic regression models were used to examine the dichotomous outcome of transition from EM in 2006 to CM in 2007 as a function of mTOQ-4 category, adjusting for covariates. Among 5,681 eligible study respondents with EM in 2006, 3.1% progressed to CM in 2007. Only 1.9% of the group with maximum treatment efficacy developed CM. Rates of new-onset CM increased in the moderate treatment efficacy (2.7%), poor treatment efficacy (4.4%), and very poor treatment efficacy (6.8%) groups. In the fully adjusted model, the very poor treatment efficacy group had a more than 2-fold increased risk of new-onset CM (odds ratio = 2.55, 95% confidence interval 1.42-4.61) compared to the maximum treatment efficacy group. Inadequate acute treatment efficacy was associated with an increased risk of new-onset CM over the course of 1 year. Improving acute treatment outcomes might prevent new-onset CM, although reverse causality cannot be excluded. © 2015 American Academy of Neurology.

Shunt diameter in agenesis of the ductus venosus with extrahepatic portosystemic shunt impacts on prognosis.

PubMed

Shen, O; Valsky, D V; Messing, B; Cohen, S M; Lipschuetz, M; Yagel, S

2011-02-01

Agenesis of the ductus venosus (ADV) is a rare condition in which there are two variants of umbilical vein drainage: intrahepatic shunt or extrahepatic (portosystemic) shunt. It has been posited that the extrahepatic variant carries a poorer prognosis. However, in the absence of associated anomalies there is still a wide variation in outcome. We evaluated the portal system in cases of ADV and aimed to identify parameters that might predict outcome. We conducted a retrospective study of cases of ADV with extrahepatic shunt that had been examined in two centers, and collected new cases prospectively. The route of the shunt was depicted using two-dimensional (2D) and three-dimensional (3D) ultrasound imaging. In an attempt to characterize portal system and shunt developmental variations and their possible impact on outcome, the diameter of the shunt was compared with the diameter of the umbilical vein and the entire portal vasculature was assessed. Poor outcome was defined as persistent morbidity or fetal or neonatal death. Twenty-two cases of ADV were identified: nine retrospectively and 13 prospectively. Aberrant shunts from the umbilical vein were identified to the right atrium, coronary sinus, inferior vena cava (IVC) and iliac vein. In seven of 22 cases (32%) a wide connection was observed. In six of these seven cases (86%) the outcome was poor, including four with severe associated anomalies and two with hepatic dysfunction. In five of these cases, cardiomegaly with tricuspid regurgitation was observed, as well as underdevelopment of the portal system. In only five of 15 cases with a narrow shunt (33%) was the outcome poor, and in all five cases the poor outcome was related to associated anomalies. In cases of ADV with extrahepatic shunt, portal system development is impacted by the diameter of the shunt. If the shunt is narrow, the portal system will have developed normally. A wide shunt is associated with underdevelopment or absence of the portal system. In cases of ADV with extrahepatic shunt, prognosis is determined by the severity of associated anomalies, the diameter of the shunt and development of the portal system. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke: The ACROSS-China Study (Abnormal Glucose Regulation in Patients With Acute Stroke Across China).

PubMed

Jing, Jing; Pan, Yuesong; Zhao, Xingquan; Zheng, Huaguang; Jia, Qian; Mi, Donghua; Chen, Weiqi; Li, Hao; Liu, Liping; Wang, Chunxue; He, Yan; Wang, David; Wang, Yilong; Wang, Yongjun

2017-04-01

Insulin resistance was common in patients with stroke. This study investigated the association between insulin resistance and outcomes in nondiabetic patients with first-ever acute ischemic stroke. Patients with ischemic stroke without history of diabetes mellitus in the ACROSS-China registry (Abnormal Glucose Regulation in Patients With Acute Stroke Across China) were included. Insulin resistance was defined as a homeostatis model assessment-insulin resistance (HOMA-IR) index in the top quartile (Q4). HOMA-IR was calculated as fasting insulin (μU/mL)×fasting glucose (mmol/L)/22.5. Multivariable logistic regression or Cox regression was performed to estimate the association between HOMA-IR and 1-year prognosis (mortality, stroke recurrence, poor functional outcome [modified Rankin scale score 3-6], and dependence [modified Rankin scale score 3-5]). Among the 1245 patients with acute ischemic stroke enrolled in this study, the median HOMA-IR was 1.9 (interquartile range, 1.1-3.1). Patients with insulin resistance were associated with a higher mortality risk than those without (adjusted hazard ratio, 1.68; 95% confidence interval, 1.12-2.53; P =0.01), stroke recurrence (adjusted hazard ratio, 1.57, 95% confidence interval, 1.12-2.19; P =0.008), and poor outcome (adjusted odds ratio, 1.42; 95% confidence interval, 1.03-1.95; P =0.03) but not dependence after adjustment for potential confounders. Higher HOMA-IR quartile categories were associated with a higher risk of 1-year death, stroke recurrence, and poor outcome ( P for trend =0.005, 0.005, and 0.001, respectively). Insulin resistance was associated with an increased risk of death, stroke recurrence, and poor outcome but not dependence in nondiabetic patients with acute ischemic stroke. © 2017 American Heart Association, Inc.

Rates, patterns, causes, and costs of hospitalization of nursing home residents: a population-based study.

PubMed Central

Barker, W H; Zimmer, J G; Hall, W J; Ruff, B C; Freundlich, C B; Eggert, G M

1994-01-01

OBJECTIVES. Hospitalization of nursing home residents is a growing, poorly defined problem. The purposes of this study were to define rates, patterns, costs, and outcomes of hospitalizations from nursing homes and to consider implications for reducing this problem as part of health care reform. METHODS. Communitywide nursing home utilization review and hospital discharge data were used to define retrospectively a cohort of 2120 patients newly admitted to nursing homes; these patients were followed for 2 years to identify all hospitalizations. Resident characteristics were analyzed for predictors of hospitalization. Charges and outcomes were compared with hospitalization of community-dwelling elders. RESULTS. Hospitalization rates were strikingly higher for intermediate vs skilled levels of care (566 and 346 per 1000 resident years, respectively). Approximately 40% of all hospitalizations occurred within 3 months of admission. No strong predictors were identified. Length of stay, charges, and mortality rates were higher than for hospitalizations from the community. CONCLUSIONS. Hospitalizations from nursing homes are not easily predicted but may in large part be prevented through health care reforms that integrate acute and longterm care. PMID:7943480

Attention-deficit/hyperactivity disorder and adverse health outcomes

PubMed Central

Nigg, Joel

2015-01-01

Attention-deficit/hyperactivity disorder (ADHD) is defined by extreme levels of inattention–disorganization and/or hyperactivity–impulsivity. In DSM-IV, the diagnostic criteria required impairment in social, academic, or occupational functioning. With DSM-5 publication imminent in 2013, further evaluation of impairment in ADHD is timely. This article reviews the current state of knowledge on health-related impairments of ADHD, including smoking, drug abuse, accidental injury, sleep, obesity, hypertension, diabetes, and suicidal behavior. It concludes by suggesting the need for new avenues of research on mechanisms of association and the potential for ADHD to be an early warning sign for secondary prevention of some poor health outcomes. PMID:23298633

Telangiectatic osteosarcoma: a review of literature.

PubMed

Liu, Jun-Jian; Liu, Shen; Wang, Jian-Guang; Zhu, Wei; Hua, Ying-Qi; Sun, Wei; Cai, Zheng-Dong

2013-01-01

Telangiectatic osteosarcoma is a rare variant of osteosarcoma and hence its occurrence, presentation, and prognosis are poorly understood. With advancements in technology and available treatment options, the scenario of its diagnosis, management, and outcome has changed. Chemotherapy with surgery was challenged previously, but has now been proved to be beneficial. We reviewed the available literature and compared results to define the characteristics of the disease, its presentation, radiographic and pathologic features, optimal treatment, and prognosis.

Telangiectatic osteosarcoma: a review of literature

PubMed Central

Liu, Jun-jian; Liu, Shen; Wang, Jian-guang; Zhu, Wei; Hua, Ying-qi; Sun, Wei; Cai, Zheng-dong

2013-01-01

Telangiectatic osteosarcoma is a rare variant of osteosarcoma and hence its occurrence, presentation, and prognosis are poorly understood. With advancements in technology and available treatment options, the scenario of its diagnosis, management, and outcome has changed. Chemotherapy with surgery was challenged previously, but has now been proved to be beneficial. We reviewed the available literature and compared results to define the characteristics of the disease, its presentation, radiographic and pathologic features, optimal treatment, and prognosis. PMID:23745051

Clinical Prognosis in Neonatal Bacterial Meningitis: The Role of Cerebrospinal Fluid Protein.

PubMed

Tan, Jintong; Kan, Juan; Qiu, Gang; Zhao, Dongying; Ren, Fang; Luo, Zhongcheng; Zhang, Yongjun

2015-01-01

Neonates are at high risk of meningitis and of resulting neurologic complications. Early recognition of neonates at risk of poor prognosis would be helpful in providing timely management. From January 2008 to June 2014, we enrolled 232 term neonates with bacterial meningitis admitted to 3 neonatology departments in Shanghai, China. The clinical status on the day of discharge from these hospitals or at a postnatal age of 2.5 to 3 months was evaluated using the Glasgow Outcome Scale (GOS). Patients were classified into two outcome groups: good (167 cases, 72.0%, GOS = 5) or poor (65 cases, 28.0%, GOS = 1-4). Neonates with good outcome had less frequent apnea, drowsiness, poor feeding, bulging fontanelle, irritability and more severe jaundice compared to neonates with poor outcome. The good outcome group also had less pneumonia than the poor outcome group. Besides, there were statistically significant differences in hemoglobin, mean platelet volume, platelet distribution width, C-reaction protein, procalcitonin, cerebrospinal fluid (CSF) glucose and CSF protein. Multivariate logistic regression analyses suggested that poor feeding, pneumonia and CSF protein were the predictors of poor outcome. CSF protein content was significantly higher in patients with poor outcome. The best cut-offs for predicting poor outcome were 1,880 mg/L in CSF protein concentration (sensitivity 70.8%, specificity 86.2%). After 2 weeks of treatment, CSF protein remained higher in the poor outcome group. High CSF protein concentration may prognosticate poor outcome in neonates with bacterial meningitis.

The Association of Frailty With Outcomes and Resource Use After Emergency General Surgery: A Population-Based Cohort Study.

PubMed

McIsaac, Daniel I; Moloo, Husein; Bryson, Gregory L; van Walraven, Carl

2017-05-01

Older patients undergoing emergency general surgery (EGS) experience high rates of postoperative morbidity and mortality. Studies focused primarily on elective surgery indicate that frailty is an important predictor of adverse outcomes in older surgical patients. The population-level effect of frailty on EGS is poorly described. Therefore, our objective was to measure the association of preoperative frailty with outcomes in a population of older patients undergoing EGS. We created a population-based cohort study using linked administrative data in Ontario, Canada, that included community-dwelling individuals aged >65 years having EGS. Our main exposure was preoperative frailty, as defined by the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. The Adjusted Clinical Groups frailty-defining diagnoses indicator is a binary variable that uses 12 clusters of frailty-defining diagnoses. Our main outcome measures were 1-year all-cause mortality (primary), intensive care unit admission, length of stay, institutional discharge, and costs of care (secondary). Of 77,184 patients, 19,779 (25.6%) were frail. Death within 1 year occurred in 6626 (33.5%) frail patients compared with 11,366 (19.8%) nonfrail patients. After adjustment for sociodemographic and surgical confounders, this resulted in a hazard ratio of 1.29 (95% confidence interval [CI] 1.25-1.33). The risk of death for frail patients varied significantly across the postoperative period and was particularly high immediately after surgery (hazard ratio on postoperative day 1 = 23.1, 95% CI 22.3-24.1). Frailty was adversely associated with all secondary outcomes, including a 5.82-fold increase in the adjusted odds of institutional discharge (95% CI 5.53-6.12). After EGS, frailty is associated with increased rates of mortality, institutional discharge, and resource use. Strategies that might improve perioperative outcomes in frail EGS patients need to be developed and tested.

Features of Patients With Severe Hepatitis Due to Mushroom Poisoning and Factors Associated With Outcome.

PubMed

Bonacini, Maurizio; Shetler, Katerina; Yu, Ira; Osorio, Robert C; Osorio, Robert W

2017-05-01

Acute liver failure after ingestion of toxic mushrooms is a significant medical problem. Most exposures to toxic mushrooms produce no symptoms or only mild gastroenteritis, but some lead to severe hepatic necrosis and fulminant hepatic failure requiring liver transplantation. We aimed to assess mortality from mushroom poisoning and identify variables associated with survival and liver transplantation. We collected information from 27 patients (13 male; median age, 47 years) admitted to the emergency department within 24 hours of ingesting wild mushrooms. They developed severe liver injury (serum levels of transaminases greater than 400 IU/L) and were treated with activated charcoal and N-acetylcysteine at a tertiary medical center in San Francisco, California from January 1997 through December 2014. Viral hepatitis, autoimmune liver disease, acetaminophen, salicylate toxicity, and chronic liver diseases were ruled out for all patients. We analyzed patient demographics, time since ingestion, presenting symptoms, laboratory values, and therapies administered. A good outcome was defined as survival without need for liver transplant. A poor outcome was defined as death or liver transplant. Positive predictive values were calculated, and the χ 2 test was used to analyze dichotomous variables. Liver injury was attributed to ingestion of Amanita phalloides in 24 patients and Amanita ocreata in 3 patients. Twenty-four of the patients ingested mushrooms with meals and 3 patients for hallucinogenic purpose. At 24-48 hours after ingestion, all patients had serum levels of alanine aminotransferase ranging from 554 to 4546 IU/L (median, 2185 IU/L). Acute renal impairment developed in 5 patients. Twenty-three patients survived without liver transplantation, and 4 patients had poor outcomes (1 woman underwent liver transplantation on day 20 after mushroom ingestion, and 3 women died of hepatic failure). Of the 23 patients with peak levels of total bilirubin of 2 mg/dL or more during hospitalization, only 4 had a poor outcome. Peak serum level of aspartate aminotransferase less than 4000 IU/L, peak international normalized ratio less than 2, and a value of serum factor V greater than 30% identified patients with good outcomes with 100% positive predictive value; if these peak values were used as a cutoff, 10 of 27 patients (37%), 7 of 27 patients (26%), and 6 of 12 patients (50%), respectively, could have avoided transfer to a transplant center. In an analysis of 27 patients with hepatocellular damage due to mushroom (Amanita) poisoning and peak levels of total bilirubin greater than 2 mg/dL, the probability of liver transplantation or death is 17%, fulfilling Hy's law. Patients with peak levels of aspartate aminotransferase less than 4000 IU/L can be monitored in a local hospital, whereas patients with higher levels should be transferred to liver transplant centers. Women and older patients were more likely to have a poor outcome than men and younger patients. Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

Germline BRCA mutations are associated with higher risk of nodal involvement, distant metastasis, and poor survival outcomes in prostate cancer.

PubMed

Castro, Elena; Goh, Chee; Olmos, David; Saunders, Ed; Leongamornlert, Daniel; Tymrakiewicz, Malgorzata; Mahmud, Nadiya; Dadaev, Tokhir; Govindasami, Koveela; Guy, Michelle; Sawyer, Emma; Wilkinson, Rosemary; Ardern-Jones, Audrey; Ellis, Steve; Frost, Debra; Peock, Susan; Evans, D Gareth; Tischkowitz, Marc; Cole, Trevor; Davidson, Rosemarie; Eccles, Diana; Brewer, Carole; Douglas, Fiona; Porteous, Mary E; Donaldson, Alan; Dorkins, Huw; Izatt, Louise; Cook, Jackie; Hodgson, Shirley; Kennedy, M John; Side, Lucy E; Eason, Jacqueline; Murray, Alex; Antoniou, Antonis C; Easton, Douglas F; Kote-Jarai, Zsofia; Eeles, Rosalind

2013-05-10

To analyze the baseline clinicopathologic characteristics of prostate tumors with germline BRCA1 and BRCA2 (BRCA1/2) mutations and the prognostic value of those mutations on prostate cancer (PCa) outcomes. This study analyzed the tumor features and outcomes of 2,019 patients with PCa (18 BRCA1 carriers, 61 BRCA2 carriers, and 1,940 noncarriers). The Kaplan-Meier method and Cox regression analysis were used to evaluate the associations between BRCA1/2 status and other PCa prognostic factors with overall survival (OS), cause-specific OS (CSS), CSS in localized PCa (CSS_M0), metastasis-free survival (MFS), and CSS from metastasis (CSS_M1). PCa with germline BRCA1/2 mutations were more frequently associated with Gleason ≥ 8 (P = .00003), T3/T4 stage (P = .003), nodal involvement (P = .00005), and metastases at diagnosis (P = .005) than PCa in noncarriers. CSS was significantly longer in noncarriers than in carriers (15.7 v 8.6 years, multivariable analyses [MVA] P = .015; hazard ratio [HR] = 1.8). For localized PCa, 5-year CSS and MFS were significantly higher in noncarriers (96% v 82%; MVA P = .01; HR = 2.6%; and 93% v 77%; MVA P = .009; HR = 2.7, respectively). Subgroup analyses confirmed the poor outcomes in BRCA2 patients, whereas the role of BRCA1 was not well defined due to the limited size and follow-up in this subgroup. Our results confirm that BRCA1/2 mutations confer a more aggressive PCa phenotype with a higher probability of nodal involvement and distant metastasis. BRCA mutations are associated with poor survival outcomes and this should be considered for tailoring clinical management of these patients.

Germline BRCA Mutations Are Associated With Higher Risk of Nodal Involvement, Distant Metastasis, and Poor Survival Outcomes in Prostate Cancer

PubMed Central

Castro, Elena; Goh, Chee; Olmos, David; Saunders, Ed; Leongamornlert, Daniel; Tymrakiewicz, Malgorzata; Mahmud, Nadiya; Dadaev, Tokhir; Govindasami, Koveela; Guy, Michelle; Sawyer, Emma; Wilkinson, Rosemary; Ardern-Jones, Audrey; Ellis, Steve; Frost, Debra; Peock, Susan; Evans, D. Gareth; Tischkowitz, Marc; Cole, Trevor; Davidson, Rosemarie; Eccles, Diana; Brewer, Carole; Douglas, Fiona; Porteous, Mary E.; Donaldson, Alan; Dorkins, Huw; Izatt, Louise; Cook, Jackie; Hodgson, Shirley; Kennedy, M. John; Side, Lucy E.; Eason, Jacqueline; Murray, Alex; Antoniou, Antonis C.; Easton, Douglas F.; Kote-Jarai, Zsofia; Eeles, Rosalind

2013-01-01

Purpose To analyze the baseline clinicopathologic characteristics of prostate tumors with germline BRCA1 and BRCA2 (BRCA1/2) mutations and the prognostic value of those mutations on prostate cancer (PCa) outcomes. Patients and Methods This study analyzed the tumor features and outcomes of 2,019 patients with PCa (18 BRCA1 carriers, 61 BRCA2 carriers, and 1,940 noncarriers). The Kaplan-Meier method and Cox regression analysis were used to evaluate the associations between BRCA1/2 status and other PCa prognostic factors with overall survival (OS), cause-specific OS (CSS), CSS in localized PCa (CSS_M0), metastasis-free survival (MFS), and CSS from metastasis (CSS_M1). Results PCa with germline BRCA1/2 mutations were more frequently associated with Gleason ≥ 8 (P = .00003), T3/T4 stage (P = .003), nodal involvement (P = .00005), and metastases at diagnosis (P = .005) than PCa in noncarriers. CSS was significantly longer in noncarriers than in carriers (15.7 v 8.6 years, multivariable analyses [MVA] P = .015; hazard ratio [HR] = 1.8). For localized PCa, 5-year CSS and MFS were significantly higher in noncarriers (96% v 82%; MVA P = .01; HR = 2.6%; and 93% v 77%; MVA P = .009; HR = 2.7, respectively). Subgroup analyses confirmed the poor outcomes in BRCA2 patients, whereas the role of BRCA1 was not well defined due to the limited size and follow-up in this subgroup. Conclusion Our results confirm that BRCA1/2 mutations confer a more aggressive PCa phenotype with a higher probability of nodal involvement and distant metastasis. BRCA mutations are associated with poor survival outcomes and this should be considered for tailoring clinical management of these patients. PMID:23569316

Health Seeking in Men: A Concept Analysis.

PubMed

Hooper, Gwendolyn L; Quallich, Susanne A

2016-01-01

This article describes the analysis of the concept of health seeking in men. Men have shorter life expectancies and utilize health services less often than women, leading to poor health outcomes, but a gendered basis for health seeking remains poorly defined. Walker and Avant’s framework was used to guide this concept analysis. Literature published in English from 1990-2015 was reviewed. Thematic analysis identified attributes, antecedents, and consequences of the concept. Based on the analysis, a contemporary definition for health seeking in men was constructed, rooted in the concept of health. The definition is based on the concept analysis and the defining attributes that were identified. This analysis provides a definition specifically for health seeking in American men, making it more specific and gender-based than the parent concept of “health.” This concept analysis provides conceptual clarity that can guide development of a conceptual framework that may be uniquely relevant to providers in urology. Further exploration will uncover specific cultural, social, sexual, and geographic perspectives.

Hospital Stay as a Proxy Indicator for Severe Injury in Earthquakes: A Retrospective Analysis

PubMed Central

Zhao, Lu-Ping; Gerdin, Martin; Westman, Lina; Rodriguez-Llanes, Jose Manuel; Wu, Qi; van den Oever, Barbara; Pan, Liang; Albela, Manuel; Chen, Gao; Zhang, De-Sheng; Guha-Sapir, Debarati; von Schreeb, Johan

2013-01-01

Introduction Earthquakes are the most violent type of natural disasters and injuries are the dominant medical problem in the early phases after earthquakes. However, likely because of poor data availability, high-quality research on injuries after earthquakes is lacking. Length of hospital stay (LOS) has been validated as a proxy indicator for injury severity in high-income settings and could potentially be used in retrospective research of injuries after earthquakes. In this study, we assessed LOS as an adequate proxy indicator for severe injury in trauma survivors of an earthquake. Methods A retrospective analysis was conducted using a database of 1,878 injured patients from the 2008 Wenchuan earthquake. Our primary outcome was severe injury, defined as a composite measure of serious injury or resource use. Secondary outcomes were serious injury and resource use, analysed separately. Non-parametric receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to test the discriminatory accuracy of LOS when used to identify severe injury. An 0.7

Improving Ecological Response Monitoring of Environmental Flows

NASA Astrophysics Data System (ADS)

King, Alison J.; Gawne, Ben; Beesley, Leah; Koehn, John D.; Nielsen, Daryl L.; Price, Amina

2015-05-01

Environmental flows are now an important restoration technique in flow-degraded rivers, and with the increasing public scrutiny of their effectiveness and value, the importance of undertaking scientifically robust monitoring is now even more critical. Many existing environmental flow monitoring programs have poorly defined objectives, nonjustified indicator choices, weak experimental designs, poor statistical strength, and often focus on outcomes from a single event. These negative attributes make them difficult to learn from. We provide practical recommendations that aim to improve the performance, scientific robustness, and defensibility of environmental flow monitoring programs. We draw on the literature and knowledge gained from working with stakeholders and managers to design, implement, and monitor a range of environmental flow types. We recommend that (1) environmental flow monitoring programs should be implemented within an adaptive management framework; (2) objectives of environmental flow programs should be well defined, attainable, and based on an agreed conceptual understanding of the system; (3) program and intervention targets should be attainable, measurable, and inform program objectives; (4) intervention monitoring programs should improve our understanding of flow-ecological responses and related conceptual models; (5) indicator selection should be based on conceptual models, objectives, and prioritization approaches; (6) appropriate monitoring designs and statistical tools should be used to measure and determine ecological response; (7) responses should be measured within timeframes that are relevant to the indicator(s); (8) watering events should be treated as replicates of a larger experiment; (9) environmental flow outcomes should be reported using a standard suite of metadata. Incorporating these attributes into future monitoring programs should ensure their outcomes are transferable and measured with high scientific credibility.

Hospital stay as a proxy indicator for severe injury in earthquakes: a retrospective analysis.

PubMed

Zhao, Lu-Ping; Gerdin, Martin; Westman, Lina; Rodriguez-Llanes, Jose Manuel; Wu, Qi; van den Oever, Barbara; Pan, Liang; Albela, Manuel; Chen, Gao; Zhang, De-Sheng; Guha-Sapir, Debarati; von Schreeb, Johan

2013-01-01

Earthquakes are the most violent type of natural disasters and injuries are the dominant medical problem in the early phases after earthquakes. However, likely because of poor data availability, high-quality research on injuries after earthquakes is lacking. Length of hospital stay (LOS) has been validated as a proxy indicator for injury severity in high-income settings and could potentially be used in retrospective research of injuries after earthquakes. In this study, we assessed LOS as an adequate proxy indicator for severe injury in trauma survivors of an earthquake. A retrospective analysis was conducted using a database of 1,878 injured patients from the 2008 Wenchuan earthquake. Our primary outcome was severe injury, defined as a composite measure of serious injury or resource use. Secondary outcomes were serious injury and resource use, analysed separately. Non-parametric receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to test the discriminatory accuracy of LOS when used to identify severe injury. An 0.7

Early central diabetes insipidus: An ominous sign in post-cardiac arrest patients.

PubMed

Chae, Minjung Kathy; Lee, Jeong Hoon; Lee, Tae Rim; Yoon, Hee; Hwang, Sung Yeon; Cha, Won Chul; Shin, Tae Gun; Sim, Min Seob; Jo, Ik Joon; Song, Keun Jeong; Rhee, Joong Eui; Jeong, Yeon Kwon

2016-04-01

Central diabetes insipidus (CDI) after cardiac arrest is not well described. Thus, we aim to study the occurrences, outcomes, and risk factors of CDI of survivors after out-of-hospital cardiac arrest (OHCA). We retrospectively analyzed post-OHCA patients treated at a single center. Central diabetes insipidus was retrospectively defined by diagnostic criteria. One-month cerebral performance category (CPC) scores were collected for outcomes. Of the 169 patients evaluated, 36 patients (21.3%) were diagnosed with CDI. All CDI patients had a poor neurologic outcome of either CPC 4 (13.9%) or CPC 5 (86.1%), and CDI was strongly associated with mortality. Age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), respiratory arrest (OR, 6.62; 95% CI, 1.23-35.44), asphyxia (OR, 9.26; 95% CI, 2.17-34.61), and gray to white matter ratio on brain computed tomogram (OR, 0.88; 95% CI, 0.81-0.95) were associated with the development of CDI. The onset of CDI was earlier (P < .001) and the maximum 24-hour urine output was larger (P = .03) in patients with worst outcomes. All patients diagnosed with CDI had poor neurologic outcomes, and occurrence of CDI was associated with mortality. Central diabetes insipidus patients with death or brain death had earlier occurrence of CDI and more maximum urine output. Copyright © 2015 Elsevier Inc. All rights reserved.

Postoperative Biomarkers Predict Acute Kidney Injury and Poor Outcomes after Pediatric Cardiac Surgery

PubMed Central

Devarajan, Prasad; Zappitelli, Michael; Sint, Kyaw; Thiessen-Philbrook, Heather; Li, Simon; Kim, Richard W.; Koyner, Jay L.; Coca, Steven G.; Edelstein, Charles L.; Shlipak, Michael G.; Garg, Amit X.; Krawczeski, Catherine D.

2011-01-01

Acute kidney injury (AKI) occurs commonly after pediatric cardiac surgery and associates with poor outcomes. Biomarkers may help the prediction or early identification of AKI, potentially increasing opportunities for therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 311 children undergoing surgery for congenital cardiac lesions to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. Severe AKI, defined by dialysis or doubling in serum creatinine during hospital stay, occurred in 53 participants at a median of 2 days after surgery. The first postoperative urine IL-18 and urine NGAL levels strongly associated with severe AKI. After multivariable adjustment, the highest quintiles of urine IL-18 and urine NGAL associated with 6.9- and 4.1-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine NGAL levels associated with longer hospital stay, longer intensive care unit stay, and duration of mechanical ventilation. The accuracy of urine IL-18 and urine NGAL for diagnosis of severe AKI was moderate, with areas under the curve of 0.72 and 0.71, respectively. The addition of these urine biomarkers improved risk prediction over clinical models alone as measured by net reclassification improvement and integrated discrimination improvement. In conclusion, urine IL-18 and urine NGAL, but not plasma NGAL, associate with subsequent AKI and poor outcomes among children undergoing cardiac surgery. PMID:21836147

Sexual Harassment Victimization, School Belonging, and Depressive Symptoms Among LGBTQ Adolescents: Temporal Insights.

PubMed

Hatchel, Tyler; Espelage, Dorothy L; Huang, Yuanhong

2017-06-15

Peer victimization and the associated poor outcomes among lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth have been the focus of countless studies. School climate is a factor that has garnered significant attention. Perceptions of school contexts may even be mechanisms that define how victimization relates to poor outcomes. However, there is a lack of rigorous scholarship that could demonstrate directionality and therefore further augment our understanding of these relations. Specifically, it is not clear if victimization is strictly an antecedent to mental health issues like depressive symptoms. This longitudinal study examined the associations among sexual harassment victimization, school belonging, and depressive symptoms among LGBTQ high school students (n = 404). Self-report measures were completed at 3 time points across 3 school years in 6 Midwest high schools. Structural equation modeling indicated that peer victimization was an antecedent to depressive symptoms, and that school belonging mediated the association. Implications and future directions are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Consumerism in healthcare can be detrimental to child health: lessons from children with functional abdominal pain.

PubMed

Lindley, K J; Glaser, D; Milla, P J

2005-04-01

To determine prognostic indicators in children with severe functional abdominal pain (FAP) and to test the hypothesis that "healthcare consumerism" in these families might be deleterious to the child. Retrospective analysis of a cohort of 23 children aged <16 years fulfilling the Rome II diagnostic criteria for FAP during the period December 1997 to February 2001. Poor outcome was defined as continued pain and failure to return to normal functioning >12 months after onset. Poor outcome was associated with refusal to engage with psychological services, involvement of more than three consultants, lodging of a manipulative complaint with hospital management by the child's family, and lack of development of insight into psychosocial influences on symptoms. Three of four adverse prognostic indicators reflected healthcare consumerism by the families. Actions of families who lack insight into their child's illness may perpetuate FAP in childhood. A culture of parental consumerism in healthcare, however well intentioned, needs to be accompanied by robust systems to protect the interests of the child.

Autologous hematopoietic stem cell transplantation in peripheral T-cell lymphoma using a uniform high-dose regimen.

PubMed

Smith, S D; Bolwell, B J; Rybicki, L A; Brown, S; Dean, R; Kalaycio, M; Sobecks, R; Andresen, S; Hsi, E D; Pohlman, B; Sweetenham, J W

2007-08-01

The role of high-dose therapy and autologous stem cell transplantation (ASCT) for patients with peripheral T-cell lymphoma (PTCL) is poorly defined. Comparisons of outcomes between PTCL and B-cell non-Hodgkin's lymphoma (NHL) have yielded conflicting results, in part due to the rarity and heterogeneity of PTCL. Some retrospective studies have found comparable survival rates for patients with T- and B-cell NHL. In this study, we report our single-center experience of ASCT over one decade using a uniform chemotherapy-only high-dose regimen. Thirty-two patients with PTCL-unspecified (PTCL-u; 11 patients) and anaplastic large-cell lymphoma (21 patients) underwent autologous stem cell transplant, mostly for relapsed or refractory disease. The preparative regimen consisted of busulfan, etoposide and cyclophosphamide. Kaplan-Meier 5-year overall survival (OS) and relapse-free survival (RFS) are 34 and 18%, respectively. These results suggest a poor outcome for patients with PTCL after ASCT, and new therapies for T-cell lymphoma are needed.

Study of MET protein levels and MET gene copy number in 72 sinonasal intestinal-type adenocarcinomas.

PubMed

Projetti, Fabrice; Mesturoux, Laura; Coulibaly, Béma; Durand, Karine; Chaunavel, Alain; Léobon, Sophie; Gadeaud, Emilie; Caire, François; Bessède, Jean-Pierre; Labrousse, François

2015-11-01

Sinonasal intestinal-type adenocarcinomas (ITACs) have a poor prognosis, and are defined on the basis of their morphological similarities to colorectal adenocarcinomas. MET signaling pathway is involved in oncogenesis in various cancers. Nothing is currently known about the role of MET in ITACs. In a series of 72 ITACs, we investigated MET protein levels by immunohistochemistry (IHC) and gene copy number by in situ hybridization. These findings were analyzed as a function of clinical data, histological typing, and patient outcome. MET protein was overproduced in 64% of cases and chromosome 7 polysomy was observed in 52% of cases. No tumor displayed MET amplification. The presence of mucinous or solid histological components, T3/T4 tumors, and incomplete resection were associated with a poor outcome. MET is overproduced in about two third of ITACs, suggesting a role for the MET signaling pathway in the oncogenesis of these tumors. © 2014 Wiley Periodicals, Inc.

Computerized assessment of placental calcification post-ultrasound: a novel software tool.

PubMed

Moran, M; Higgins, M; Zombori, G; Ryan, J; McAuliffe, F M

2013-05-01

Placental calcification is associated with an increased risk of perinatal morbidity and mortality. The subjectivity of current ultrasound methods of assessment of placental calcification indicates that a more objective method is required. The aim of this study was to correlate the percentage of calcification defined by the clinician using a new software tool for calculating the extent of placental calcification with traditional ultrasound methods and with pregnancy outcome. Ninety placental images were individually assessed. An upper threshold was defined, based on high intensity, to quantify calcification within the placenta. Output metrics were then produced including the overall percentage of calcification with respect to the total number of pixels within the region of interest. The results were correlated with traditional ultrasound methods of assessment of placental calcification and with pregnancy outcome. The results demonstrate a significant correlation between placental calcification, as defined using the software, and traditional methods of Grannum grading of placental calcification. Whilst correlation with perinatal outcome and cord pH was not significant as a result of small numbers, patients with placental calcification assessed using the computerized software at the upper quartile had higher rates of poor perinatal outcome when compared with those at the lower quartile (8/22 (36%) vs 3/23 (13%); P = 0.069). These results suggest that this computerized software tool has the potential to become an alternative method of assessing placental calcification. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

Transglutaminase 2 expression in acute myeloid leukemia: Association with adhesion molecule expression and leukemic blast motility

PubMed Central

Meyer, Stefan; Ravandi-Kashani, Farhad; Borthakur, Gautam; Coombes, Kevin R.; Zhang, Nianxiang; Kornblau, Steven

2016-01-01

Acute myeloid leukemia (AML) is a heterogenous disease with differential oncogene association, outcome and treatment regimens. Treatment strategies for AML have improved outcome but despite increased molecular biological information AML is still associated with poor prognosis. Proteomic analysis on the effects of a range of leukemogenic oncogenes showed that the protein transglutaminase 2 (TG2) is expressed at greater levels as a consequence of oncogenic transformation. Further analysis of this observation was performed with 511 AML samples using reverse phase proteomic arrays, demonstrating that TG2 expression was higher at relapse than diagnosis in many cases. In addition elevated TG2 expression correlated with increased expression of numerous adhesion proteins and many apoptosis regulating proteins, two processes related to leukemogenesis. TG2 has previously been linked to drug resistance in cancer and given the negative correlation between TG2 levels and peripheral blasts observed increased TG2 levels may lead to the protection of the leukemic stem cell due to increased adhesion/reduced motility. TG2 may therefore form part of a network of proteins that define poor outcome in AML patients and potentially offer a target to sensitize AML stem cells to drug treatment. PMID:23576428

Bispectral index to predict neurological outcome early after cardiac arrest.

PubMed

Stammet, Pascal; Collignon, Olivier; Werer, Christophe; Sertznig, Claude; Devaux, Yvan

2014-12-01

To address the value of continuous monitoring of bispectral index (BIS) to predict neurological outcome after cardiac arrest. In this prospective observational study in adult comatose patients treated by therapeutic hypothermia after cardiac arrest we measured bispectral index (BIS) during the first 24 hours of intensive care unit stay. A blinded neurological outcome assessment by cerebral performance category (CPC) was done 6 months after cardiac arrest. Forty-six patients (48%) had a good neurological outcome at 6-month, as defined by a cerebral performance category (CPC) 1-2, and 50 patients (52%) had a poor neurological outcome (CPC 3-5). Over the 24h of monitoring, mean BIS values over time were higher in the good outcome group (38 ± 9) compared to the poor outcome group (17 ± 12) (p<0.001). Analysis of BIS recorded every 30 minutes provided an optimal prediction after 12.5h, with an area under the receiver operating characteristic curve (AUC) of 0.89, a specificity of 89% and a sensitivity of 86% using a cut-off value of 23. With a specificity fixed at 100% (sensitivity 26%) the cut-off BIS value was 2.4 over the first 271 minutes. In multivariable analyses including clinical characteristics, mean BIS value over the first 12.5h was a predictor of neurological outcome (p = 6E-6) and provided a continuous net reclassification index of 1.28% (p = 4E-10) and an integrated discrimination improvement of 0.31 (p=1E-10). Mean BIS value calculated over the first 12.5h after ICU admission potentially predicts 6-months neurological outcome after cardiac arrest. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Insulin-like growth factor 1 as a predictor of ischemic stroke outcome in the elderly.

PubMed

Denti, Licia; Annoni, Valentina; Cattadori, Evelina; Salvagnini, Maria Angela; Visioli, Sandra; Merli, Maria Francesca; Corradi, Francesco; Ceresini, Graziano; Valenti, Giorgio; Hoffman, Andrew R; Ceda, Gian Paolo

2004-09-01

To examine whether serum insulin-like growth factor 1 (IGF-1) and IGF binding protein 3 (IGFBP-3) concentrations, determined early after the onset of stroke, are predictive of clinical outcome in elderly patients. The sample comprised 85 patients (mean [+/- SD] age, 83 +/- 7.4 years; range, 67 to 99 years; 34% male) who were admitted with acute stroke to a geriatric ward between January 1998 and June 2000, and 88 control patients who were similar in age and sex. Clinical and laboratory assessments, computed tomographic scan of the head, carotid ultrasonography, and electrocardiography were employed to define the clinical and etiologic stroke subtype. Fasting blood samples were collected within 24 hours of admission for IGF-I and IGFBP-3 measurement. Univariate and multiple logistic regression analyses, with adjustment for other related clinical covariates, were used to assess the relation of IGF-I and IGFBP-3 to poor outcome, defined as severe disability (Barthel index <60/100) or death, at 1 month (or at discharge), 3 months, and 6 months. Mean (+/- SD) IGF-1 levels were lower in patients with stroke than in controls (69 +/- 45 ng/mL vs. 102 +/- 67 ng/mL, P adjusted for age = 0.001). The mean IGF-1/IGFBP-3 molar ratio was also lower in stroke patients (0.12 +/- 0.07 vs. 0.19 +/- 0.09, P adjusted for age <0.0001). However, there was no relation of hormone levels to either the clinical subtype of stroke or the extent of neurologic impairment. IGF-1 levels were inversely related to poor outcome (mainly death) at 3 and 6 months, independent of other clinical covariates that were highly predictive of outcome, such as age and stroke scale score on admission (hazard ratio for death at 6 months for each 20-ng/mL increase = 0.7; 95% confidence interval: 0.5 to 0.9). An independent association of the molar ratio with death at 3 and 6 months was also found. Low levels of circulating IGF-1 may predict the clinical outcome of stroke in elderly patients.

Co-morbid depression is associated with poor work outcomes in persons with cardiovascular disease (CVD): A large, nationally representative survey in the Australian population

PubMed Central

2012-01-01

Background Co-morbid major depressive disorder (MDD) and cardiovascular disease (CVD) is associated with poor clinical and psychological outcomes. However, the full extent of the burden of, and interaction between, this co-morbidity on important vocational outcomes remains less clear, particularly at the population level. We examine the association of co-morbid MDD with work outcomes in persons with and without CVD. Methods This study utilised cross-sectional, population-based data from the 2007 Australian National Survey of Mental Health and Wellbeing (n = 8841) to compare work outcomes of individuals with diagnostically-defined MDD and CVD, MDD but not CVD, CVD but not MDD, with a reference group of "healthy" Australians. Workforce participation was defined as being in full- or part-time employment. Work functioning was measured using a WHO Disability Assessment Schedule item. Absenteeism was assessed using the 'days out of role' item. Results Of the four groups, those with co-morbid MDD and CVD were least likely to report workforce participation (adj OR:0.4, 95% CI: 0.3-0.6). Those with MDD only (adj OR:0.8, 95% CI:0.7-0.9) and CVD only (adj OR:0.8, 95% CI: 0.6-0.9) also reported significantly reduced odds of participation. Employed individuals with co-morbid MDD and CVD were 8 times as likely to experience impairments in work functioning (adj OR:8.1, 95% CI: 3.8- 17.3) compared with the reference group. MDD was associated with a four-fold increase in impaired functioning. Further, individuals with co-morbid MDD and CVD reported greatest likelihood of workplace absenteeism (adj. OR:3.0, 95% CI: 1.4-6.6). Simultaneous exposure to MDD and CVD conferred an even greater likelihood of poorer work functioning. Conclusions Co-morbid MDD and CVD is associated with significantly poorer work outcomes. Specifically, the effects of these conditions on work functioning are synergistic. The development of specialised treatment programs for those with co-morbid MDD and CVD is required. PMID:22257700

Clinical Risk Index for Babies score for the prediction of neurodevelopmental outcomes at 3 years of age in infants of very low birthweight.

PubMed

Lodha, Abhay; Sauvé, Reg; Chen, Sophie; Tang, Selphee; Christianson, Heather

2009-11-01

In this study, we evaluated the Clinical Risk Index for Babies - revised (CRIB-II) score as a predictor of long-term neurodevelopmental outcomes in preterm infants at 36 months' corrected age. CRIB-II scores, which include birthweight, gestational age, sex, admission temperature, and base excess, were recorded prospectively on all infants weighing 1250g or less admitted to the neonatal intensive care unit (NICU). The sensitivity and specificity of CRIB-II scores to predict poor outcomes were examined using receiver operating characteristic curves, and predictive accuracy was assessed using the area under the curve (AUC), based on the observed values entered on a continuous scale. Poor outcomes were defined as death or major neurodevelopmental disability (cerebral palsy, neurosensory hearing loss requiring amplification, legal blindness, severe seizure disorder, or cognitive score >2SD below the mean for adjusted age determined by clinical neurological examination and on the Wechsler Preschool and Primary Scale of Intelligence, Bayley Scales of Infant Development, or revised Leiter International Performance Scale). Of the 180 infants admitted to the NICU, 155 survived. Complete follow-up data were available for 107 children. The male:female ratio was 50:57 (47-53%), median birthweight was 930g (range 511-1250g), and median gestational age was 27 weeks (range 23-32wks). Major neurodevelopmental impairment was observed in 11.2% of participants. In a regression model, the CRIB-II score was significantly correlated with long-term neurodevelopmental outcomes. It predicted major neurodevelopmental impairment (odds ratio [OR] 1.57, bootstrap 95% confidence interval [CI] 1.26-3.01; AUC 0.84) and poor outcome (OR 1.46; bootstrap 95% CI 1.31-1.71, AUC 0.82) at 36 months' corrected age. CRIB-II scores of 13 or more in the first hour of life can reliably predict major neurodevelopmental impairment at 36 months' corrected age (sensitivity 83%; specificity 84%).

Comparing current definitions of return to work: a measurement approach.

PubMed

Steenstra, I A; Lee, H; de Vroome, E M M; Busse, J W; Hogg-Johnson, S J

2012-09-01

Return-to-work (RTW) status is an often used outcome in work and health research. In low back pain, work is regarded as a normal activity a worker should return to in order to fully recover. Comparing outcomes across studies and even jurisdictions using different definitions of RTW can be challenging for readers in general and when performing a systematic review in particular. In this study, the measurement properties of previously defined RTW outcomes were examined with data from two studies from two countries. Data on RTW in low back pain (LBP) from the Canadian Early Claimant Cohort (ECC); a workers' compensation based study, and the Dutch Amsterdam Sherbrooke Evaluation (ASE) study were analyzed. Correlations between outcomes, differences in predictive validity when using different outcomes and construct validity when comparing outcomes to a functional status outcome were analyzed. In the ECC all definitions were highly correlated and performed similarly in predictive validity. When compared to functional status, RTW definitions in the ECC study performed fair to good on all time points. In the ASE study all definitions were highly correlated and performed similarly in predictive validity. The RTW definitions, however, failed to compare or compared poorly with functional status. Only one definition compared fairly on one time point. Differently defined outcomes are highly correlated, give similar results in prediction, but seem to differ in construct validity when compared to functional status depending on societal context or possibly birth cohort. Comparison of studies using different RTW definitions appears valid as long as RTW status is not considered as a measure of functional status.

35% Good Outcome Rate in IV-tPA treated Patients with CTA Confirmed Severe Anterior Circulation Occlusive Stroke

PubMed Central

González, R. Gilberto; Furie, Karen L.; Goldmacher, Gregory V.; Smith, Wade S.; Kamalian, Shervin; Payabvash, Seyedmehdi; Harris, Gordon J.; Halpern, Elkan F.; Koroshetz, Walter J.; Camargo, Erica C. S.; Dillon, William P.; Lev, Michael H.

2015-01-01

BACKGROUND AND PURPOSE To determine the effect of IV-tPA on outcomes in patients with severe major anterior circulation ischemic stroke. METHODS Prospectively, 649 acute stroke patients had admission NIH stroke scale scores (NIHSS), non-contrast CT, CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale (mRS). IV-tPA treatment decisions were made prior to CTA, at the time of non-contrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as mRS>2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed. RESULTS Of 649 patients, 188 (29%) presented with NIHSS>10, and 64/188 (34%) of these received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes, however a significant interaction existed between IV-tPA and occlusion (p<0.001). Of NIHSS>10 patients with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17/49, 35%), than if they did not (13/77, 17%; p=0.031). The “number needed to treat” was 7 (95% CI = 3–60). CONCLUSIONS IV-tPA treatment resulted in significantly more good outcomes in severely symptomatic stroke patients with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies. PMID:24003051

Contrast enema findings in patients presenting with poor functional outcome after primary repair for Hirschsprung disease.

PubMed

Garrett, Kevin M; Levitt, Marc A; Peña, Alberto; Kraus, Steven J

2012-09-01

The radiologic evaluation of Hirschsprung disease is well described in the literature. However, there is a paucity of literature describing the appearance of the neo-rectum and colon after repair, specifically describing findings in patients with poor functional outcome, which would suggest the need for reoperation. We describe findings on contrast enema and correlate them with surgical findings at reoperation in children with poor functional outcome after primary repair for Hirschsprung disease who suffer from bowel dysfunction that can manifest with either soiling or obstructive symptoms such as enterocolitis. Children were identified from our colorectal surgery database. At the time of abstract submission, 35 children had contrast enemas prior to reoperation. Additional children continue to present for evaluation. The majority of children included in the study had their primary repair performed elsewhere. The initial procedures included: Duhamel (n = 11), Soave (n = 20) or Swenson (n = 3). One child had undergone a primary Soave repair and subsequently had a Swenson-type reoperation but continued to have a poor outcome. One child's initial surgical repair could not be determined. Images were reviewed by a staff pediatric radiologist and a pediatric radiology fellow. Findings encountered on contrast enema in these children include a distal narrowed segment due to stricture or aganglionic/transitional zone segment (8), dilated/hypomotile distal segment (7), thickened presacral space due to compressing Soave cuff (11), dilated Duhamel pouch (8), active enterocolitis (3) and partially obstructing twist of the pull-through segment (1). Multiple anatomical and pathological complications exist that can lead to bowel dysfunction in children after repair of Hirschsprung disease. Little recent literature exists regarding the radiographic findings in children. We had the opportunity to review a substantial series of these children, describe the contrast enema findings in these difficult cases and correlate them with operative findings. Radiologic evaluation is key to assessing such patients; it defines the potential anatomical problem with the pull-through and facilitates surgical planning.

Using the ovarian sensitivity index to define poor, normal, and high response after controlled ovarian hyperstimulation in the long gonadotropin-releasing hormone-agonist protocol: suggestions for a new principle to solve an old problem.

PubMed

Huber, Malin; Hadziosmanovic, Nermin; Berglund, Lars; Holte, Jan

2013-11-01

To explore the utility of using the ratio between oocyte yield and total dose of FSH, i.e., the ovarian sensitivity index (OSI), to define ovarian response patterns. Retrospective cross-sectional study. University-affiliated private center. The entire unselected cohort of 7,520 IVF/intracytoplasmic sperm injection treatments (oocyte pick-ups [OPUs]) during an 8-year period (long GnRH agonist-recombinant FSH protocol). None. The distribution of the OSI (oocytes recovered × 1,000/total dose of FSH), the cutoff levels for poor and high response, set at ±1 SD, and the relationship between OSI and treatment outcome. OSI showed a log-normal distribution with cutoff levels for poor and high response at 1.697/IU and 10.07/IU, respectively. A nomogram is presented. Live-birth rates per OPU were 10.5 ± 0.1%, 26.9 ± 0.6%, and 36.0 ± 1.4% for poor, normal, and high response treatments, respectively. The predictive power (C-statistic) for OSI to predict live birth was superior to that of oocyte yield. The OSI improves the definition of ovarian response patterns because it takes into account the degree of stimulation. The nomogram presents evidence-based cutoff levels for poor, normal, and high response and could be used for unifying study designs involving ovarian response patterns. Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

C-GRApH: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management.

PubMed

Kiehl, Erich L; Parker, Alex M; Matar, Ralph M; Gottbrecht, Matthew F; Johansen, Michelle C; Adams, Mark P; Griffiths, Lori A; Dunn, Steven P; Bidwell, Katherine L; Menon, Venu; Enfield, Kyle B; Gimple, Lawrence W

2017-05-20

Out-of-hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post-OHCA remains difficult in patients receiving targeted temperature management. Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32-34°C) for 24 hours at a tertiary-care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3-5). Patient demographics, pre-OHCA diagnoses, and initial laboratory studies post-resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system ( C-GRApH ). The C-GRApH score ranges 0 to 5 using equally weighted variables: ( C ): coronary artery disease, known pre-OHCA; ( G ): glucose ≥200 mg/dL; ( R ): rhythm of arrest not ventricular tachycardia/fibrillation; ( A ): age >45; ( pH ): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary-care health system (n=272) from 2012 to 2014. The c-statistic for predicting neurologic outcome was 0.82 (0.74-0.90, P <0.001) in the development cohort and 0.81 (0.76-0.87, P <0.001) in the validation cohort. When subdivided by C-GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0-1, n=60), 22% versus 19% for medium (2-3, n=307), and 0% versus 2% for high (4-5, n=99) C-GRApH scores in the development and validation cohorts, respectively. C-GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32-34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable ( C-GRApH ≤1) and poor ( C-GRApH ≥4) prognoses. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

The prognostic value of midregional proatrial natriuretic peptide in patients with hemorrhagic stroke.

PubMed

Fischer, Marlene; Katan, Mira; Morgenthaler, Nils G; Seiler, Marleen; Müller, Beat; Lackner, Peter; Errath, Mario; Helbok, Raimund; Pfausler, Bettina; Beer, Ronny; Schmutzhard, Erich; Broessner, Gregor

2014-01-01

Atrial natriuretic peptide (ANP) is a well-known prognostic marker of outcome and mortality in patients with cardiovascular disease. Midregional proatrial natriuretic peptide (MR-proANP) is a stable fragment of the ANP precursor hormone. As a prognostic marker after ischemic stroke, it reliably predicts poststroke mortality and functional outcome. This study aimed to analyze the prognostic value of MR-proANP in patients with hemorrhagic stroke, i.e. subarachnoid (SAH) and intracerebral hemorrhage (ICH). MR-proANP was analyzed in patients with spontaneous SAH or spontaneous ICH. All patients were prospectively randomized into two treatment arms: (1) a prophylactic normothermia group with a target core temperature 36.5°C using endovascular cooling, and (2) a control group with conventional stepwise predefined fever management using antipyretic medication and surface cooling. Blood samples were obtained on admission and on days 4 and 7. Measurement of MR-proANP was performed in serum using sandwich immunoassay. The primary endpoint was functional outcome [assessed by the Glasgow Outcome Score (GOS)] and the secondary endpoints were mortality within 180 days after hemorrhagic stroke and influence of temperature on MR-proANP. A favorable outcome was defined as GOS 4-5, and the patients were considered to have a poor outcome with a 180-day GOS score between 1 and 3. Analysis of MR-proANP was performed in 24 patients with spontaneous SAH and 22 patients with spontaneous ICH. MR-proANP was elevated on days 4 and 7 as compared to baseline levels (p < 0.05 and p < 0.001, respectively). High MR-proANP levels (>120 pmol/l) were associated with increased mortality and poor outcome (after 180 days; p < 0.05, respectively). There was no significant difference regarding MR-proANP serum concentrations between the endovascular and the control groups. Increased levels of MR-proANP are independently associated with poor functional outcome and increased mortality after 180 days in patients with hemorrhagic stroke. Endovascular temperature control had no significant influence on MR-proANP levels.

Unraveling the meaning of patient engagement: A concept analysis.

PubMed

Higgins, Tracy; Larson, Elaine; Schnall, Rebecca

2017-01-01

Patient engagement has been credited with contributing to improved outcomes and experiences of care. Patient engagement has become a widely used term, but remains a poorly understood concept in healthcare. Citations for the term have increased throughout the healthcare-related disciplines without a common definition. This study seeks to define the concept by identifying its attributes in the context of its use. A concept analysis of the scientific literature in the health disciplines was performed using the Rogers method. The analysis revealed four defining attributes of patient engagement: personalization, access, commitment and therapeutic alliance. Patient engagement is defined as the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes of maximizing outcomes or improving experiences of care. Patient engagement is both process and behavior and is shaped by the relationship between the patient and provider and the environment in which healthcare delivery takes place. The definition and the identified attributes serve as a heuristic in designing patient engagement strategies and as a basis for future development of the patient engagement concept in healthcare. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Treatment of idiopathic peripheral facial nerve paralysis (Bell's palsy)].

PubMed

Meyer, Martin Willy; Hahn, Christoffer Holst

2013-01-28

Bell's palsy is defined as an idiopathic peripheral facial nerve paralysis of sudden onset. It affects 11-40 persons per 100,000 per annum. Many patients recover without intervention; however, up to 30% have poor recovery of facial muscle control and experience facial disfigurement. The aim of this study was to make an overview of which pharmacological treatments have been used to improve outcomes. The available evidence from randomized controlled trials shows significant benefit from treating Bell's palsy with corticosteroids but shows no benefit from antivirals.

Association between muscle function, cognitive state, depression symptoms and quality of life of older people: evidence from clinical practice.

PubMed

Gariballa, Salah; Alessa, Awad

2018-04-01

Although low muscle function/strength is an important predictor of poor clinical outcome in older patients, information on its impact on mental health in clinical practice is still lacking. The aim of this report is to measure the impact of low muscle function measured by handgrip strength on mental health of older people during both acute illness and recovery. Four hundred and thirty-two randomly selected hospitalized older patients had their baseline demographic and clinical characteristics assessed within 72 h of admission, at 6 weeks and at 6 months. Low muscle strength-handgrip was defined using the European Working Group criteria. Mental health outcome measures including cognitive state, depression symptoms and quality of life were also measured. Among the 432 patients recruited, 308 (79%) had low muscle strength at baseline. Corresponding figures at 6 weeks and at 6 months were 140 (73%) and 158 (75%). Patients with poor muscle strength were significantly older with increased disability and poor nutritional status compared with those with normal muscle strength. After adjustment for age, gender, disability, comorbidity including severity of acute illness and body mass index patients with low muscle strength had worse cognitive function, quality of life and higher depression symptoms compared with those with normal muscle strength over a 6-month period (p < 0.05). Poor muscle strength in older people is associated with poor cognitive state and quality of life and increased depression symptoms during both acute illness and recovery.

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis: Individual Patient Data Meta-Analysis.

PubMed

Charidimou, Andreas; Turc, Guillaume; Oppenheim, Catherine; Yan, Shenqiang; Scheitz, Jan F; Erdur, Hebun; Klinger-Gratz, Pascal P; El-Koussy, Marwan; Takahashi, Wakoh; Moriya, Yusuke; Wilson, Duncan; Kidwell, Chelsea S; Saver, Jeffrey L; Sallem, Asma; Moulin, Solene; Edjlali-Goujon, Myriam; Thijs, Vincent; Fox, Zoe; Shoamanesh, Ashkan; Albers, Gregory W; Mattle, Heinrich P; Benavente, Oscar R; Jäger, H Rolf; Ambler, Gareth; Aoki, Junya; Baron, Jean-Claude; Kimura, Kazumi; Kakuda, Wataru; Takizawa, Shunya; Jung, Simon; Nolte, Christian H; Lou, Min; Cordonnier, Charlotte; Werring, David J

2017-07-18

We assessed whether the presence, number, and distribution of cerebral microbleeds (CMBs) on pre-intravenous thrombolysis MRI scans of acute ischemic stroke patients are associated with an increased risk of intracerebral hemorrhage (ICH) or poor functional outcome. We performed an individual patient data meta-analysis, including prospective and retrospective studies of acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2-4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3- to 6-month functional outcome (modified Rankin score >2). In 1973 patients from 8 centers, the crude prevalence of CMBs was 526 of 1973 (26.7%). A total of 77 of 1973 (3.9%) patients experienced symptomatic ICH, 210 of 1806 (11.6%) experienced PH, and 56 of 1720 (3.3%) experienced PHr. In adjusted analyses, patients with CMBs (compared with those without CMBs) had increased risk of PH (odds ratio: 1.50; 95% confidence interval: 1.09-2.07; P =0.013) and PHr (odds ratio: 3.04; 95% confidence interval: 1.73-5.35; P <0.001) but not symptomatic ICH. Both cerebral amyloid angiopathy and noncerebral amyloid angiopathy patterns of CMBs were associated with PH and PHr. Increasing CMB burden category was associated with the risk of symptomatic ICH ( P =0.014), PH ( P =0.013), and PHr ( P <0.00001). Five or more and >10 CMBs independently predicted poor 3- to 6-month outcome (odds ratio: 1.85; 95% confidence interval: 1.10-3.12; P =0.020; and odds ratio: 3.99; 95% confidence interval: 1.55-10.22; P =0.004, respectively). Increasing CMB burden is associated with increased risk of ICH (including PHr) and poor 3- to 6-month functional outcome after intravenous thrombolysis for acute ischemic stroke. © 2017 American Heart Association, Inc.

DALI: Defining Antibiotic Levels in Intensive care unit patients: a multi-centre point of prevalence study to determine whether contemporary antibiotic dosing for critically ill patients is therapeutic.

PubMed

Roberts, Jason A; De Waele, Jan J; Dimopoulos, George; Koulenti, Despoina; Martin, Claude; Montravers, Philippe; Rello, Jordi; Rhodes, Andrew; Starr, Therese; Wallis, Steven C; Lipman, Jeffrey

2012-07-06

The clinical effects of varying pharmacokinetic exposures of antibiotics (antibacterials and antifungals) on outcome in infected critically ill patients are poorly described. A large-scale multi-centre study (DALI Study) is currently underway describing the clinical outcomes of patients achieving pre-defined antibiotic exposures. This report describes the protocol. DALI will recruit over 500 patients administered a wide range of either beta-lactam or glycopeptide antibiotics or triazole or echinocandin antifungals in a pharmacokinetic point-prevalence study. It is anticipated that over 60 European intensive care units (ICUs) will participate. The primary aim will be to determine whether contemporary antibiotic dosing for critically ill patients achieves plasma concentrations associated with maximal activity. Secondary aims will compare antibiotic pharmacokinetic exposures with patient outcome and will describe the population pharmacokinetics of the antibiotics included. Various subgroup analyses will be conducted to determine patient groups that may be at risk of very low or very high concentrations of antibiotics. The DALI study should inform clinicians of the potential clinical advantages of achieving certain antibiotic pharmacokinetic exposures in infected critically ill patients.

Fasting blood glucose is a novel prognostic indicator for extranodal natural killer/T-cell lymphoma, nasal type

PubMed Central

Cai, Q; Luo, X; Liang, Y; Rao, H; Fang, X; Jiang, W; Lin, T; Lin, T; Huang, H

2013-01-01

Background: Extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKTL) is an aggressive disease with poor prognosis, requiring risk stratification. However, the prognosis of ENKTL is not fully defined and needs supplementation. We hypothesised that fasting blood glucose (FBG) may be a new prognostic factor for ENKTL. Methods: We retrospectively analysed 130 patients newly diagnosed with ENKTL. Results: Both univariate analysis and multivariate analysis revealed that FBG >100 mg dl−1 was associated with a poor outcome. Patients with FBG >100 mg dl−1 at diagnosis had more adverse clinical features, achieved lower complete remission rates (P=0.003) and had worse overall survival (P<0.001) and progression-free survival (P<0.001) compared with low-FBG patients. Measurement of FBG was helpful in differentiating between low-risk patients using the International Prognostic Index (IPI) and Prognosis Index for peripheral T-cell lymphoma (PIT) scoring and patients in a different category using the Korean Prognostic Index (KPI) scores with different survival outcomes (P<0.05). Conclusion: Our data suggest that measuring FBG levels at diagnosis is a novel, independent predictor of prognosis in ENKTL and helps to distinguish low-risk patients with poor survival, and this holds true in patients considered low-risk by IPI, PIT and KPI. PMID:23299534

Prognosis moderates the engagement-outcome relationship in unguided cCBT for depression: A proof of concept for the prognosis moderation hypothesis.

PubMed

Forand, Nicholas R; Huibers, Marcus J H; DeRubeis, Robert J

2017-05-01

Understanding how treatments work is a goal of psychotherapy research, however the strength of relationships between therapy processes and outcomes is inconsistent. DeRubeis, Cohen, et al. (2014) proposed that process-outcome relationships are moderated by patient characteristics. These "patient response patterns" (PRPs) indicate individuals' responsiveness to the active ingredients of treatment. Given the same quality of therapy, one individual may receive more benefit than another depending on their PRP. The "prognosis moderation hypothesis" states that PRPs can be defined by pretreatment prognostic indicators. Medium prognosis groups ("pliant-like") will have stronger process-outcome relationships than good ("easy-like") or poor ("challenging-like") groups. N = 190 individuals received unguided computerized CBT. They were 58% women, aged 44.7 years. Engagement with the cCBT program was the process variable. PRPs were defined by predicted scores from a prognostic regression model. Outcomes were BDI scores at 3, 6, and 12 months. "Easy-like," "pliant-like" and "challenging-like" groups were created and the engagement-outcome relationship was assessed as a function of group. Engagement-outcome correlations by PRP were: easy-like, r = -.27 (p < .05); pliant-like, r = -.36 (p < .01); and challenging-like, r = .05 (p = .70). The pliant-like group was found to be the only moderator of the engagement-outcome relationship. Results were similar at 6 months but faded at 12. The engagement-outcome relationship varied as a function of prognosis, providing support for the prognosis moderation hypothesis. The "pliant-like" group appeared most sensitive to treatment procedures. Future research is needed to refine the methods for identifying PRPs. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Community-Acquired Meningitis in Older Adults: Clinical Features, Etiology, and Prognostic Factors

PubMed Central

Wang, Amy Y.; Machicado, Jorge D.; Khoury, Nabil T.; Wootton, Susan H.; Salazar, Lucrecia; Hasbun, Rodrigo

2014-01-01

Background Bacterial meningitis in older adults is a well-studied and serious disease, but few studies have investigated the epidemiology and outcomes of community-acquired meningitis in older adults. Methods We conducted a retrospective study of 619 adults in Houston, Texas, with community-acquired meningitis hospitalized between January 1, 2005, and January 1, 2010. Patients were categorized as older if age ≥65 (N=54) and younger if age 18–64 (N=565). An adverse clinical outcome was defined as a Glasgow Outcome Scale score of 4 or less. Results Older patients consisted of 8.7% (54/619) of the total cohort and had higher rates of comorbidities, abnormal neurological and laboratory findings, abnormalities on computed tomography and magnetic resonance imaging of the head and adverse clinical outcomes (ACO) (p<0.05). The majority of patients (65.8%) had meningitis of unknown etiology. Bacterial meningitis was an infrequent cause (7.4%). Of the known causes, bacterial meningitis and West Nile virus were more common in older patients. In contrast, younger patients more frequently had cryptococcal and viral meningitis. On logistic regression, female gender was predictive of a poor outcome in the older patients, whereas abnormal neurologic exam, fever, and CSF glucose <45mg/dLwere significant poor prognostic factors in younger patients (p<0.05). Conclusion Most cases of community-acquired meningitis are of unknown origin. Older patients are more likely to have bacterial meningitis and West Nile virus infection when a cause can be identified. They also have more neurologic abnormalities, laboratory and imaging abnormalities, as well as adverse clinical outcomes. PMID:25370434

The Effects of Combinations of Cognitive Impairment and Pre-frailty on Adverse Outcomes from a Prospective Community-Based Cohort Study of Older Chinese People.

PubMed

Yu, Ruby; Morley, John E; Kwok, Timothy; Leung, Jason; Cheung, Osbert; Woo, Jean

2018-01-01

To examine how various combinations of cognitive impairment (overall performance and specific domains) and pre-frailty predict risks of adverse outcomes; and to determine whether cognitive frailty may be defined as the combination of cognitive impairment and the presence of pre-frailty. Community-based cohort study. Chinese men and women ( n  = 3,491) aged 65+ without dementia, Parkinson's disease and/or frailty at baseline. Frailty was characterized using the Cardiovascular Health Study criteria. Overall cognitive impairment was defined by a Cantonese Mini-Mental Status Examination (CMMSE) total score (<21/24/27, depending on participants' educational levels); delayed recall impairment by a CMMSE delayed recall score (<3); and language and praxis impairment by a CMMSE language and praxis score (<9). Adverse outcomes included poor quality of life, physical limitation, increased cumulative hospital stay, and mortality. Compared to those who were robust and cognitively intact at baseline, those who were robust but cognitively impaired were more likely to develop pre-frailty/frailty after 4 years ( P  < 0.01). Compared to participants who were robust and cognitively intact at baseline, those who were pre-frail and with overall cognitive impairment had lower grip strength ( P  < 0.05), lower gait speed ( P  < 0.01), poorer lower limb strength ( P  < 0.01), and poorer delayed recall at year 4 [OR, 1.6; 95% confidence interval (CI), 1.2-2.3]. They were also associated with increased risks of poor quality of life (OR, 1.5; 95% CI, 1.1-2.2) and incident physical limitation at year 4 (OR, 1.8; 95% CI, 1.3-2.5), increased cumulative hospital stay at year 7 (OR, 1.5; 95% CI, 1.1-2.1), and mortality over an average of 12 years (OR, 1.5; 95% CI, 1.0-2.1) after adjustment for covariates. There was no significant difference in risks of adverse outcomes between participants who were pre-frail, with/without cognitive impairment at baseline. Similar results were obtained with delayed recall and language and praxis impairments. Robust and cognitively impaired participants had higher risks of becoming pre-frail/frail over 4 years compared with those with normal cognition. Cognitive impairment characterized by the CMMSE overall score or its individual domain score improved the predictive power of pre-frailty for poor quality of life, incident physical limitation, increased cumulative hospital stay, and mortality. Our findings support to the concept that cognitive frailty may be defined as the occurrence of both cognitive impairment and pre-frailty, not necessarily progressing to dementia.

Infantile Hemangiomas of the Lip: Patterns, Outcomes, and Implications.

PubMed

Yanes, Daniel A; Pearson, Gregory D; Witman, Patricia M

2016-09-01

Infantile hemangiomas of the lip are potentially problematic because of high visibility and risk of disfigurement and ulceration. This study examined sizes, patterns, and locations of lip hemangiomas, their prognostic value, and their implications in hemangioma pathogenesis. Records of 106 patients seen for lip hemangiomas from 2006 to 2013 at Nationwide Children's Hospital were reviewed. Localized hemangiomas were mapped to a location on the lip based on their focus. Size, location, and morphology were assessed with regard to outcome. Poor outcomes were considered to be marked anatomic deformity, scarring, functional complications, and ulceration. Of 72 untreated hemangiomas with discernible outcomes, 92% of segmental lip hemangiomas were associated with poor outcomes, as opposed to 32% of localized hemangiomas (p < 0.001). Localized lip hemangiomas originated from six distinct locations. Localized untreated hemangiomas with poor outcomes were, on average, approximately 2.36 cm(2) larger (95% confidence interval 1.47, 3.25) than those that resolved favorably (p < 0.001); 52% of upper lip untreated hemangiomas and 6% of lower lip hemangiomas had poor outcomes (p = 0.001), and 61% of untreated localized hemangiomas involving the vermilion border and 25% of those that did not had poor outcomes (p = 0.01). Hemangiomas that received early medical or surgical intervention were less likely to have poor outcomes than untreated hemangiomas (p = 0.03). Localized lip hemangiomas occur in distinct locations on the lip that are not random and appear to reflect known models of facial development. Segmental morphology is associated with poor outcomes. In localized hemangiomas, the upper lip is associated with more problematic outcomes than the lower lip. Large size and involvement of the vermilion border are also valuable prognostic indicators associated with poor outcomes. Early intervention in lip hemangiomas is associated with better outcomes. © 2016 Wiley Periodicals, Inc.

Plasma cell leukemia: update on biology and therapy.

PubMed

Mina, Roberto; D'Agostino, Mattia; Cerrato, Chiara; Gay, Francesca; Palumbo, Antonio

2017-07-01

Plasma cell leukemia (PCL) is a rare, but very aggressive, plasma cell dyscrasia, representing a distinct clinicopathological entity as compared to multiple myeloma (MM), with peculiar biological and clinical features. A hundred times rarer than MM, the disease course is characterized by short remissions and poor survival. PCL is defined by an increased percentage (>20%) and absolute number (>2 × 10 9 /l) of plasma cells in the peripheral blood. PCL is defined as 'primary' when peripheral plasmacytosis is detected at diagnosis, 'secondary' when leukemization occurs in a patient with preexisting MM. Novel agents have revolutionized the outcomes of MM patients and have been introduced also for the treatment of PCL. Here, we provide an update on biology and treatment options for PCL.

Hazardous waste and health impact: a systematic review of the scientific literature.

PubMed

Fazzo, L; Minichilli, F; Santoro, M; Ceccarini, A; Della Seta, M; Bianchi, F; Comba, P; Martuzzi, M

2017-10-11

Waste is part of the agenda of the European Environment and Health Process and included among the topics of the Sixth Ministerial Conference on Environment and Health. Disposal and management of hazardous waste are worldwide challenges. We performed a systematic review to evaluate the evidence of the health impact of hazardous waste exposure, applying transparent and a priori defined methods. The following five steps, based on pre-defined systematic criteria, were applied. 1. Specify the research question, in terms of "Population-Exposure-Comparators-Outcomes" (PECO). people living near hazardous waste sites; Exposure: exposure to hazardous waste; Comparators: all comparators; Outcomes: all diseases/health disorders. 2. Carry out the literature search, in Medline and EMBASE. 3. Select studies for inclusion: original epidemiological studies, published between 1999 and 2015, on populations residentially exposed to hazardous waste. 4. Assess the quality of selected studies, taking into account study design, exposure and outcome assessment, confounding control. 5. Rate the confidence in the body of evidence for each outcome taking into account the reliability of each study, the strength of the association and concordance of results.Fifty-seven papers of epidemiological investigations on the health status of populations living near hazardous waste sites were selected for the evidence evaluation. The association between 95 health outcomes (diseases and disorders) and residential exposure to hazardous waste sites was evaluated. Health effects of residential hazardous waste exposure, previously partially unrecognized, were highlighted. Sufficient evidence was found of association between exposure to oil industry waste that releases high concentrations of hydrogen sulphide and acute symptoms. The evidence of causal relationship with hazardous waste was defined as limited for: liver, bladder, breast and testis cancers, non-Hodgkin lymphoma, asthma, congenital anomalies overall and anomalies of the neural tube, urogenital, connective and musculoskeletal systems, low birth weight and pre-term birth; evidence was defined as inadequate for the other health outcomes. The results, although not conclusive, provide indications that more effective public health policies on hazardous waste management are urgently needed. International, national and local authorities should oppose and eliminate poor, outdated and illegal practices of waste disposal, including illegal transboundary trade, and increase support regulation and its enforcement.

Outcome of bone mineral density in anorexia nervosa patients 11.7 years after first admission.

PubMed

Herzog, W; Minne, H; Deter, C; Leidig, G; Schellberg, D; Wüster, C; Gronwald, R; Sarembe, E; Kröger, F; Bergmann, G

1993-05-01

Osteopenia is a typical finding in patients suffering from anorexia nervosa. Unfortunately, available longitudinal studies are limited by a relatively short follow-up period. Therefore cross-sectional long-term followup studies may help to determine both the outcome of this bone lesion and variables that influence its subsequent development. Of an initial 66 consecutive patients with anorexia nervosa, 51 (77.3%) could be further evaluated. After an average of 11.7 years following first admission, cross-sectional measurements of lumbar and proximal radial bone mineral density (BMD) were performed. The ability to predict BMD using variables obtained from anamnestic and clinical data was then determined by multiple-regression analysis. The BMD of both radial and lumbar bone in anorexic patients with poor disease outcome (as defined by the Morgan-Russell general outcome categories) deviated by -2.18 and -1.73 SD (Z score), respectively. In patients with a good disease outcome lumbar BMD was significantly less reduced compared with radial BMD (-0.26 versus -0.68 SD). Variables reflecting estrogen deficiency and nutritional status in the course of the disease, that is, relative estrogen exposure (for lumbar BMD) and years of anorexia nervosa (for radial BMD), allowed the best prediction of BMD. A marked reduction in cortical and trabecular BMD in anorexic patients with poor disease outcome suggests a higher risk of fractures in these patients. Furthermore, the finding of a persistently reduced cortical and a slightly reduced trabecular BMD, even in patients with good disease outcome, suggests that a recovery of trabecular BMD might be possible, at least in part. Recovery of cortical bone, if possible at all, seems to proceed more slowly.

Mechanical dispersion is associated with poor outcome in heart failure with a severely depressed left ventricular function and bundle branch blocks.

PubMed

Stankovic, Ivan; Janicijevic, Aleksandra; Dimic, Aleksandra; Stefanovic, Milica; Vidakovic, Radosav; Putnikovic, Biljana; Neskovic, Aleksandar N

2018-03-01

Bundle branch blocks (BBB)-related mechanical dyssynchrony and dispersion may improve patient selection for device therapy, but their effect on the natural history of this patient population is unknown. A total of 155 patients with LVEF ≤ 35% and BBB, not treated with device therapy, were included. Mechanical dyssynchrony was defined as the presence of either septal flash or apical rocking. Contraction duration was assessed as time interval from the electrocardiographic R-(Q-)wave to peak longitudinal strain in each of 17 left ventricular segments. Mechanical dispersion was defined as either the standard deviation of all time intervals (dispersion SD ) or as the difference between the longest and shortest time intervals (dispersion delta ). Patients were followed for cardiac mortality during a median period of 33 months. Mechanical dyssynchrony was not associated with survival. More pronounced mechanical dispersion delta was found in patients with dyssynchrony than in those without. In the multivariate regression analysis, patients' functional class, diabetes mellitus and dispersion delta were independently associated with mortality. Mechanical dispersion, but not dyssynchrony, was independently associated with mortality and it may be useful for risk stratification of patients with heart failure (HF) and BBB. Key Messages Mechanical dispersion, measured by strain echocardiography, is associated with poor outcome in heart failure with a severely depressed left ventricular function and bundle branch blocks. Mechanical dispersion may be useful for risk stratification of patients with heart failure and bundle branch blocks.

Aggressive behavior and anaplasia in pleomorphic xanthoastrocytoma: a plea for a revision of the current WHO classification.

PubMed

Kahramancetin, Nesibe; Tihan, Tarik

2013-11-01

Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic neoplasm that commonly affects children and young adults, and presents with seizures. PXA is typically supratentorial with a predilection to the temporal lobe, and often involves the cortex and the meninges. PXAs have a favorable prognosis with a 10-year survival probability of >70%, and are WHO grade II neoplasms. Recent observations and studies demonstrate that PXAs are clinically, histologically and genetically distinct. Some PXAs recur and exhibit aggressive clinical behavior. In such cases, certain histological and clinical factors could account for the aggressive behavior. However, the histological features that predict adverse outcome are poorly defined. In the current WHO classification of CNS tumors, there is no option for a high-grade PXA, even if the tumor had numerous recurrences and poor outcome. In this review, we focus on aggressive clinical behavior and anaplasia in PXA, and discuss how our current experience suggests modifications in the current WHO classification. We also review recent discoveries on the molecular characteristics of PXA that could help us better understand their biological behavior.

Consumerism in healthcare can be detrimental to child health: lessons from children with functional abdominal pain

PubMed Central

Lindley, K; Glaser, D; Milla, P

2005-01-01

Aims: To determine prognostic indicators in children with severe functional abdominal pain (FAP) and to test the hypothesis that "healthcare consumerism" in these families might be deleterious to the child. Methods: Retrospective analysis of a cohort of 23 children aged <16 years fulfilling the Rome II diagnostic criteria for FAP during the period December 1997 to February 2001. Poor outcome was defined as continued pain and failure to return to normal functioning >12 months after onset. Results: Poor outcome was associated with refusal to engage with psychological services, involvement of more than three consultants, lodging of a manipulative complaint with hospital management by the child's family, and lack of development of insight into psychosocial influences on symptoms. Three of four adverse prognostic indicators reflected healthcare consumerism by the families. Conclusions: Actions of families who lack insight into their child's illness may perpetuate FAP in childhood. A culture of parental consumerism in healthcare, however well intentioned, needs to be accompanied by robust systems to protect the interests of the child. PMID:15781917

Low Cerebral Blood Volume Identifies Poor Outcome in Stent Retriever Thrombectomy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Protto, Sara, E-mail: sara.protto@pshp.fi; Pienimäki, Juha-Pekka; Seppänen, Janne

BackgroundMechanical thrombectomy (MT) is an efficient treatment of acute stroke caused by large-vessel occlusion. We evaluated the factors predicting poor clinical outcome (3-month modified Rankin Scale, mRS >2) although MT performed with modern stent retrievers.MethodsWe prospectively collected the clinical and imaging data of 105 consecutive anterior circulation stroke patients who underwent MT after multimodal CT imaging. Patients with occlusion of the internal carotid artery and/or middle cerebral artery up to the M2 segment were included. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome and the clinical outcome. Differences between the groups were studied with appropriatemore » statistical tests and binary logistic regression analysis.ResultsLow cerebral blood volume Alberta stroke program early CT score (CBV-ASPECTS) was associated with poor clinical outcome (median 7 vs. 9, p = 0.01). Lower collateral score (CS) significantly predicted poor outcome in regression modelling with CS = 0 increasing the odds of poor outcome 4.4-fold compared to CS = 3 (95% CI 1.27–15.5, p = 0.02). Lower CBV-ASPECTS significantly predicted poor clinical outcome among those with moderate or severe stroke (OR 0.82, 95% CI 0.68–1, p = 0.05) or poor collateral circulation (CS 0–1, OR 0.66, 95% CI 0.48–0.90, p = 0.009) but not among those with mild strokes or good collaterals.ConclusionsCBV-ASPECTS estimating infarct core is a significant predictor of poor clinical outcome among anterior circulation stroke patients treated with MT, especially in the setting of poor collateral circulation and/or moderate or severe stroke.« less

Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) and T2 mapping of talar osteochondral lesions: Indicators of clinical outcomes.

PubMed

Rehnitz, Christoph; Kuni, Benita; Wuennemann, Felix; Chloridis, Dimitrios; Kirwadi, Anand; Burkholder, Iris; Kauczor, Hans-Ulrich; Weber, Marc-André

2017-12-01

To evaluate the utility of delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T 2 mapping in evaluation of type II osteochondral lesions (OCLs) of the talus and define cutoff values for identifying patients with good/poor clinical outcomes. 28 patients (mean age, 42.3 years) underwent T 2 mapping and dGEMRIC at least 1.5 years (mean duration, 3.5 years) after microfracture (n = 12) or conservative (n = 16) treatment for type II OCL. Clinical outcomes were considered good with an American Orthopedic Foot and Ankle Society score ≥80. The T 1 /T 2 -values and indices of repair tissue (RT; cartilage above the OCL) were compared to those of the adjacent normal cartilage (NC) by region-of-interest analysis. The ability of the two methods to discriminate RT from NC was determined by area under the receiver operating characteristics curve (AUC) analysis. The Youden index was maximized for T 1 /T 2 measures for identifying cutoff values indicative of good/poor clinical outcomes. Repair tissue exhibited lower dGEMRIC values (629.83 vs. 738.51 msec) and higher T 2 values (62.07 vs. 40.69 msec) than NC (P < 0.001). T 2 mapping exhibited greater AUC than dGEMRIC (0.88 vs. 0.69; P = 0.0398). All T 1 measures exhibited higher maximized Youden indices than the corresponding T 2 measures. The highest maximized Youden index for T 1difference was observed at a cutoff value of 84 msec (sensitivity, 78%; specificity, 83%). While T 2 mapping is superior to dGEMRIC in discriminating RT, the latter better identifies good/poor clinical outcomes in patients with type II talar OCL. 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1601-1610. © 2017 International Society for Magnetic Resonance in Medicine.

Changes in Case-Mix and Health Outcomes of Medicare Fee-for-Service Beneficiaries and Managed Care Enrollees During the Years 1992-2011.

PubMed

Koroukian, Siran M; Basu, Jayasree; Schiltz, Nicholas K; Navale, Suparna; Bakaki, Paul M; Warner, David F; Dor, Avi; Given, Charles W; Stange, Kurt C

2018-01-01

Recent studies suggest that managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) have become similar in case-mix over time; but comparisons of health outcomes have yielded mixed results. To examine changes in differentials between MCEs and FFSBs both in case-mix and health outcomes over time. Temporal study of the linked Health and Retirement Study (HRS) and Medicare data, comparing case-mix and health outcomes between MCEs and FFSBs across 3 time periods: 1992-1998, 1999-2004, and 2005-2011. We used multivariable analysis, stratified by, and pooled across the study periods. The unit of analysis was the person-wave (n=167,204). HRS participants who were also enrolled in Medicare. Outcome measures included self-reported fair/poor health, 2-year self-rated worse health, and 2-year mortality. Our main covariate was a composite measure of multimorbidity (MM), MM0-MM3, defined as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. The case-mix differential between MCEs and FFSBs persisted over time. Results from multivariable models on the pooled data and incorporating interaction terms between managed care status and study period indicated that MCEs and FFSBs were as likely to die within 2 years from the HRS interview (P=0.073). This likelihood remained unchanged across the study periods. However, MCEs were more likely than FFSBs to report fair/poor health in the third study period (change in probability for the interaction term: 0.024, P=0.008), but less likely to rate their health worse in the last 2 years, albeit at borderline significance (change in probability: -0.021, P=0.059). Despite the persistence of selection bias, the differential in self-reported fair/poor status between MCEs and FFSBs seems to be closing over time.

A preoperative serum signature of CEA+/CA125+/CA19-9 ≥ 1000 U/mL indicates poor outcome to pancreatectomy for pancreatic cancer.

PubMed

Liu, Liang; Xu, Huaxiang; Wang, Wenquan; Wu, Chuntao; Chen, Yong; Yang, Jingxuan; Cen, Putao; Xu, Jin; Liu, Chen; Long, Jiang; Guha, Sushovan; Fu, Deliang; Ni, Quanxing; Jatoi, Aminah; Chari, Suresh; McCleary-Wheeler, Angela L; Fernandez-Zapico, Martin E; Li, Min; Yu, Xianjun

2015-05-01

Pancreatectomy is associated with significant morbidity and unpredictable outcome, with few diagnostic tools to determine, which patients gain the most benefit from this treatment, especially before the operation. This study aimed to define a preoperative signature panel of serum markers to indicate response to pancreatectomy for pancreatic cancer. Over 1000 patients with pancreatic cancer treated at two independent high-volume institutions were included in this study and were divided into three groups, including resected, locally advanced and metastatic. Eight serum tumor markers most commonly used in gastrointestinal cancers were analyzed for patient outcome. Preoperative CA19-9 independently indicated surgical response in pancreatic cancer. Patients with CA19-9 ≥1000 U/mL generally had a poor surgical benefit. However, a subset of these patients still achieved a survival advantage when CA19-9 levels decreased postoperatively. CEA and CA125 in the presence of CA19-9 ≥1000 U/mL could independently predict the non-decrease of CA19-9 postoperatively. The combination of the three markers was useful for predicting a worse surgical outcome with a median survival of 5.1 months vs. 23.0 months (p < 0.001) for the training cohort and 7.0 months vs. 18.2 months (p < 0.001) for the validation cohort and also suggested a higher prevalence of early distant metastasis after surgery. Resected patients with this proposed signature showed no survival advantage over patients in the locally advanced group who did not receive pancreatectomy. Therefore, a preoperative serum signature of CEA(+)/CA125(+)/CA19-9 ≥1000 U/mL is associated with poor surgical outcome and can be used to select appropriate patients with pancreatic cancer for pancreatectomy. © 2014 UICC.

Good outcome rate of 35% in IV-tPA-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke.

PubMed

González, R Gilberto; Furie, Karen L; Goldmacher, Gregory V; Smith, Wade S; Kamalian, Shervin; Payabvash, Seyedmehdi; Harris, Gordon J; Halpern, Elkan F; Koroshetz, Walter J; Camargo, Erica C S; Dillon, William P; Lev, Michael H

2013-11-01

To determine the effect of intravenous tissue plasminogen activator (IV-tPA) on outcomes in patients with severe major anterior circulation ischemic stroke. Prospectively, 649 patients with acute stroke had admission National Institutes of Health stroke scale (NIHSS) scores, noncontrast computed tomography (CT), CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale. IV-tPA treatment decisions were made before CTA, at the time of noncontrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as modified Rankin scale >2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed. Of 649 patients, 188 (29%) patients presented with NIHSS>10, and 64 out of 188 (34%) patients received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes; however, a significant interaction existed between IV-tPA and occlusion (P<0.001). Of the patients who presented with NIHSS>10 with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17 out of 49 patients, 35%) than if they did not (13 out of 77 patients, 17%; P=0.031). The number needed to treat was 7 (95% confidence interval, 3-60). IV-tPA treatment resulted in significantly better outcomes in patients with severely symptomatic stroke with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies.

Septic shock: desperately seeking treatment.

PubMed

Huet, Olivier; Chin-Dusting, Jaye P F

2014-01-01

Septic shock results from the dysregulation of the innate immune response following infection. Despite major advances in fundamental and clinical research, patients diagnosed with septic shock still have a poor prognostic outcome, with a mortality rate of up to 50%. Indeed, the reasons leading to septic shock are still poorly understood. First postulated 30 years ago, the general view of septic shock as an acute and overwhelming inflammatory response still prevails today. Recently, the fact that numerous clinical trials have failed to demonstrate any positive medical outcomes has caused us to question our fundamental understanding of this condition. New and sophisticated technologies now allow us to accurately profile the various stages and contributory components of the inflammatory response defining septic shock, and many studies now report a more complex inflammatory response, particularly during the early phase of sepsis. In addition, novel experimental approaches, using more clinically relevant animal models, to standardize and stratify research outcomes are now being argued for. In the present review, we discuss the most recent findings in relation to our understanding of the underlying mechanisms involved in septic shock, and highlight the attempts made to improve animal experimental models. We also review recent studies reporting promising results with two vastly different therapeutic approaches influencing the renin-angiotensin system and applying mesenchymal stem cells for clinical intervention.

Transcriptomes define distinct subgroups of salivary gland adenoid cystic carcinoma with different driver mutations and outcomes

PubMed Central

Frerich, Candace A.; Brayer, Kathryn J.; Painter, Brandon M.; Kang, Huining; Mitani, Yoshitsugu; El-Naggar, Adel K.; Ness, Scott A.

2018-01-01

The relative rarity of salivary gland adenoid cystic carcinoma (ACC) and its slow growing yet aggressive nature has complicated the development of molecular markers for patient stratification. To analyze molecular differences linked to the protracted disease course of ACC and metastases that form 5 or more years after diagnosis, detailed RNA-sequencing (RNA-seq) analysis was performed on 68 ACC tumor samples, starting with archived, formalin-fixed paraffin-embedded (FFPE) samples up to 25 years old, so that clinical outcomes were available. A statistical peak-finding approach was used to classify the tumors that expressed MYB or MYBL1, which had overlapping gene expression signatures, from a group that expressed neither oncogene and displayed a unique phenotype. Expression of MYB or MYBL1 was closely correlated to the expression of the SOX4 and EN1 genes, suggesting that they are direct targets of Myb proteins in ACC tumors. Unsupervised hierarchical clustering identified a subgroup of approximately 20% of patients with exceptionally poor overall survival (median less than 30 months) and a unique gene expression signature resembling embryonic stem cells. The results provide a strategy for stratifying ACC patients and identifying the high-risk, poor-outcome group that are candidates for personalized therapies. PMID:29484115

The Effect of School-Based Health Clinics on Teenage Pregnancy and Parenting Outcomes: An Integrated Literature Review

ERIC Educational Resources Information Center

Strunk, Julie A.

2008-01-01

Teenage pregnancy outcomes have become an increasing concern in the United States. Education and support of pregnant teens are critical factors that may determine good or poor pregnancy outcomes. Poor outcomes may include low birth weight, developmental delays, and poor academic performance. Although the number of teenagers experiencing pregnancy…

Current Treatment Strategies for Tricuspid Regurgitation.

PubMed

Al-Hijji, Mohammed; Fender, Erin A; El Sabbagh, Abdallah; Holmes, David R

2017-09-14

Tricuspid regurgitation is common; however, recognition and diagnosis, clinical outcomes, and management strategies are poorly defined. Here, we will describe the etiology and natural history of tricuspid regurgitation (TR), evaluate existing surgical outcomes data, and review the evolving field of percutaneous interventions to treat TR. Previously, the only definitive corrective therapy for TR was surgical valve repair or replacement which is associated with significant operative mortality. Advances in percutaneous valve repair techniques are now being translated to the tricuspid valve. These novel interventions may offer a lower-risk alternative treatment in patients at increased surgical risk. Significant TR adversely impacts survival. Surgery remains the only proven therapy for treatment of TR and may be underutilized due to mixed outcomes data. Early experience with percutaneous interventions is promising, but large clinical experience is lacking. Further study will be required before these therapies are introduced into broader clinical practice.

Predictive Factors of Surgical Outcome in Frontal Lobe Epilepsy Explored with Stereoelectroencephalography.

PubMed

Bonini, Francesca; McGonigal, Aileen; Scavarda, Didier; Carron, Romain; Régis, Jean; Dufour, Henry; Péragut, Jean-Claude; Laguitton, Virginie; Villeneuve, Nathalie; Chauvel, Patrick; Giusiano, Bernard; Trébuchon, Agnès; Bartolomei, Fabrice

2017-06-29

Resective surgery established treatment for pharmacoresistant frontal lobe epilepsy (FLE), but seizure outcome and prognostic indicators are poorly characterized and vary between studies. To study long-term seizure outcome and identify prognostic factors. We retrospectively analyzed 42 FLE patients having undergone surgical resection, mostly preceded by invasive recordings with stereoelectroencephalography (SEEG). Postsurgical outcome up to 10-yr follow-up and prognostic indicators were analyzed using Kaplan-Meier analysis and multivariate and conditional inference procedures. At the time of last follow-up, 57.1% of patients were seizure-free. The estimated chance of seizure freedom was 67% (95% confidence interval [CI]: 54-83) at 6 mo, 59% (95% CI: 46-76) at 1 yr, 53% (95% CI: 40-71) at 2 yr, and 46% (95% CI: 32-66) at 5 yr. Most relapses (83%) occurred within the first 12 mo. Multivariate analysis showed that completeness of resection of the epileptogenic zone (EZ) as defined by SEEG was the main predictor of seizure outcome. According to conditional inference trees, in patients with complete resection of the EZ, focal cortical dysplasia as etiology and focal EZ were positive prognostic indicators. No difference in outcome was found in patients with positive vs negative magnetic resonance imaging. Surgical resection in drug-resistant FLE can be a successful therapeutic approach, even in the absence of neuroradiologically visible lesions. SEEG may be highly useful in both nonlesional and lesional FLE cases, because complete resection of the EZ as defined by SEEG is associated with better prognosis. Copyright © 2017 by the Congress of Neurological Surgeons

Medication self-management skills and cognitive impairment in older adults hospitalized for heart failure: A cross-sectional study.

PubMed

Howell, Erik H; Senapati, Alpana; Hsich, Eileen; Gorodeski, Eiran Z

2017-01-01

Cognitive impairment is highly prevalent among older adults (aged ≥65 years) hospitalized for heart failure and has been associated with poor outcomes. Poor medication self-management skills have been associated with poor outcomes in this population as well. The presence and extent of an association between cognitive impairment and poor medication self-management skills in this population has not been clearly defined. We assessed the cognition of consecutive older adults hospitalized for heart failure, in relation to their medication self-management skills. We conducted a cross-sectional study of older adults (aged ≥65 years) who were hospitalized for heart failure and were being discharged home. Prior to discharge, we assessed cognition using the Mini-Cog. We also tested patients' ability to read a pill bottle label, open a pill bottle safety cap, and allocate mock pills to a pill box. Pill allocation performance was assessed quantitatively (counts of errors of omission and commission) and qualitatively (patterns suggestive of knowledge-based mistakes, rule-based mistakes, or skill-based slips). Of 55 participants, 22% were found to have cognitive impairment. Patients with cognitive impairment tended to be older as compared to those without cognitive impairment (mean age = 81 vs 76 years, p = NS). Patients with cognitive impairment had a higher prevalence of inability to read pill bottle label (prevalence ratio = 5.8, 95% confidence interval = 3.2-10.5, p = 0.001) and inability to open pill bottle safety cap (prevalence ratio = 3.3, 95% confidence interval = 1.3-8.4, p = 0.03). While most patients (65%) had pill-allocation errors regardless of cognition, those patients with cognitive impairment tended to have more errors of omission (mean number of errors = 48 vs 23, p = 0.006), as well as more knowledge-based mistakes (75% vs 40%, p = 0.03). There is an association between cognitive impairment and poor medication self-management skills. Medication taking failures due to poor medication self-management skills may be part of the pathway linking cognitive impairment to poor post-discharge outcomes among patients with heart failure transitioning from hospital to home.

Youth and administrator perspectives on transition in Kentucky's state agency schools.

PubMed

Marshall, Amy; Powell, Norman; Pierce, Doris; Nolan, Ronnie; Fehringer, Elaine

2012-01-01

Students, a large percentage with disabilities, are at high risk for poor post-secondary outcomes in state agency education programs. This mixed-methods study describes the understandings of student transitions in state agency education programs from the perspectives of youth and administrators. Results indicated that: transition is more narrowly defined within alternative education programs; key strengths of transition practice are present in nontraditional schools; and the coordination barriers within this fluid inter-agency transition system are most apparent in students' frequent inter-setting transitions between nontraditional and home schools.

Dynamic interaction between fetal adversity and a genetic score reflecting dopamine function on developmental outcomes at 36 months.

PubMed

Bischoff, Adrianne R; Pokhvisneva, Irina; Léger, Étienne; Gaudreau, Hélène; Steiner, Meir; Kennedy, James L; O'Donnell, Kieran J; Diorio, Josie; Meaney, Michael J; Silveira, Patrícia P

2017-01-01

Fetal adversity, evidenced by poor fetal growth for instance, is associated with increased risk for several diseases later in life. Classical cut-offs to characterize small (SGA) and large for gestational age (LGA) newborns are used to define long term vulnerability. We aimed at exploring the possible dynamism of different birth weight cut-offs in defining vulnerability in developmental outcomes (through the Bayley Scales of Infant and Toddler Development), using the example of a gene vs. fetal adversity interaction considering gene choices based on functional relevance to the studied outcome. 36-month-old children from an established prospective birth cohort (Maternal Adversity, Vulnerability, and Neurodevelopment) were classified according to birth weight ratio (BWR) (SGA ≤0.85, LGA >1.15, exploring a wide range of other cut-offs) and genotyped for polymorphisms associated with dopamine signaling (TaqIA-A1 allele, DRD2-141C Ins/Ins, DRD4 7-repeat, DAT1-10- repeat, Met/Met-COMT), composing a score based on the described function, in which hypofunctional variants received lower scores. There were 251 children (123 girls and 128 boys). Using the classic cut-offs (0.85 and 1.15), there were no statistically significant interactions between the neonatal groups and the dopamine genetic score. However, when changing the cut-offs, it is possible to see ranges of BWR that could be associated with vulnerability to poorer development according to the variation in the dopamine function. The classic birth weight cut-offs to define SGA and LGA newborns should be seen with caution, as depending on the outcome in question, the protocols for long-term follow up could be either too inclusive-therefore most costly, or unable to screen true vulnerabilities-and therefore ineffective to establish early interventions and primary prevention.

EFFECT OF STRUCTURED PHYSICAL ACTIVITY ON SLEEP-WAKE BEHAVIORS IN SEDENTARY ELDERS WITH MOBILITY LIMITATIONS

PubMed Central

Vaz Fragoso, Carlos A.; Miller, Michael E.; King, Abby C.; Kritchevsky, Stephen B.; Liu, Christine K.; Myers, Valerie H.; Nadkarni, Neelesh K.; Pahor, Marco; Spring, Bonnie J.; Gill, Thomas M.

2016-01-01

OBJECTIVE To evaluate the effect of structured physical activity on sleep-wake behaviors in sedentary community-dwelling elders with mobility limitations. DESIGN Multicenter, randomized trial of moderate-intensity physical activity versus health education, with sleep-wake behaviors pre-specified as a tertiary outcome over a planned intervention period ranging between 24 and 30 months. SETTING Lifestyle Interventions and Independence in Elder (LIFE) Study. PARTICIPANTS 1635 community-dwelling persons, aged 70–89 years, who were initially sedentary with a Short Physical Performance Battery score <10. MEASUREMENTS Sleep-wake behaviors were evaluated by the Insomnia Severity Index (ISI) (≥8 defined insomnia), Epworth Sleepiness Scale (ESS) (≥10 defined daytime drowsiness), and Pittsburgh Sleep Quality Index (PSQI) (> 5 defined poor sleep quality) — administered at baseline and subsequently at 6, 18, and 30 months. RESULTS The randomized groups were similar on baseline demographic variables, including mean age (79 years) and sex (67% female). Relative to health education, structured physical activity significantly reduced the likelihood of having poor sleep quality (adjusted odds ratios [adjOR] for PSQI >5 of 0.80 [0.68, 0.94]), including a reduction in new cases (adjOR for PSQI >5 of 0.70 [0.54, 0.89]) but not in resolution of prevalent cases (adjOR for PSQI ≤5 of 1.13 [0.90, 1.43]). No significant intervention effects were observed for ISI or ESS. CONCLUSION Structured physical activity reduced the likelihood of developing poor sleep quality (PSQI >5) over the intervention period, when compared with health education, but had no effect on prevalent cases of poor sleep quality, or on sleep-wake behaviors evaluated by the ISI or ESS. These results suggest that the benefit of physical activity in this sample was preventive and limited to sleep-wake behaviors evaluated by the PSQI. PMID:26115386

Effect of Structured Physical Activity on Sleep-Wake Behaviors in Sedentary Elderly Adults with Mobility Limitations.

PubMed

Vaz Fragoso, Carlos A; Miller, Michael E; King, Abby C; Kritchevsky, Stephen B; Liu, Christine K; Myers, Valerie H; Nadkarni, Neelesh K; Pahor, Marco; Spring, Bonnie J; Gill, Thomas M

2015-07-01

To evaluate the effect of structured physical activity on sleep-wake behaviors in sedentary community-dwelling elderly adults with mobility limitations. Multicenter, randomized trial of moderate-intensity physical activity versus health education, with sleep-wake behaviors prespecified as a tertiary outcome over a planned intervention period ranging from 24 to 30 months. Lifestyle Interventions and Independence for Elders Study. Community-dwelling persons aged 70 to 89 who were initially sedentary and had a Short Physical Performance Battery score less than 10 (N = 1,635). Sleep-wake behaviors were evaluated using the Insomnia Severity Index (ISI) (≥8 defined insomnia), Epworth Sleepiness Scale (ESS) (≥10 defined daytime drowsiness), and Pittsburgh Sleep Quality Index (PSQI) (>5 defined poor sleep quality) administered at baseline and 6, 18, and 30 months. The randomized groups were similar in terms of baseline demographic variables, including mean age (79) and sex (67% female). Structured physical activity resulted in a significantly lower likelihood of having poor sleep quality (adjusted odds ratios (aOR) for PSQI >5 = 0.80, 95% confidence interval (CI) = 0.68-0.94), including fewer new cases (aOR for PSQI >5 = 0.70, 95% CI = 0.54-0.89), than health education but not in resolution of prevalent cases (aOR for PSQI ≤5 = 1.13, 95% CI = 0.90-1.43). No significant intervention effects were observed for the ISI or ESS. Structured physical activity resulted in a lower likelihood of developing poor sleep quality (PSQI >5) over the intervention period than health education but had no effect on prevalent cases of poor sleep quality or on sleep-wake behaviors evaluated using the ISI or ESS. These results suggest that the benefit of physical activity in this sample was preventive and limited to sleep-wake behaviors evaluated using the PSQI. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Progressive deficit in isolated pontine infarction: the association with etiological subtype, lesion topography and outcome.

PubMed

Gökçal, Elif; Niftaliyev, Elvin; Baran, Gözde; Deniz, Çiğdem; Asil, Talip

2017-09-01

It is important to predict progressive deficit (PD) in isolated pontine infarction, a relatively common problem of clinical stroke practice. Traditionally, lacunar infarctions are known with their progressive course. However, few studies have analyzed the branch atheromatous disease subtype as a subtype of lacunar infarction, separately. There are also conflicting results regarding the relationship with the topography of lesion and PD. In this study, we classified etiological subtypes and lesion topography in isolated pontine infarction and aimed to investigate the association of etiological subtypes, lesion topography and clinical outcome with PD. We analyzed demographics, laboratory parameters, and risk factors of 120 patients having isolated pontine infarction and admitted within 24 h retrospectively. PD was defined as an increase in the National Institutes of Health Stroke scale ≥2 units in 5 days after onset. Patients were classified as following: large artery disease (LAA), basilar artery branch disease (BABD) and small vessel disease (SVD). Upper, middle and lower pontine infarcts were identified longitudinally. Functional outcome at 3 months was determined according to modified Rankin scores. Of 120 patients, 41.7% of the patients were classified as BABD, 30.8% as SVD and 27.5% as LAA. 23 patients (19.2%) exhibited PD. PD was significantly more frequent in patient with BABD (p 0.006). PD was numerically higher in patients with lower pontine infarction. PD was associated with BABD and poor functional outcome. It is important to discriminate the BABD neuroradiologically from other stroke subtypes to predict PD which is associated with poor functional outcome in patients with isolated pontine infarctions.

Predictors of outcome in acute encephalitis

PubMed Central

Thakur, Kiran T.; Motta, Melissa; Asemota, Anthony O.; Kirsch, Hannah L.; Benavides, David R.; Schneider, Eric B.; McArthur, Justin C.; Geocadin, Romergryko G.

2013-01-01

Objective: To investigate predictors of outcome in patients with all-cause encephalitis receiving care in the intensive care unit. Methods: A retrospective analysis of encephalitis cases at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center was performed. Using multivariate logistic regression analysis, we examined mortality and predictors of good outcome (defined as modified Rankin Scale scores of 1–3) and poor outcome (scores 4 and 5) in those surviving to hospital discharge. Results: In our cohort of 103 patients, the median age was 52 years (interquartile range 26), 52 patients (50.49%) were male, 28 patients (27.18%) had viral encephalitis, 19 (18.45%) developed status epilepticus (SE), 15 (14.56%) had cerebral edema, and 19 (18.45%) died. In our multivariate logistic regression analysis, death was associated with cerebral edema (odds ratio [OR] 18.06, 95% confidence interval [CI] 3.14–103.92), SE (OR 8.16, 95% CI 1.55–43.10), and thrombocytopenia (OR 6.28, 95% CI 1.41–28.03). Endotracheal intubation requirement with ventilator support was highly correlated with death (95%). In addition, in those patients who survived, viral, nonviral, and unknown causes of encephalitis were less likely to have a poor outcome at hospital discharge compared with an autoimmune etiology (viral encephalitis: OR 0.09, 95% CI 0.01–0.57; nonviral encephalitis: OR 0.02, 95% CI 0.01–0.31; unknown etiology: OR 0.18, 95% CI 0.04–0.91). Conclusions: Our study suggests that predictors of death in patients with encephalitis comprise potentially reversible conditions including cerebral edema, SE, and thrombocytopenia. Further prospective studies are needed to determine whether aggressive management of these complications in patients with encephalitis improves outcome. PMID:23892708

Antenatal testing to predict outcome in pregnancies with unexplained antepartum haemorrhage.

PubMed

Ajayi, R A; Soothill, P W; Campbell, S; Nicolaides, K H

1992-02-01

To investigate whether Doppler studies of placental perfusion and antenatal tests for fetal hypoxia can identify reduced placental functional reserve in women with unexplained antepartum haemorrhage (APH). A prospective, longitudinal study. Fetal Surveillance Unit, King's College Hospital, London. 48 women with bleeding from the genital tract after 26 weeks gestation without a clinical diagnosis of abruption or ultrasound evidence of placenta praevia. Fetal surveillance by Doppler measurements of the umbilical and uterine arteries, biophysical profile scoring and computerized measurement of the mean minute range of FHR variation. A poor outcome was defined by one or more of the following: (i) birthweight greater than 2SD below the normal mean for gestational age and sex, (ii) abnormal FHR pattern in labour resulting in operative delivery, (iii) umbilical vein blood pH at delivery less than 7.15, (iv) a 5-min Apgar score less than 7. Fifteen of the 48 pregnancies had a poor outcome; seven occurred in the 10 women delivered preterm (less than 37 weeks) and eight in the 36 women delivered between 37 and 42 weeks. Two women were delivered after 42 weeks and both infants had a good outcome. The results of Doppler studies of uterine and umbilical arteries, fetal biophysical profile or FHR variation were not significantly different between the two outcome groups. The 36 pregnancies delivered between 37 and 42 weeks were matched retrospectively for maternal age, parity and race with 36 pregnancies without APH; there was no significant difference in outcome between the women with unexplained APH and the matched comparison group. Morbidity related to unexplained APH is associated with preterm delivery rather than with damage to utero-placental function.

Off-Hour Admission and Outcomes in Patients with Acute Intracerebral Hemorrhage in the INTERACT2 Trial.

PubMed

Sato, Shoichiro; Arima, Hisatomi; Heeley, Emma; Hirakawa, Yoichiro; Delcourt, Candice; Lindley, Richard I; Robinson, Thompson; Huang, Yining; Morgenstern, Lewis; Stapf, Christian; Wang, Jiguang; Chalmers, John; Anderson, Craig S

2015-01-01

Conflicting data exist of an association between off-hour (weekend, holiday, or night-time) hospital admission and adverse outcome in intracerebral hemorrhage (ICH). We determined the association between off-hour admissions and poor clinical outcome, and of any differential effect of early intensive blood pressure (BP) lowering treatment between off- and on-hour admissions, among participants of the Intensive BP Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Subsidiary analysis of INTERACT2, a multinational, multicenter, clinical trial of patients with spontaneous ICH with elevated systolic BP, randomly assigned to intensive (target systolic BP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Primary outcome was death or major disability (modified Rankin scale of 3-6) at 90 days. Off-hour admission was defined as night-time (4:30 p.m. to 8:30 a.m.) on weekdays, weekends (Saturday and Sunday), and public holidays in each participating country. Of 2,794 patients with information on the primary outcome, 1,770 (63%) were admitted to study centers during off-hours. Off-hour admission was not associated with risk of poor outcome at 90 days (53% off-hour vs. 55% on-hour; p = 0.49), even after adjustment for comorbid risk factors (odds ratio 0.92; 95% CI 0.76-1.12). Consistency exists in the effects of intensive BP lowering between off- and on-hour admission (p = 0.85 for homogeneity). Off-hour admission was not associated with increased risks of death or major disability among trial protocol participants with acute ICH. Intensive BP lowering can provide similar treatment effect irrespective of admission hours. © 2015 S. Karger AG, Basel.

Advances in Risk Classification and Treatment Strategies for Neuroblastoma

PubMed Central

Pinto, Navin R.; Applebaum, Mark A.; Volchenboum, Samuel L.; Matthay, Katherine K.; London, Wendy B.; Ambros, Peter F.; Nakagawara, Akira; Berthold, Frank; Schleiermacher, Gudrun; Park, Julie R.; Valteau-Couanet, Dominique; Pearson, Andrew D.J.

2015-01-01

Risk-based treatment approaches for neuroblastoma have been ongoing for decades. However, the criteria used to define risk in various institutional and cooperative groups were disparate, limiting the ability to compare clinical trial results. To mitigate this problem and enhance collaborative research, homogenous pretreatment patient cohorts have been defined by the International Neuroblastoma Risk Group classification system. During the past 30 years, increasingly intensive, multimodality approaches have been developed to treat patients who are classified as high risk, whereas patients with low- or intermediate-risk neuroblastoma have received reduced therapy. This treatment approach has resulted in improved outcome, although survival for high-risk patients remains poor, emphasizing the need for more effective treatments. Increased knowledge regarding the biology and genetic basis of neuroblastoma has led to the discovery of druggable targets and promising, new therapeutic approaches. Collaborative efforts of institutions and international cooperative groups have led to advances in our understanding of neuroblastoma biology, refinements in risk classification, and stratified treatment strategies, resulting in improved outcome. International collaboration will be even more critical when evaluating therapies designed to treat small cohorts of patients with rare actionable mutations. PMID:26304901

Competing in value-based health care: keys to winning the foot race.

PubMed

Hamid, Kamran S; Nwachukwu, Benedict U; Ellis, Scott J

2014-05-01

The US health care system is transitioning to a value-based model of health care in which providers will be rewarded for delivering services that achieve excellent clinical outcomes with efficient cost utilization. The concept of "value" in health care (defined as health outcomes achieved per dollar spent) is rapidly spreading as physicians and health systems brace for the paradigm shift from "fee-for-volume" to "fee-for-value" reimbursement. What constitutes good value versus poor value in health care remains nebulous at this time. Various specialties across medicine and within orthopaedics are seeking to better demonstrate value delivered to patients, payers, and policy makers. The objective of this article is to develop a framework for defining and measuring value in foot and ankle surgery. In this new era of health care, we believe that a working knowledge of value and its determinants will be imperative for foot and ankle surgeons to unify research and quality improvement efforts so as to demonstrate the value of services rendered within the subspecialty. Level V, expert opinion.

Acute kidney injury after cardiac arrest.

PubMed

Tujjar, Omar; Mineo, Giulia; Dell'Anna, Antonio; Poyatos-Robles, Belen; Donadello, Katia; Scolletta, Sabino; Vincent, Jean-Louis; Taccone, Fabio Silvio

2015-04-17

The aim of this study was to evaluate the incidence and determinants of AKI in a large cohort of cardiac arrest patients. We reviewed all patients admitted, for at least 48 hours, to our Dept. of Intensive Care after CA between January 2008 and October 2012. AKI was defined as oligo-anuria (daily urine output <0.5 ml/kg/h) and/or an increase in serum creatinine (≥0.3 mg/dl from admission value within 48 hours or a 1.5 time from baseline level). Demographics, comorbidities, CA details, and ICU interventions were recorded. Neurological outcome was assessed at 3 months using the Cerebral Performance Category scale (CPC 1-2 = favorable outcome; 3-5 = poor outcome). A total of 199 patients were included, 85 (43%) of whom developed AKI during the ICU stay. Independent predictors of AKI development were older age, chronic renal disease, higher dose of epinephrine, in-hospital CA, presence of shock during the ICU stay, a low creatinine clearance (CrCl) on admission and a high cumulative fluid balance at 48 hours. Patients with AKI had higher hospital mortality (55/85 vs. 57/114, p = 0.04), but AKI was not an independent predictor of poor 3-month neurological outcome. AKI occurred in more than 40% of patients after CA. These patients had more severe hemodynamic impairment and needed more aggressive ICU therapy; however the development of AKI did not influence neurological recovery.

Septic arthritis associated with systemic sepsis.

PubMed

Jung, Sung-Weon; Kim, Dong-Hee; Shin, Sung-Jin; Kang, Byoung-Youl; Eho, Yil-Ju; Yang, Seong-Wook

2018-01-01

Septic arthritis presents with good joint function, but sometimes leads to poor outcomes. Concurrent systemic sepsis has been regarded as the poor outcome, and the exact cause remains unclear. This paper was performed to identify factors associated with concurrent systemic sepsis and to research results to predict poor outcomes in patients with septic arthritis. Laboratory and medical data were reviewed for 137 adults with acute septic arthritis who underwent open or arthroscopic surgical debridement at our institution between January 2005 and December 2014. The patients were divided according to whether they had septic arthritis alone (Group A) or in combination with systemic sepsis (Group B). Systemic sepsis was defined as two more systemic inflammatory signs in response to an infectious process. Patient characteristics, laboratory findings, synovial fluid findings and cultures, and surgical results were compared between two groups. Of the 137 patients, 41 (29.9%) had initial systemic sepsis at the diagnosis of septic arthritis. Independent t test revealed that duration of prodromal symptom (p = 0.012), serum neutrophil percent (p = 0.008), C-reactive protein (p = 0.001), Charlson comorbidity index (p = 0.001), positive culture in synovial fluid (p = 0.001), and methicillin-sensitive Staphylococcus aureus (MSSA) isolate in synovial fluid (p = 0.001) had significant correlations with the group B. Repeated debridement was performed for those who had recurrence of infection, and this procedure was more often in group B (23 versus 21 joints, 23.9 versus 51.2%, p = 0.012). Progression of arthritis occurred more often in group B (16 versus 17 joints, 16.7 versus 41.5%, p = 0.001). Septic arthritis combined with systemic sepsis was related to duration of prodromal symptom, serum neutrophil percent, C-reactive protein, Charlson comorbidity index, positive culture in synovial fluid, and a MSSA isolate in synovial fluid. Concurrent systemic sepsis led to poor outcomes in patients with septic arthritis in terms of recurrence of infection and progression of arthritis. III Case control study.

Identifying the poorest older Americans.

PubMed

Fisher, Jonathan D; Johnson, David S; Marchand, Joseph T; Smeeding, Timothy M; Torrey, Barbara B

2009-11-01

Public policies target a subset of the population defined as poor or needy, but rarely are people poor or needy in the same way. This is particularly true among older adults. This study investigates poverty among older adults in order to identify who among them is financially worst off. We use 20 years of data from the Consumer Expenditure Survey to examine the income and consumption of older Americans. The poverty rate is cut in fourth if both income and consumption are used to define poverty. Those most likely to be poor defined by only income but not poor defined by income and consumption together are married, White, and homeowners and have a high school diploma or higher. The income poor alone display sufficient assets to raise consumption above poverty thresholds, whereas the consumption poor are shown to have income just above the poverty threshold and few assets. The poorest among the older population are those who are income and consumption poor. Understanding the nature of this double poverty population is important in measuring the success of future public policies to reduce poverty among this group.

More than science: family learning in a Mexican science museum

NASA Astrophysics Data System (ADS)

Briseño-Garzón, Adriana

2013-06-01

Latin American audiences living in their countries of origin are poorly understood as museum learners due to the scarcity of research in this field. Through a case study approach, I investigate and report on the ways of learning of 20 Mexican family groups. In particular, I examine the influence of the Mexican sociocultural context on the participant family members' learning outcomes from a Mexican science museum. Conducted in Universum Museo de las Ciencias, a science museum located in Mexico City, this research study is based on the premise that understanding the role of the sociocultural elements of learning is essential to understanding the nature of learning in museums. The cognitive and social outcomes of the participants are discussed in the light of the sociocultural elements that define Mexicans as museum learners.

Developing from child to adult: Risk factors for poor psychosocial outcome in adolescents and young adults with epilepsy.

PubMed

Geerlings, R P J; Aldenkamp, A P; Gottmer-Welschen, L M C; de With, P H N; Zinger, S; van Staa, A L; de Louw, A J A

2015-10-01

Childhood-onset epilepsy during the years of transition to adulthood may affect normal social, physical, and mental development, frequently leading to psychosocial and health-related problems in the long term. This study aimed to describe the main characteristics of patients in transition and to identify risk factors for poor psychosocial outcome in adolescents and young adults with epilepsy. Patients with epilepsy, 15-25years of age, who visited the Kempenhaeghe Epilepsy Transition Clinic from March 2012 to December 2014 were included (n=138). Predefined risk scores for medical, educational/occupational status, and independence/separation/identity were obtained, along with individual risk profile scores for poor psychosocial outcome. Multivariate linear regression analysis and discriminant analysis were used to identify variables associated with an increased risk of poor long-term psychosocial outcome. Demographic, epilepsy-related, and psychosocial variables associated with a high risk of poor long-term outcome were lower intelligence, higher seizure frequency, ongoing seizures, and an unsupportive and unstable family environment. Using the aforementioned factors in combination, we were able to correctly classify the majority (55.1%) of the patients regarding their risk of poor psychosocial outcome. Our analysis may allow early identification of patients at high risk of prevention, preferably at pretransition age. The combination of a chronic refractory epilepsy and an unstable family environment constitutes a higher risk of transition problems and poor outcome in adulthood. As a consequence, early interventions should be put into place to protect youth at risk of poor transition outcome. Copyright © 2015 Elsevier Inc. All rights reserved.

Logic Learning Machine creates explicit and stable rules stratifying neuroblastoma patients

PubMed Central

2013-01-01

Background Neuroblastoma is the most common pediatric solid tumor. About fifty percent of high risk patients die despite treatment making the exploration of new and more effective strategies for improving stratification mandatory. Hypoxia is a condition of low oxygen tension occurring in poorly vascularized areas of the tumor associated with poor prognosis. We had previously defined a robust gene expression signature measuring the hypoxic component of neuroblastoma tumors (NB-hypo) which is a molecular risk factor. We wanted to develop a prognostic classifier of neuroblastoma patients' outcome blending existing knowledge on clinical and molecular risk factors with the prognostic NB-hypo signature. Furthermore, we were interested in classifiers outputting explicit rules that could be easily translated into the clinical setting. Results Shadow Clustering (SC) technique, which leads to final models called Logic Learning Machine (LLM), exhibits a good accuracy and promises to fulfill the aims of the work. We utilized this algorithm to classify NB-patients on the bases of the following risk factors: Age at diagnosis, INSS stage, MYCN amplification and NB-hypo. The algorithm generated explicit classification rules in good agreement with existing clinical knowledge. Through an iterative procedure we identified and removed from the dataset those examples which caused instability in the rules. This workflow generated a stable classifier very accurate in predicting good and poor outcome patients. The good performance of the classifier was validated in an independent dataset. NB-hypo was an important component of the rules with a strength similar to that of tumor staging. Conclusions The novelty of our work is to identify stability, explicit rules and blending of molecular and clinical risk factors as the key features to generate classification rules for NB patients to be conveyed to the clinic and to be used to design new therapies. We derived, through LLM, a set of four stable rules identifying a new class of poor outcome patients that could benefit from new therapies potentially targeting tumor hypoxia or its consequences. PMID:23815266

Logic Learning Machine creates explicit and stable rules stratifying neuroblastoma patients.

PubMed

Cangelosi, Davide; Blengio, Fabiola; Versteeg, Rogier; Eggert, Angelika; Garaventa, Alberto; Gambini, Claudio; Conte, Massimo; Eva, Alessandra; Muselli, Marco; Varesio, Luigi

2013-01-01

Neuroblastoma is the most common pediatric solid tumor. About fifty percent of high risk patients die despite treatment making the exploration of new and more effective strategies for improving stratification mandatory. Hypoxia is a condition of low oxygen tension occurring in poorly vascularized areas of the tumor associated with poor prognosis. We had previously defined a robust gene expression signature measuring the hypoxic component of neuroblastoma tumors (NB-hypo) which is a molecular risk factor. We wanted to develop a prognostic classifier of neuroblastoma patients' outcome blending existing knowledge on clinical and molecular risk factors with the prognostic NB-hypo signature. Furthermore, we were interested in classifiers outputting explicit rules that could be easily translated into the clinical setting. Shadow Clustering (SC) technique, which leads to final models called Logic Learning Machine (LLM), exhibits a good accuracy and promises to fulfill the aims of the work. We utilized this algorithm to classify NB-patients on the bases of the following risk factors: Age at diagnosis, INSS stage, MYCN amplification and NB-hypo. The algorithm generated explicit classification rules in good agreement with existing clinical knowledge. Through an iterative procedure we identified and removed from the dataset those examples which caused instability in the rules. This workflow generated a stable classifier very accurate in predicting good and poor outcome patients. The good performance of the classifier was validated in an independent dataset. NB-hypo was an important component of the rules with a strength similar to that of tumor staging. The novelty of our work is to identify stability, explicit rules and blending of molecular and clinical risk factors as the key features to generate classification rules for NB patients to be conveyed to the clinic and to be used to design new therapies. We derived, through LLM, a set of four stable rules identifying a new class of poor outcome patients that could benefit from new therapies potentially targeting tumor hypoxia or its consequences.

Methods of defining the non-inferiority margin in randomized, double-blind controlled trials: a systematic review.

PubMed

Althunian, Turki A; de Boer, Anthonius; Klungel, Olaf H; Insani, Widya N; Groenwold, Rolf H H

2017-03-07

There is no consensus on the preferred method for defining the non-inferiority margin in non-inferiority trials, and previous studies showed that the rationale for its choice is often not reported. This study investigated how the non-inferiority margin is defined in the published literature, and whether its reporting has changed over time. A systematic PubMed search was conducted for all published randomized, double-blind, non-inferiority trials from January 1, 1966, to February 6, 2015. The primary outcome was the number of margins that were defined by methods other than the historical evidence of the active comparator. This was evaluated for a time trend. We also assessed the under-reporting of the methods of defining the margin as a secondary outcome, and whether this changed over time. Both outcomes were analyzed using a Poisson log-linear model. Predictors for better reporting of the methods, and the use of the fixed-margin method (one of the historical evidence methods) were also analyzed using logistic regression. Two hundred seventy-three articles were included, which account for 273 non-inferiority margins. There was no statistically significant difference in the number of margins that were defined by other methods compared to those defined based on the historical evidence (ratio 2.17, 95% CI 0.86 to 5.82, p = 0.11), and this did not change over time. The number of margins for which methods were unreported was similar to those with reported methods (ratio 1.35, 95% CI 0.76 to 2.43, p = 0.31), with no change over time. The method of defining the margin was less often reported in journals with low-impact factors compared to journals with high-impact factors (OR 0.20; 95% CI 0.10 to 0.37, p < 0.0001). The publication of the FDA draft guidance in 2010 was associated with increased reporting of the fixed-margin method (after versus before 2010) (OR 3.54; 95% CI 1.12 to 13.35, p = 0.04). Non-inferiority margins are not commonly defined based on the historical evidence of the active comparator, and they are poorly reported. Authors, reviewers, and editors need to take notice of reporting this critical information to allow for better judgment of non-inferiority trials.

Extending the time window for endovascular procedures according to collateral pial circulation.

PubMed

Ribo, Marc; Flores, Alan; Rubiera, Marta; Pagola, Jorge; Sargento-Freitas, Joao; Rodriguez-Luna, David; Coscojuela, Pilar; Maisterra, Olga; Piñeiro, Socorro; Romero, Francisco J; Alvarez-Sabin, Jose; Molina, Carlos A

2011-12-01

Good collateral pial circulation (CPC) predicts a favorable outcome in patients undergoing intra-arterial procedures. We aimed to determine if CPC status may be used to decide about pursuing recanalization efforts. Pial collateral score (0-5) was determined on initial angiogram. We considered good CPC when pial collateral score<3, defined total time of ischemia (TTI) as onset-to-recanalization time, and clinical improvement>4-point decline in admission-discharge National Institutes of Health Stroke Scale. We studied CPC in 61 patients (31 middle cerebral artery, 30 internal carotid artery). Good CPC patients (n=21 [34%]) had lower discharge National Institutes of Health Stroke Scale score (7 versus 21; P=0.02) and smaller infarcts (56 mL versus 238 mL; P<0.001). In poor CPC patients, a receiver operating characteristic curve defined a TTI cutoff point<300 minutes (sensitivity 67%, specificity 75%) that better predicted clinical improvement (TTI<300: 66.7% versus TTI>300: 25%; P=0.05). For good CPC patients, no temporal cutoff point could be defined. Although clinical improvement was similar for patients recanalizing within 300 minutes (poor CPC: 60% versus good CPC: 85.7%; P=0.35), the likelihood of clinical improvement was 3-fold higher after 300 minutes only in good CPC patients (23.1% versus 90.1%; P=0.01). Similarly, infarct volume was reduced 7-fold in good as compared with poor CPC patients only when TTI>300 minutes (TTI<300: poor CPC: 145 mL versus good CPC: 93 mL; P=0.56 and TTI>300: poor CPC: 217 mL versus good CPC: 33 mL; P<0.01). After adjusting for age and baseline National Institutes of Health Stroke Scale score, TTI<300 emerged as an independent predictor of clinical improvement in poor CPC patients (OR, 6.6; 95% CI, 1.01-44.3; P=0.05) but not in good CPC patients. In a logistic regression, good CPC independently predicted clinical improvement after adjusting for TTI, admission National Institutes of Health Stroke Scale score, and age (OR, 12.5; 95% CI, 1.6-74.8; P=0.016). Good CPC predicts better clinical response to intra-arterial treatment beyond 5 hours from onset. In patients with stroke receiving endovascular treatment, identification of good CPC may help physicians when considering pursuing recanalization efforts in late time windows.

Equity monitoring for social marketing: use of wealth quintiles and the concentration index for decision making in HIV prevention, family planning, and malaria programs.

PubMed

Chakraborty, Nirali M; Firestone, Rebecca; Bellows, Nicole

2013-01-01

The majority of social marketing programs are intended to reach the poor. It is therefore essential that social marketing organizations monitor the health equity of their programs and improve targeting when the poor are not being reached. Current measurement approaches are often insufficient for decision making because they fail to show a program's ability to reach the poor and demonstrate progress over time. Further, effective program equity metrics should be benchmarked against a national reference population and consider exposure, not just health outcomes, to measure direct results of implementation. This study compares two measures of health equity, concentration indices and wealth quintiles, using a defined reference population, and considers benefits of both measures together to inform programmatic decision making. Three datasets from recent cross-sectional behavioral surveys on malaria, HIV, and family planning from Nepal and Burkina Faso were used to calculate concentration indices and wealth quintiles. Each sample was standardized to national wealth distributions based on recent Demographic and Health Surveys. Wealth quintiles were generated and concentration indices calculated for health outcomes and program exposure in each sample. Chi-square and t-tests were used to assess statistical significance of results. Reporting wealth quintiles showed that recipients of Population Services International (PSI) interventions were wealthier than national populations. Both measures indicated that desirable health outcomes were usually concentrated among wealthier populations. Positive and significant concentration indices in all three surveys indicated that wealth and program exposure were correlated; however this relationship was not necessarily linear. In analyzing the equity of modern contraceptive use stratified by exposure to family planning messages in Nepal, the outcome was equitable (concentration index = 0.006, p = 0.68) among the exposed, while the wealthy were more likely to use modern contraceptives (concentration index = 0.071, p < 0.01) among the unexposed. Using wealth quintiles and concentration indices together for equity monitoring improves usability of findings for decision making. Applying both metrics, and analyzing equity of exposure along with health outcomes, provides results that have statistical and programmatic significance. Benchmarking equity data against national data improves generalizability. This approach benefits social marketers and global health implementers to improve strategic decision making and programs' ability to reach the poor.

Equity monitoring for social marketing: use of wealth quintiles and the concentration index for decision making in HIV prevention, family planning, and malaria programs

PubMed Central

2013-01-01

Background The majority of social marketing programs are intended to reach the poor. It is therefore essential that social marketing organizations monitor the health equity of their programs and improve targeting when the poor are not being reached. Current measurement approaches are often insufficient for decision making because they fail to show a program's ability to reach the poor and demonstrate progress over time. Further, effective program equity metrics should be benchmarked against a national reference population and consider exposure, not just health outcomes, to measure direct results of implementation. This study compares two measures of health equity, concentration indices and wealth quintiles, using a defined reference population, and considers benefits of both measures together to inform programmatic decision making. Methods Three datasets from recent cross-sectional behavioral surveys on malaria, HIV, and family planning from Nepal and Burkina Faso were used to calculate concentration indices and wealth quintiles. Each sample was standardized to national wealth distributions based on recent Demographic and Health Surveys. Wealth quintiles were generated and concentration indices calculated for health outcomes and program exposure in each sample. Chi-square and t-tests were used to assess statistical significance of results. Results Reporting wealth quintiles showed that recipients of Population Services International (PSI) interventions were wealthier than national populations. Both measures indicated that desirable health outcomes were usually concentrated among wealthier populations. Positive and significant concentration indices in all three surveys indicated that wealth and program exposure were correlated; however this relationship was not necessarily linear. In analyzing the equity of modern contraceptive use stratified by exposure to family planning messages in Nepal, the outcome was equitable (concentration index = 0.006, p = 0.68) among the exposed, while the wealthy were more likely to use modern contraceptives (concentration index = 0.071, p < 0.01) among the unexposed. Conclusions Using wealth quintiles and concentration indices together for equity monitoring improves usability of findings for decision making. Applying both metrics, and analyzing equity of exposure along with health outcomes, provides results that have statistical and programmatic significance. Benchmarking equity data against national data improves generalizability. This approach benefits social marketers and global health implementers to improve strategic decision making and programs' ability to reach the poor. PMID:23902715

Approach to evaluation of fever in ambulatory cancer patients receiving chemotherapy: A systematic review.

PubMed

Krzyzanowska, M K; Walker-Dilks, C; Morris, A M; Gupta, R; Halligan, R; Kouroukis, C T; McCann, K; Atzema, C L

2016-12-01

To define the optimal model of care for patients receiving outpatient chemotherapy who experience a fever. Fever is a common symptom in patients receiving chemotherapy, but the approach to evaluation of fever is not standardized. We conducted a search for existing guidelines and a systematic review of the primary literature from database inception to November 2015. Full-text reports and conference abstracts were considered for inclusion. The search focused on the following topics: the relationship between temperature and poor outcome; predictors for the development of febrile neutropenia (FN); the timing, location, and personnel involved in fever assessment; and the provision of information to patients receiving chemotherapy. Eight guidelines and 38 studies were included. None of the guidelines were directly relevant to the target population because they dealt primarily with the management of FN after diagnosis. The primary studies tended to include fever as one of many symptoms assessed in the setting of chemotherapy. Temperature level was a weak predictor of poor outcomes. We did not find validated prediction models for identifying patients at risk of FN among patients receiving chemotherapy. Several studies presented approaches to symptom management that included fever among the symptoms, but results were not mature enough to merit widespread adoption. Despite the frequency and risks of fever in the setting of chemotherapy, there is limited evidence to define who needs urgent assessment, where the assessment should be performed, and how quickly. Future research in this area is greatly needed to inform new models of care. Copyright © 2016 Elsevier Ltd. All rights reserved.

Increased household financial strain, the Great Recession and child health-findings from the UK Millennium Cohort Study.

PubMed

McKenna, Caoimhe; Law, Catherine; Pearce, Anna

2017-03-09

There is a growing body of evidence associating financial strain (FS) with poor health but most of this research has been cross-sectional and adult-focused. During the 'Great Recession' many UK households experienced increased FS. The primary aim of this study was to determine the impact of increased FS on child health. We analysed the Millennium Cohort Study, a longitudinal study of children born in the UK between 2000 and 2002. Surveys at 7 years (T1, 2008) and 11 years (T2, 2012) spanned the 'Great Recession'. Three measures of increased FS were defined; 'became income poor' (self-reported household income dropped below the 'poverty line' between T1 and T2); 'developed difficulty managing' (parental report of being 'financially comfortable' at T1 and finding it 'difficult to manage' at T2); 'felt worse off' (parental report of feeling financially 'worse off' at T2 compared with T1). Poisson regression was used to estimate risk ratios (RR), adjusted risk ratios (aRR) and 95% CIs for six child health outcomes: measured overweight/obesity, problematic behaviour as scored by parents and teachers, and parental reports of fair/poor general health, long-standing illness and bedwetting at T2 (N=13 112). In subanalyses we limited our sample to those who were above the poverty line at T2. Compared with those who were not financially strained at both time points, children in households which experienced increased FS were at an increased risk of all unhealthy outcomes examined. In most cases, these increased risks persisted after adjustment for confounding and when limiting the sample to those above the poverty line. FS is associated with a range of new or continued poor child health outcomes. During times of widespread economic hardship, such as the 'Great Recession', measures should be taken to buffer children and their families from the impact of FS, and these should not be limited to those who are income poor. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Optimizing the pretransplant regimen for autologous stem cell transplantation in acute myelogenous leukemia: Better outcomes with busulfan and melphalan compared with busulfan and cyclophosphamide in high risk patients autografted in first complete remission: A study from the acute leukemia working party of the EBMT.

PubMed

Gorin, Norbert Claude; Labopin, Myriam; Blaise, Didier; Dumas, Pierre-Yves; Pabst, Thomas; Trisolini, Silvia Maria; Arcese, William; Houhou, Mohamed; Mohty, Mohamad; Nagler, Arnon

2018-04-12

Autologous stem cell transplantation remains a clinical option to consolidate some adult patients with acute myelogenous leukemia (AML) in first complete remission (CR1). In a small cohort of patients, we have previously shown better outcomes following Busulfan and Melphalan (BUMEL) over Busulfan and Cyclophosphamide (BUCY). To identify the subpopulations that might get the highest benefit with BUMEL, we designed a larger study. All adult patients with primary AML and available cytogenetics, autografted from January 2000 to December 2016 in CR1, were included: 1137 patients received BUCY and 512 BUMEL. All factors differing in distribution between the 2 conditioning groups were introduced in multivariate analyzes. In a primary analysis, we found an interaction between conditioning and the poor risk group defined as poor cytogenetics and/or presence of the FLT3-ITD mutation. During analysis of the poor risk group, 176 patients received BUCY and 62 BUMEL. BUMEL was associated with a lower RI at 5 years (53% versus 69%, HR: 0.52, P = .002), a better Leukaemia-free survival (LFS) (42% versus 25%, HR: 0.54, P = .002) and a better OS (54% versus 36%, HR: 0.61, P = .02). During analysis of the non poor risk group, 961 patients received BUCY and 450 BUMEL. At 5 years, the RI was 50% and 47%, the LFS 45% and 48% and the OS 56% and 60% respectively, with no significant difference. We conclude that BUMEL is the preferable conditioning regimen for the poor risk leukemic patients, while in AML patients without poor risk cytogenetics or FLT3 both conditioning regimens are valid. © 2018 Wiley Periodicals, Inc.

Incidence, predictors and clinical outcomes of residual stenosis after aortic valve-in-valve.

PubMed

Bleiziffer, Sabine; Erlebach, Magdalena; Simonato, Matheus; Pibarot, Philippe; Webb, John; Capek, Lukas; Windecker, Stephan; George, Isaac; Sinning, Jan-Malte; Horlick, Eric; Napodano, Massimo; Holzhey, David M; Petursson, Petur; Cerillo, Alfredo; Bonaros, Nikolaos; Ferrari, Enrico; Cohen, Mauricio G; Baquero, Giselle; Jones, Tara L; Kalra, Ankur; Reardon, Michael J; Chhatriwalla, Adnan; Gama Ribeiro, Vasco; Alnasser, Sami; Van Mieghem, Nicolas M; Rustenbach, Christian Jörg; Schofer, Joachim; Garcia, Santiago; Zeus, Tobias; Champagnac, Didier; Bekeredjian, Raffi; Kornowski, Ran; Lange, Rüdiger; Dvir, Danny

2018-05-01

We aimed to analyse the incidence of prosthesis-patient mismatch (PPM) and elevated gradients after aortic valve in valve (ViV), and to evaluate predictors and associations with clinical outcomes of this adverse event. A total of 910 aortic ViV patients were investigated. Elevated residual gradients were defined as ≥20 mm Hg. PPM was identified based on the indexed effective orifice area (EOA), measured by echocardiography, and patient body mass index (BMI). Moderate and severe PPM (cases) were defined by European Association of Cardiovascular Imaging (EACVI) criteria and compared with patients without PPM (controls). Moderate or greater PPM was found in 61% of the patients, and severe in 24.6%. Elevated residual gradients were found in 27.9%. Independent risk factors for the occurrence of lower indexed EOA and therefore severe PPM were higher gradients of the failed bioprosthesis at baseline (unstandardised beta -0.023; 95% CI -0.032 to -0.014; P<0.001), a stented (vs a stentless) surgical bioprosthesis (unstandardised beta -0.11; 95% CI -0.161 to -0.071; P<0.001), higher BMI (unstandardised beta -0.01; 95% CI -0.013 to -0.007; P<0.001) and implantation of a SAPIEN/SAPIEN XT/SAPIEN 3 transcatheter device (unstandardised beta -0.064; 95% CI -0.095 to -0.032; P<0.001). Neither severe PPM nor elevated gradients had an association with VARC II-defined outcomes or 1-year survival (90.9% severe vs 91.5% moderate vs 89.3% none, P=0.44). Severe PPM and elevated gradients after aortic ViV are very common but were not associated with short-term survival and clinical outcomes. The long-term effect of poor post-ViV haemodynamics on clinical outcomes requires further evaluation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Unacceptable treatment outcomes and associated factors among India's initial cohorts of multidrug-resistant tuberculosis (MDR-TB) patients under the revised national TB control programme (2007-2011): Evidence leading to policy enhancement.

PubMed

Parmar, Malik M; Sachdeva, Kuldeep Singh; Dewan, Puneet K; Rade, Kiran; Nair, Sreenivas A; Pant, Rashmi; Khaparde, Sunil D

2018-01-01

Globally, India has the world's highest burden of multidrug-resistant tuberculosis (MDR-TB). Programmatic Management of Drug Resistant TB (PMDT) in India began in 2007 and nationwide coverage was achieved in early 2013. Poor initial microbiological outcomes under the Revised National Tuberculosis Control Programme (RNTCP) prompted detailed analysis. This is the first study on factors significantly associated with poor outcomes in MDR-TB patients treated under the RNTCP. To evaluate initial sputum culture conversion, culture reversion and final treatment outcomes among MDR-TB patients registered in India from 2007 to early 2011 who were treated with a standard 24-month regimen under daily-observed treatment. This is a retrospective cohort study. Clinical and microbiological data were abstracted from PMDT records. Initial sputum culture conversion, culture reversion and treatment outcomes were defined by country adaptation of the standard WHO definitions (2008). Cox proportional hazards modeling with logistic regression, multinomial logistic regression and adjusted odds ratio was used to evaluate factors associated with interim and final outcomes respectively, controlling for demographic and clinical characteristics. In the cohort of 3712 MDR-TB patients, 2735 (73.6%) had initial sputum culture conversion at 100 median days (IQR 92-125), of which 506 (18.5%) had culture reversion at 279 median days (IQR 202-381). Treatment outcomes were available for 2264 (60.9%) patients while 1448 (39.0%) patients were still on treatment or yet to have a definite outcome at the time of analysis. Of 2264 patients, 781 (34.5%) had treatment success, 644 (28.4%) died, 670 (29.6%) were lost to follow up, 169 (7.5%) experienced treatment failure or were changed to XDR-TB treatment. Factors significantly associated with either culture non-conversion, culture reversion and/or unfavorable treatment outcomes were baseline BMI < 18; ≥ seven missed doses in intensive phase (IP) and continuation phase (CP); cavitary disease; prior treatment episodes characterized by re-treatment regimen taken twice, longer duration and more episodes of treatment; any weight loss during treatment; males and additional resistance to first line drugs (Ethambutol, Streptomycin). In a subgroup of 104 MDR-TB patients, 62 (59.6%) had Ofloxacin resistance among whom only 25.8% had treatment success, half of the success (54.8%) seen in Ofloxacin sensitive patients. Baseline susceptibility to Ofloxacin (HR 2.04) and Kanamycin (HR 4.55) significantly doubled and quadrupled the chances for culture conversion respectively while baseline susceptibility to Ofloxacin (AOR 0.37) also significantly reduced the odds of unfavorable treatment outcomes (p value ≤0.05) in multinomial logistic regression model. India's initial MDR-TB patients' cohort treated under the RNTCP experienced poor treatment outcomes. To address the factors associated with poor treatment outcomes revealed in our study, a systematic multi-pronged approach would be needed. A series of policies and interventions have been developed to address these factors to improve DR-TB treatment outcomes and are being scaled-up in India.

Unacceptable treatment outcomes and associated factors among India's initial cohorts of multidrug-resistant tuberculosis (MDR-TB) patients under the revised national TB control programme (2007–2011): Evidence leading to policy enhancement

PubMed Central

Sachdeva, Kuldeep Singh; Dewan, Puneet K.; Rade, Kiran; Nair, Sreenivas A.; Pant, Rashmi; Khaparde, Sunil D.

2018-01-01

Background Globally, India has the world’s highest burden of multidrug-resistant tuberculosis (MDR-TB). Programmatic Management of Drug Resistant TB (PMDT) in India began in 2007 and nationwide coverage was achieved in early 2013. Poor initial microbiological outcomes under the Revised National Tuberculosis Control Programme (RNTCP) prompted detailed analysis. This is the first study on factors significantly associated with poor outcomes in MDR-TB patients treated under the RNTCP. Objective To evaluate initial sputum culture conversion, culture reversion and final treatment outcomes among MDR-TB patients registered in India from 2007 to early 2011 who were treated with a standard 24-month regimen under daily-observed treatment. Methods This is a retrospective cohort study. Clinical and microbiological data were abstracted from PMDT records. Initial sputum culture conversion, culture reversion and treatment outcomes were defined by country adaptation of the standard WHO definitions (2008). Cox proportional hazards modeling with logistic regression, multinomial logistic regression and adjusted odds ratio was used to evaluate factors associated with interim and final outcomes respectively, controlling for demographic and clinical characteristics. Results In the cohort of 3712 MDR-TB patients, 2735 (73.6%) had initial sputum culture conversion at 100 median days (IQR 92–125), of which 506 (18.5%) had culture reversion at 279 median days (IQR 202–381). Treatment outcomes were available for 2264 (60.9%) patients while 1448 (39.0%) patients were still on treatment or yet to have a definite outcome at the time of analysis. Of 2264 patients, 781 (34.5%) had treatment success, 644 (28.4%) died, 670 (29.6%) were lost to follow up, 169 (7.5%) experienced treatment failure or were changed to XDR-TB treatment. Factors significantly associated with either culture non-conversion, culture reversion and/or unfavorable treatment outcomes were baseline BMI < 18; ≥ seven missed doses in intensive phase (IP) and continuation phase (CP); cavitary disease; prior treatment episodes characterized by re-treatment regimen taken twice, longer duration and more episodes of treatment; any weight loss during treatment; males and additional resistance to first line drugs (Ethambutol, Streptomycin). In a subgroup of 104 MDR-TB patients, 62 (59.6%) had Ofloxacin resistance among whom only 25.8% had treatment success, half of the success (54.8%) seen in Ofloxacin sensitive patients. Baseline susceptibility to Ofloxacin (HR 2.04) and Kanamycin (HR 4.55) significantly doubled and quadrupled the chances for culture conversion respectively while baseline susceptibility to Ofloxacin (AOR 0.37) also significantly reduced the odds of unfavorable treatment outcomes (p value ≤0.05) in multinomial logistic regression model. Conclusion India’s initial MDR-TB patients’ cohort treated under the RNTCP experienced poor treatment outcomes. To address the factors associated with poor treatment outcomes revealed in our study, a systematic multi-pronged approach would be needed. A series of policies and interventions have been developed to address these factors to improve DR-TB treatment outcomes and are being scaled-up in India. PMID:29641576

Adverse psychosocial working conditions and poor quality of life among financial service employees in Brazil.

PubMed

Silva, Luiz Sergio; Barreto, Sandhi Maria

2012-01-01

Workers in the financial services sector are exposed to great stress at work. This study investigates whether exposure to adverse psychosocial work conditions is independently associated with poor health-related physical and mental quality of life among financial services workers. We studied a nationwide representative sample of 2,054 workers of a large Brazilian state bank in 2008. Adverse psychosocial work conditions were investigated by the Effort-reward imbalance (ERI) scale and the Job content questionnaire (JCQ). Health-related quality of life (HRQL) was assessed using the Medical Outcomes Study Short-Form General Health Survey (SF-12). Poor mental and physical HRQL was defined by the lowest quartiles of the SF-12 final score distributions. Associations were investigated using multiple logistic regression analysis. In the multivariate analysis, exposures to low control and lack of social support at work (JCQ) were associated with poor HRQL in the physical domain. Increasing effort-reward imbalance and overcommitment (ERI), on the other hand, were associated with poor HRQL in the mental domain, with a significant statistical trend. Overcommitment was also associated with poor physical HRQL. The results suggest that exposure to adverse psychosocial work conditions has a negative impact on both domains of HRQL among financial service workers. They also indicate that ERI and DC models capture different aspects of job strain.

Factors associated with glycemic control among diabetic adult out-patients in Northeast Ethiopia.

PubMed

Fiseha, Temesgen; Alemayehu, Ermiyas; Kassahun, Wongelawit; Adamu, Aderaw; Gebreweld, Angesom

2018-05-18

The aim of this study was to determine the status of glycemic control and identify factors associated with poor glycemic control among diabetic out-patients. A hospital based cross-sectional study was conducted among randomly selected 384 (126 type 1 and 258 type 2) diabetic adults attending a hospital in Northeast Ethiopia from January 1 to April 30, 2017. Of the total participants, 70.8% had poor status of glycemic control (defined as mean fasting blood glucose level above 130 mg/dl). In the multivariate analysis, rural residence (AOR = 2.61, 95% CI 1.37-4.96), low educational level (AOR = 7.10, 95% CI 2.94-17.17) and longer duration of diabetes (AOR = 2.20, 95% CI 1.18-4.08) were significantly associated with increased odds of poor glycemic control. Moreover, merchants (AOR = 3.39, 95% CI 1.16-9.96) were significantly more likely to have poor glycemic control compared to government employee. Diabetic patients receiving oral anti-diabetics (AOR = 5.12, 95% CI 2.10-12.52) or insulin (AOR = 3.26, 95% CI 1.26-8.48) were more likely to be poorly controlled. These results highlight the needed for appropriate management of patients focusing on associated factors identified for poor glycemic control to maintain good glycemic control and improve adverse outcomes of the disease in this study setting.

Prevalence and long-term clinical significance of intracranial atherosclerosis after ischaemic stroke or transient ischaemic attack: a cohort study.

PubMed

Ovesen, Christian; Abild, Annemette; Christensen, Anders Fogh; Rosenbaum, Sverre; Hansen, Christine Krarup; Havsteen, Inger; Nielsen, Jens Kellberg; Christensen, Hanne

2013-10-21

We investigated the prevalence and long-term risk associated with intracranial atherosclerosis identified during routine evaluation. This study presents data from a prospective cohort of patients admitted to our stroke unit for thrombolysis evaluation. We included 652 with a final diagnosis of ischaemic stroke or transient ischaemic attack (TIA) from April 2009 to December 2011. All patients were acutely evaluated with cerebral CT and CT angiography (CTA). Acute radiological examinations were screened for intracranial arterial stenosis (IAS) or intracranial arterial calcifications (IAC). Intracranial stenosis was grouped into 30-50%, 50-70% and >70% lumen reduction. The extent of IAC was graded as number of vessels affected. Patients were followed until July 2013. Recurrence of an ischaemic event (stroke, ischaemic heart disease (IHD) and TIA) was documented through the national chart system. Poor outcome was defined as death or recurrence of ischaemic event. 101 (15.5%) patients showed IAS (70: 30-50%, 29: 50-70% and 16: >70%). Two-hundred and fifteen (33%) patients had no IAC, 339 (52%) in 1-2 vessels and 102 (16%) in >2 vessels. During follow-up, 53 strokes, 20 TIA and 14 IHD occurred, and 95 patients died. The risk of poor outcome was significantly different among different extents of IAS as well as IAC (log-rank test p<0.01 for both). In unadjusted analysis IAS and IAC predicted poor outcome and recurrent ischaemic event. When adjusted, IAS and IAC independently increased the risk of a recurrent ischaemic event (IAS: HR 1.67; CI 1.04 to 2.64 and IAC: HR 1.22; CI 1.02 to 1.47). Intracranial atherosclerosis detected during acute evaluation predicts an increased risk of recurrent stroke.

Is there a threshold age and burn size associated with poor outcomes in the elderly after burn injury?

PubMed Central

Jeschke, Marc G; Pinto, Ruxandra; Costford, Sheila R.; Amini-Nik, Saeid

2016-01-01

Elderly burn care represents a vast challenge. The elderly are one of the most susceptible populations to burn injuries, but also one of the fastest growing demographics, indicating a substantial increase in patient numbers in the near future. Despite the need and importance of elderly burn care, survival of elderly burn patients is poor. Additionally, little is known about the responses of elderly patients after burn. One central question that has not been answered is what age defines an elderly patient. The current study was conducted to determine whether there is a cut-off age for elderly burn patients that is correlated with an increased risk for mortality and to determine the burn size in modern burn care that is associated with increased mortality. To answer these questions, we applied appropriate statistical analyses to the Ross Tilley Burn Centre and the Inflammatory and Host Response to Injury databases. We could not find a clear cut-off age that differentiates or predicts between survival and death. Risk of death increased linearly with increasing age. Additionally, we found that the LD50 decreases from 45% total body surface area (TBSA) to 25% TBSA from the age of 55 years to the age of 70 years, indicating that even small burns lead to poor outcome in the elderly. We therefore concluded that age is not an ideal to predictor of burn outcome, but we strongly suggest that burn care providers be aware that if an elderly patient sustains even a 25% TBSA burn, the risk of mortality is 50% despite the implementation of modern protocolized burn care. PMID:26803373

Association between Household Air Pollution Exposure and Chronic Obstructive Pulmonary Disease Outcomes in 13 Low- and Middle-Income Country Settings.

PubMed

Siddharthan, Trishul; Grigsby, Matthew R; Goodman, Dina; Chowdhury, Muhammad; Rubinstein, Adolfo; Irazola, Vilma; Gutierrez, Laura; Miranda, J Jaime; Bernabe-Ortiz, Antonio; Alam, Dewan; Kirenga, Bruce; Jones, Rupert; van Gemert, Frederick; Wise, Robert A; Checkley, William

2018-03-01

Forty percent of households worldwide burn biomass fuels for energy, which may be the most important contributor to household air pollution. To examine the association between household air pollution exposure and chronic obstructive pulmonary disease (COPD) outcomes in 13 resource-poor settings. We analyzed data from 12,396 adult participants living in 13 resource-poor, population-based settings. Household air pollution exposure was defined as using biomass materials as the primary fuel source in the home. We used multivariable regressions to assess the relationship between household air pollution exposure and COPD outcomes, evaluated for interactions, and conducted sensitivity analyses to test the robustness of our findings. Average age was 54.9 years (44.2-59.6 yr across settings), 48.5% were women (38.3-54.5%), prevalence of household air pollution exposure was 38% (0.5-99.6%), and 8.8% (1.7-15.5%) had COPD. Participants with household air pollution exposure were 41% more likely to have COPD (adjusted odds ratio, 1.41; 95% confidence interval, 1.18-1.68) than those without the exposure, and 13.5% (6.4-20.6%) of COPD prevalence may be caused by household air pollution exposure, compared with 12.4% caused by cigarette smoking. The association between household air pollution exposure and COPD was stronger in women (1.70; 1.24-2.32) than in men (1.21; 0.92-1.58). Household air pollution exposure was associated with a higher prevalence of COPD, particularly among women, and it is likely a leading population-attributable risk factor for COPD in resource-poor settings.

Sarcopenia is a novel poor prognostic factor in male patients with pathological Stage I non-small cell lung cancer.

PubMed

Tsukioka, Takuma; Nishiyama, Noritoshi; Izumi, Nobuhiro; Mizuguchi, Shinjiro; Komatsu, Hiroaki; Okada, Satoshi; Toda, Michihito; Hara, Kantaro; Ito, Ryuichi; Shibata, Toshihiko

2017-04-01

Sarcopenia is the progressive loss of muscle mass and strength, and has a risk of adverse outcomes such as disability, poor quality of life and death. As prognosis depends not only on disease aggressiveness, but also on a patient's physical condition, sarcopenia can predict survival in patients with various cancer types. However, its effects on postoperative prognosis in patients with localized non-small cell lung cancers (NSCLC) have never been reported. We retrospectively investigated 215 male patients with pathological Stage I NSCLC. L3 muscle index is defined as the cross-section area of muscle at the third lumbar vertebra level, normalized for height, and is a clinical measurement of sarcopenia. We then investigated the effect of preoperative sarcopenia on their postoperative prognosis. Our 215 subjects included 30 patients with sarcopenia. Sarcopenia was significantly associated with body mass index, nutritional condition, serum CYFRA 21-1 level and pathological stage, but not with preoperative respiratory function or performance status. Frequency of postoperative complications, length of postoperative hospital stay, thoracic drainage period or causes of death were not correlated with the presence of sarcopenia. The sarcopenia group had a significantly shorter median overall survival (32 months) than the no-sarcopenia group. Sarcopenia might not affect short-term outcomes in patients with early-stage lung cancer. Sarcopenia was a predictor of poor prognosis in male patients with Stage I NSCLC. As sarcopenic patients with NSCLC patients are at risk for significantly worse outcomes, their treatments require careful planning, even for those with Stage I disease. © The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Iron deficiency defined as depleted iron stores accompanied by unmet cellular iron requirements identifies patients at the highest risk of death after an episode of acute heart failure.

PubMed

Jankowska, Ewa A; Kasztura, Monika; Sokolski, Mateusz; Bronisz, Marek; Nawrocka, Sylwia; Oleśkowska-Florek, Weronika; Zymliński, Robert; Biegus, Jan; Siwołowski, Paweł; Banasiak, Waldemar; Anker, Stefan D; Filippatos, Gerasimos; Cleland, John G F; Ponikowski, Piotr

2014-09-21

Acute heart failure (AHF) critically deranges haemodynamic and metabolic homoeostasis. Iron is a key micronutrient for homoeostasis maintenance. We hypothesized that iron deficiency (ID) defined as depleted iron stores accompanied by unmet cellular iron requirements would in this setting predict the poor outcome. Among 165 AHF patients (age 65 ± 12 years, 81% men, 31% de novo HF), for ID diagnosis we prospectively applied: low serum hepcidin reflecting depleted iron stores (<14.5 ng/mL, the 5th percentile in healthy peers), and high-serum soluble transferrin receptor (sTfR) reflecting unmet cellular iron requirements (≥1.59 mg/L, the 95th percentile in healthy peers). Concomitance of low hepcidin and high sTfR (the most profound ID) was found in 37%, isolated either high sTfR or low hepcidin was found in 29 and 9% of patients, and 25% of subjects demonstrated preserved iron status. Patients with low hepcidin and high sTfR had peripheral oedema, high NT-proBNP, high uric acid, low haemoglobin (P < 0.05), and 5% in-hospital mortality (0% in remaining patients). During the 12-month follow-up, 33 (20%) patients died. Those with low hepcidin and high sTfR had the highest 12-month mortality [(41% (95% CI: 29-53%)] when compared with those with isolated high sTfR [15% (5-25%)], isolated low hepcidin [7% (0-19%)] and preserved iron status (0%) (P < 0.001). Analogous mortality patterns were seen separately in anaemics and non-anaemics. Iron deficiency defined as depleted body iron stores and unmet cellular iron requirements is common in AHF, and identifies those with the poor outcome. Its correction may be an attractive therapeutic approach. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Coexisting cerebral infarction in Alzheimer's disease is associated with fast dementia progression: applying the National Institute for Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences Neuroimaging Criteria in Alzheimer's Disease with Concomitant Cerebral Infarction.

PubMed

Sheng, Bun; Cheng, Lik Fai; Law, Chun Bon; Li, Ho Lun; Yeung, Kwan Mo; Lau, Kwok Kwong

2007-06-01

To determine whether patients with Alzheimer's disease (AD) and coexisting cerebral infarction (CI) that satisfy the National Institute for Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) neuroimaging criteria for vascular dementia (VaD) progress faster than those who do not satisfy the neuroimaging criteria. Retrospective cohort study. Multidisciplinary memory clinic in a tertiary hospital. One hundred thirty consecutive patients with AD, with or without CI, followed up regularly for more than 1 year. The patients were classified according to the distribution and severity of CI as defined according to the NINDS-AIREN neuroimaging criteria into those with AD and no CI (AD-N), those with AD and CI not fulfilling neuroimaging criteria (AD-I), and those with AD and CI fulfilling neuroimaging criteria (AD-V), and their differences in dementia progression were tested. The loss of independence, indicated by institution admission or a clinical dementia rating (CDR) score of 3, was defined as the endpoint for a poor outcome. The mean age was 75.8, and 68.5% were women. The initial Mini-Mental State Examination (MMSE) score was 15.3+/-0.4, and the average duration of follow up was 30.4 months. Fifty-four patients had reached study endpoint at the time of analysis. AD-V (hazard ratio (HR)=3.1, 95% confidence interval (CI)=1.2-8.2), use of psychotropic drugs (HR=2.7, 95% CI=1.1-6.4), and initial MMSE score (HR=0.9, 95% CI=0.8-1.0) were independent predictors of poor outcome in the Cox regression model. In AD, co-occurrence of CI with distribution and severity as defined in the NINDS-AIREN neuroimaging criteria for VaD is associated with faster dementia progression.

How collaboration in therapy becomes therapeutic: the therapeutic collaboration coding system.

PubMed

Ribeiro, Eugénia; Ribeiro, António P; Gonçalves, Miguel M; Horvath, Adam O; Stiles, William B

2013-09-01

The quality and strength of the therapeutic collaboration, the core of the alliance, is reliably associated with positive therapy outcomes. The urgent challenge for clinicians and researchers is constructing a conceptual framework to integrate the dialectical work that fosters collaboration, with a model of how clients make progress in therapy. We propose a conceptual account of how collaboration in therapy becomes therapeutic. In addition, we report on the construction of a coding system - the therapeutic collaboration coding system (TCCS) - designed to analyse and track on a moment-by-moment basis the interaction between therapist and client. Preliminary evidence is presented regarding the coding system's psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the client's therapeutic zone of proximal development, defined as the space between the client's actual therapeutic developmental level and their potential developmental level that can be reached in collaboration with the therapist. We applied the TCCS to five cases: a good and a poor outcome case of narrative therapy, a good and a poor outcome case of cognitive-behavioural therapy, and a dropout case of narrative therapy. The TCCS offers markers that may help researchers better understand the therapeutic collaboration on a moment-to-moment basis and may help therapists better regulate the relationship. © 2012 The British Psychological Society.

Mechanical Thrombectomy in Anterior Circulation Occlusion Could Be More Effective than Medical Management Even in Low DWI-ASPECTS Patients.

PubMed

Ohta, Tsuyoshi; Morimoto, Masanori; Okada, Kenji; Fukuda, Maki; Onishi, Hirokazu; Masahira, Noritaka; Matsuoka, Toshiki; Tsuno, Takaya; Takemura, Mitsuhiro

2018-04-15

The purpose of this study was to investigate whether patients with low preoperative Diffusion-weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) could benefit from mechanical thrombectomy for acute anterior circulation occlusion. This was a retrospective, non-blinded, cohort study. From September 2012 to August 2016, 83 consecutive patients of acute anterior circulation occlusion were treated with thrombectomy using second-generation devices or medical management. The DWI-ASPECTS was scored after the first MRI. Patient characteristics and clinical outcomes were compared between the treatment groups. Significant dependence was defined as a modified Rankin scale score ≥3 at 90 days. As a result, 33 patients underwent mechanical thrombectomy and 50 received medical management. In the mechanical thrombectomy group, the variable of lower DWI-ASPECTS (5, 4-6 vs. 8, 7-8, P < 0.001), especially ≤6, was significantly associated with poor prognosis. However, compared with patients of DWI-ASPECTS ≤ 6 who received medical management, there were significantly fewer patients with poor outcomes in thrombectomy (dependent in 11 of 15 vs. 23 of 23, respectively; P = 0.019). Although patients with lower pretreatment DWI-ASPECTS could benefit less from thrombectomy, their outcomes were still better than medical management. Therefore, mechanical thrombectomy could be considered in some patients with low pretreatment DWI-ASPECTS.

White matter injury induced by diabetes in acute stroke is clinically relevant: A preliminary study.

PubMed

Yu, Xinfeng; Song, Ruirui; Jiaerken, Yerfan; Yuan, Lixia; Huang, Peiyu; Lou, Min; Jiang, Quan; Zhang, Minming

2017-01-01

The importance of white matter injury induced by diabetes in stroke severity and prognosis is largely unknown. We aimed to investigate the relationship between diabetes-related white matter injury beyond stroke lesions with acute neurological deficits and clinical outcome after stroke. In total, 36 stroke patients within 3-7 days after onset were enrolled. Neurological deficits on admission were assessed by National Institute of Health Stroke Score, and poor outcome at 3 months was defined as modified Rankin score >2. White matter tracts were compared between patients with diabetic and non-diabetic stroke using fractional anisotropy from diffusion tensor imaging. Regional white matter abnormality with decreased fractional anisotropy was observed in diabetic patients (n = 18) when compared to non-diabetic patients (n = 18). Decreased fractional anisotropy in ipsilesional distal corticospinal tract was independently associated with higher National Institute of Health Stroke Score motor component score (β = -0.444, p = 0.005), and decreased fractional anisotropy in contralesional superior longitudinal fasciculus I was independently related to poor outcome (odds ratio, 0.900; p = 0.033). Our findings suggested that only white matter injury induced by diabetes in specific tracts like corticospinal tract and superior longitudinal fasciculus beyond stroke lesions has clinically relevant, providing insight into the mechanism of stroke recovery under the diabetic condition. © The Author(s) 2016.

Post-traumatic stress disorder in the perinatal period: A concept analysis.

PubMed

Vignato, Julie; Georges, Jane M; Bush, Ruth A; Connelly, Cynthia D

2017-12-01

To report an analysis of the concept of perinatal post-traumatic stress disorder. Prevalence of perinatal post-traumatic stress disorder is rising in the USA, with 9% of the U.S. perinatal population diagnosed with the disorder and an additional 18% being at risk for the condition. Left untreated, adverse maternal-child outcomes result in increased morbidity, mortality and healthcare costs. Concept analysis via Walker and Avant's approach. The databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Academic Search Premier and PsychINFO were searched for articles, written in English, published between 2006-2015, containing the terms perinatal and post-traumatic stress disorder. Perinatal post-traumatic stress disorder owns unique attributes, antecedents and outcomes when compared to post-traumatic stress disorder in other contexts, and may be defined as a disorder arising after a traumatic experience, diagnosed any time from conception to 6 months postpartum, lasting longer than 1 month, leading to specific negative maternal symptoms and poor maternal-infant outcomes. Attributes include a diagnostic time frame (conception to 6 months postpartum), harmful prior or current trauma and specific diagnostic symptomatology defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Antecedents were identified as trauma (perinatal complications and abuse), postpartum depression and previous psychiatric history. Consequences comprised adverse maternal-infant outcomes. Further research on perinatal post-traumatic stress disorder antecedents, attributes and outcomes in ethnically diverse populations may provide clinicians a more comprehensive framework for identifying and treating perinatal post-traumatic stress disorder. Nurses are encouraged to increase their awareness of perinatal post-traumatic stress disorder for early assessment and intervention, and prevention of adverse maternal-infant outcomes. © 2017 John Wiley & Sons Ltd.

Vaginal microbial flora and outcome of pregnancy.

PubMed

Donati, Laura; Di Vico, Augusto; Nucci, Marta; Quagliozzi, Lorena; Spagnuolo, Terryann; Labianca, Antonietta; Bracaglia, Marina; Ianniello, Francesca; Caruso, Alessandro; Paradisi, Giancarlo

2010-04-01

The vaginal microflora of a healthy asymptomatic woman consists of a wide variety of anaerobic and aerobic bacterial genera and species dominated by the facultative, microaerophilic, anaerobic genus Lactobacillus. The activity of Lactobacillus is essential to protect women from genital infections and to maintain the natural healthy balance of the vaginal flora. Increasing evidence associates abnormalities in vaginal flora during pregnancy with preterm labor and delivery with potential neonatal sequelae due to prematurity and poor perinatal outcome. Although this phenomenon is relatively common, even in populations of women at low risk for adverse events, the pathogenetic mechanism that leads to complications in pregnancy is still poorly understood. This review summarizes the current knowledge and uncertainties in defining alterations of vaginal flora in non-pregnant adult women and during pregnancy, and, in particular, investigates the issue of bacterial vaginosis and aerobic vaginitis. This could help specialists to identify women amenable to treatment during pregnancy leading to the possibility to reduce the preterm birth rate, preterm premature rupture of membranes, chorioamnionitis, neonatal, puerperal and maternal-fetal infectious diseases. Vaginal ecosystem study with the detection of pathogens is a key instrument in the prevention of preterm delivery, pPROM, chorioamnionitis, neonatal, puerperal and maternal-fetal infections.

Survival without disability to age 5 years after neonatal caffeine therapy for apnea of prematurity.

PubMed

Schmidt, Barbara; Anderson, Peter J; Doyle, Lex W; Dewey, Deborah; Grunau, Ruth E; Asztalos, Elizabeth V; Davis, Peter G; Tin, Win; Moddemann, Diane; Solimano, Alfonso; Ohlsson, Arne; Barrington, Keith J; Roberts, Robin S

2012-01-18

Very preterm infants are prone to apnea and have an increased risk of death or disability. Caffeine therapy for apnea of prematurity reduces the rates of cerebral palsy and cognitive delay at 18 months of age. To determine whether neonatal caffeine therapy has lasting benefits or newly apparent risks at early school age. Five-year follow-up from 2005 to 2011 in 31 of 35 academic hospitals in Canada, Australia, Europe, and Israel, where 1932 of 2006 participants (96.3%) had been enrolled in the randomized, placebo-controlled Caffeine for Apnea of Prematurity trial between 1999 and 2004. A total of 1640 children (84.9%) with birth weights of 500 to 1250 g had adequate data for the main outcome at 5 years. Combined outcome of death or survival to 5 years with 1 or more of motor impairment (defined as a Gross Motor Function Classification System level of 3 to 5), cognitive impairment (defined as a Full Scale IQ<70), behavior problems, poor general health, deafness, and blindness. The combined outcome of death or disability was not significantly different for the 833 children assigned to caffeine from that for the 807 children assigned to placebo (21.1% vs 24.8%; odds ratio adjusted for center, 0.82; 95% CI, 0.65-1.03; P = .09). The rates of death, motor impairment, behavior problems, poor general health, deafness, and blindness did not differ significantly between the 2 groups. The incidence of cognitive impairment was lower at 5 years than at 18 months and similar in the 2 groups (4.9% vs 5.1%; odds ratio adjusted for center, 0.97; 95% CI, 0.61-1.55; P = .89). Neonatal caffeine therapy was no longer associated with a significantly improved rate of survival without disability in children with very low birth weights who were assessed at 5 years.

Prevalence and Predictive Factors of Chronic Postsurgical Pain and Poor Global Recovery 1 Year After Outpatient Surgery.

PubMed

Hoofwijk, Daisy M N; Fiddelers, Audrey A A; Peters, Madelon L; Stessel, Björn; Kessels, Alfons G H; Joosten, Elbert A; Gramke, Hans-Fritz; Marcus, Marco A E

2015-12-01

To prospectively describe the prevalence and predictive factors of chronic postsurgical pain (CPSP) and poor global recovery in a large outpatient population at a university hospital, 1 year after outpatient surgery. A prospective longitudinal cohort study was performed. During 18 months, patients presenting for preoperative assessment were invited to participate. Outcome parameters were measured by using questionnaires at 3 timepoints: 1 week preoperatively, 4 days postoperatively, and 1 year postoperatively. A value of >3 on an 11-point numeric rating scale was considered to indicate moderate to severe pain. A score of ≤80% on the Global Surgical Recovery Index was defined as poor global recovery. A total of 908 patients were included. The prevalence of moderate to severe preoperative pain was 37.7%, acute postsurgical pain 26.7%, and CPSP 15.3%. Risk factors for the development of CPSP were surgical specialty, preoperative pain, preoperative analgesic use, acute postoperative pain, surgical fear, lack of optimism, and poor preoperative quality of life. The prevalence of poor global recovery was 22.3%. Risk factors for poor global recovery were recurrent surgery because of the same pathology, preoperative pain, preoperative analgesic use, surgical fear, lack of optimism, poor preoperative and acute postoperative quality of life, and follow-up surgery during the first postoperative year. Moderate to severe CPSP after outpatient surgery is common, and should not be underestimated. Patients at risk for developing CPSP can be identified during the preoperative phase.

Long-term Cognitive and Health Outcomes of School-Aged Children Who Were Born Late-Term vs Full-Term.

PubMed

Figlio, David N; Guryan, Jonathan; Karbownik, Krzysztof; Roth, Jeffrey

2016-08-01

Late-term gestation (defined as the 41st week of pregnancy) is associated with increased risk of perinatal health complications. It is not known to what extent late-term gestation is associated with long-term cognitive and physical outcomes. Information about long-term outcomes may influence physician and patient decisions regarding optimal pregnancy length. To compare the cognitive and physical outcomes of school-aged children who were born full term or late term. We analyzed Florida birth certificates from 1994 to 2002 linked to Florida public school records from 1998 to 2013 and found 1 442 590 singleton births with 37 to 41 weeks' gestation in the Florida Bureau of Vital Statistics. Of these, 1 153 716 children (80.0%) were subsequently located in Florida public schools. Linear and logistic regression models were used to assess the association of gestational age with cognitive and physical outcomes at school age. Data analysis took place between April 2013 and January 2016. Late-term (born at 41 weeks) vs full-term (born at 39 or 40 weeks) gestation. There were a number of measures used, including the average Florida Comprehensive Assessment Test mathematics and reading scores at ages 8 through 15 years; whether a child was classified as gifted, defined as a student with superior intellectual development and capable of high performance; poor cognitive outcome, defined as a child scoring in the fifth percentile of test takers or having a disability that exempted him or her from taking the Florida Comprehensive Assessment Test; and Exceptional Student Education placement owing to orthopedic, speech, or sensory impairment or being hospitalbound or homebound. Of 1 536 482 children born in Florida from singleton births from 1994 to 2002 with complete demographic information, 787 105 (51.2%) were male; 338 894 (22.1%) of mothers were black and 999 684 (65.1%) were married at time of birth, and the mean (SD) age for mothers at time of birth was 27.2 (6.2) years. Late-term infants had 0.7% of an SD (95% CI, 0.001-0.013; P = .02) higher average test scores in elementary and middle school, 2.8% (95% CI, 0.4-5.2; P = .02) higher probability of being gifted, and 3.1% (95% CI, 0.0-6.1; P = .05) reduced probability of poor cognitive outcomes compared with full-term infants. These cognitive benefits appeared strongest for children with disadvantaged family background characteristics. Late-term infants were also 2.1% (95% CI, -0.3 to 4.5; P = .08) more likely to be physically impaired. There appears to be a tradeoff between cognitive and physical outcomes associated with late-term gestation. Children born late-term performed better on 3 measures of school-based cognitive functioning but worse on 1 measure of physical functioning relative to children born full term. Our findings provide longer-run information for expectant parents and physicians who are considering delivery at full term vs late term. These findings are most relevant to uncomplicated, low-risk pregnancies.

Health and wealth in Mesoamerica: findings from Salud Mesomérica 2015.

PubMed

Mokdad, Ali H; Gagnier, Marielle C; Colson, K Ellicott; Zúñiga-Brenes, Paola; Ríos-Zertuche, Diego; Haakenstad, Annie; Palmisano, Erin B; Anderson, Brent W; Desai, Sima S; Gillespie, Catherine W; Murphy, Tasha; Naghavi, Paria; Nelson, Jennifer; Ranganathan, Dharani; Schaefer, Alexandra; Usmanova, Gulnoza; Wilson, Shelley; Hernandez, Bernardo; Lozano, Rafael; Iriarte, Emma

2015-07-14

Individual income and poverty are associated with poor health outcomes. The poor face unique challenges related to access, education, financial capacity, environmental effects, and other factors that threaten their health outcomes. We examined the variation in the health outcomes and health behaviors among the poorest quintile in eight countries of Mesoamerica using data from the Salud Mesomérica 2015 baseline household surveys. We used multivariable logistic regression to measure the association between delivering a child in a health facility and select household and maternal characteristics, including education and measures of wealth. Health indicators varied greatly between geographic segments. Controlling for other demographic characteristics, women with at least secondary education were more likely to have an in-facility delivery compared to women who had not attended school (OR: 3.20, 95 % confidence interval [CI]: 2.56-3.99, respectively). Similarly, women from households with the highest expenditure were more likely to deliver in a health facility compared to those from the lowest expenditure households (OR 3.06, 95 % CI: 2.43-3.85). Household assets did not impact these associations. Moreover, we found that commonly-used definitions of poverty do not align with the disparities in health outcomes observed in these communities. Although poverty measured by expenditure or wealth is associated with health disparities or health outcomes, a composite indicator of health poverty based on coverage is more likely to focus attention on health problems and solutions. Our findings call for the public health community to define poverty by health coverage measures rather than income or wealth. Such a health-poverty metric is more likely to generate attention and mobilize targeted action by the health communities than our current definition of poverty.

Correlation between CD34 expression and chromosomal abnormalities but not clinical outcome in acute myeloid leukemia.

PubMed

Fruchart, C; Lenormand, B; Bastard, C; Boulet, D; Lesesve, J F; Callat, M P; Stamatoullas, A; Monconduit, M; Tilly, H

1996-11-01

The hemopoietic stem cell marker CD34 has been reported to be a useful predictor of treatment outcome in acute myeloid leukemia (AML). Previous data suggested that CD34 expression may be associated with other poor prognosis factors in AML such as undifferentiated leukemia, secondary AML (SAML), and clonal abnormalities involving chromosome 5 and 7. In order to analyze the correlations between the clinicopathologic features, cytogenetic and CD34 expression in AML, we retrospectively investigated 99 patients with newly diagnosed AML: 85 with de novo disease and 14 with secondary AML (SAML). Eighty-six patients who received the same induction chemotherapy were available for clinical outcome. Defining a case as positive when > or = 20% of bone marrow cells collected at diagnosis expressed the CD34 antigen, forty-five patients were included in the CD34 positive group. Ninety patients had adequate cytogenetic analysis. Thirty-two patients (72%) with CD34 positive AML exhibited an abnormal karyotype whereas 15 patients (28%) with CD34 negative AML had abnormal metaphases (P < 0.01). Monosomy 7/7q- or monosomy 5/5q- occurred in 10 patients and 8 of them expressed the CD34 antigen (P < 0.05). All patients with t(8;21) which is considered as a favorable factor in AML had levels of CD34 >/= 20% (P < 0.05). We did not find any association between CD34 expression and attainment of complete remission, overall survival, or disease-free survival. In conclusion, the variations of CD34 expression in AML are correlated with cytogenetic abnormalities associated both with poor and favorable outcome. The evaluation of the correlations between CD34 antigen and clinical outcome in AML should take into account the results of pretreatment karyotype.

Predictors of Long-Term Outcomes of Percutaneous Mitral Valvuloplasty in Patients with Rheumatic Mitral Stenosis.

PubMed

Kim, Darae; Chung, Hyemoon; Nam, Jong Ho; Park, Dong Hyuk; Shim, Chi Young; Kim, Jung Sun; Chang, Hyuk Jae; Hong, Geu Ru; Ha, Jong Won

2018-03-01

We determined factors associated with long-term outcomes of patients who underwent successful percutaneous mitral balloon valvuloplasty (PMV). Between August 1980 and May 2013, 1187 patients underwent PMV at Severance Hospital, Seoul, Korea. A total of 742 patients who underwent regular clinic visits for more than 10 years were retrospectively analyzed. The endpoints consisted of repeated PMV, mitral valve (MV) surgery, and cardiovascular-related death. The optimal result, defined as a post-PMV mitral valve area (MVA) >1.5 cm² and mitral regurgitation ≤Grade II, was obtained in 631 (85%) patients. Over a mean follow up duration of 214±50 months, 54 (7.3%) patients underwent repeat PMV, 4 (0.5%) underwent trido-PMV, and 248 (33.4%) underwent MV surgery. A total of 33 patients (4.4%) had stroke, and 35 (4.7%) patients died from cardiovascular-related reasons. In a multivariate analysis, echocardiographic score [p=0.003, hazard ratio=1.56, 95% confidence interval (CI): 1.01-2.41] and post-MVA cut-off (p<0.001, relative risk=0.39, 95% CI: 0.37-0.69) were the only significant predictors of long-term clinical outcomes after adjusting for confounding variables. A post-MVA cut-off value of 1.76 cm² showed satisfactory predictive power for poor long-term clinical outcomes. In this long-term follow up study (up to 20 years), an echocardiographic score >8 and post-MVA ≤1.76 cm² were independent predictors of poor long-term clinical outcomes after PMV, including MV reintervention, stroke, and cardiovascular-related death. © Copyright: Yonsei University College of Medicine 2018

International peripheral T-cell and natural killer/T-cell lymphoma study: pathology findings and clinical outcomes.

PubMed

Vose, Julie; Armitage, James; Weisenburger, Dennis

2008-09-01

Peripheral T-cell lymphoma (PTCL) and natural killer/T-cell lymphoma (NKTCL) are rare and heterogeneous forms of non-Hodgkin's lymphoma (NHL) that, in general, are associated with a poor clinical outcome. A cohort of 1,314 cases of PTCL and NKTCL was organized from 22 centers worldwide, consisting of patients with previously untreated PTCL or NKTCL who were diagnosed between 1990 and 2002. Tissue biopsies, immunophenotypic markers, molecular genetic studies, and clinical information from consecutive patients at each site were reviewed by panels of four expert hematopathologists and classified according to the WHO classification. A diagnosis of PTCL or NKTCL was confirmed in 1,153 (87.8%) of the cases. The most common subtypes were PTCL not otherwise specified (NOS; 25.9%), angioimmunoblastic type (18.5%), NKTCL (10.4%), and adult T-cell leukemia/lymphoma (ATLL; 9.6%). Misclassification occurred in 10.4% of the cases including Hodgkin's lymphoma (3%), B-cell lymphoma (1.4%), unclassifiable lymphoma (2.8%), or a diagnosis other than lymphoma (2.3%). We found marked variation in the frequency of the various subtypes by geographic region. The use of an anthracycline-containing regimen was not associated with an improved outcome in PTCL-NOS or angioimmunoblastic type, but was associated with an improved outcome in anaplastic large-cell lymphoma, ALK positive. The WHO classification is useful for defining subtypes of PTCL and NKTCL. However, expert hematopathology review is important for accurate diagnosis. The clinical outcome for patients with most of these lymphoma subtypes is poor with standard therapies, and novel agents and new modalities are needed to improve survival.

A randomized controlled trial of cognitive behavioral therapy (CBT) for adjusting to multiple sclerosis (the saMS trial): does CBT work and for whom does it work?

PubMed

Moss-Morris, Rona; Dennison, Laura; Landau, Sabine; Yardley, Lucy; Silber, Eli; Chalder, Trudie

2013-04-01

The aims were (a) to test the effectiveness of a nurse-led cognitive behavioral therapy (CBT) program to assist adjustment in the early stages of multiple sclerosis (MS) and (b) to determine moderators of treatment including baseline distress, social support (SS), and treatment preference. Ninety-four ambulatory people with MS within 10 years of diagnosis were randomized to receive 8 individual sessions of CBT (n = 48) or supportive listening (n = 46), most delivered on the telephone, in a multicenter randomized controlled trial. The primary outcomes were distress and functional impairment. Secondary outcomes included global improvement, acceptance of illness, and dysfunctional cognitions. Assessments were completed at home and were coordinated by a blind assessor. Data were analyzed by intention-to-treat using multilevel models. The CBT group was significantly less distressed at the end of treatment (estimated General Health Questionnaire group difference = 3.2 points, 95\\% CI 1.1 to 5.4 points) and at the 12-month follow-up (estimated group difference = 2.2 points, 95\\% CI 0.01 to 4.4 points). There were no differences between the groups on functional impairment. The CBT group also demonstrated significantly greater improvements on secondary outcomes at the end of treatment but not at the 12-month follow-up. CBT participants with poor SS and/or clinically defined levels of distress at baseline showed significantly greater gains on both primary outcomes. Treatment preference did not moderate treatment effects. CBT is more effective than supportive listening in reducing distress in people with MS. CBT appears most effective for patients with poor SS and high levels of distress. The loss of gains in the secondary outcomes by 12 months suggests further follow-up sessions may be warranted.

Prevalence and treatment outcome of pulmonary and extrapulmonary pediatric tuberculosis in southwestern Iran.

PubMed

Alavi, Seyed Mohammad; Salmanzadeh, Shokrollah; Bakhtiyariniya, Pejman; Albagi, Ali; Hemmatnia, Fatemeh; Alavi, Leila

2015-01-01

Knowledge about childhood tuberculosis (TB) in Iran is limited. This study aimed to determine the proportion of tuberculosis in children living in Khuzestan in southwest of Iran and its treatment outcomes. In this retrospective study, the child's medical records registered in national TB program (NTP) unit of Khuzestan Health Center (KHC) for TB treatment from 2005 to 2010 were studied. Data including demographic, clinical presentation, laboratory test results, and treatment outcomes were extracted from the files and were analyzed. Of total 4104 new TB cases registered in KHC, 203 (4.9%) were children. The mean age was 10.7±4.3 years, and 75.7% of them were females. More than 84% of TB children cases were 10 years or older, whereas, young children (< 5 years old) accounted for 5.6%. Of the total studied cases, 57.1% were pulmonary TB and 42.9% were extra pulmonary, 91.7% were successfully treated and 8.3% had poor treatment outcome. The main risk factors for poor treatment outcome were: age <5 years (OR: 0.17, 95% CI, 0.04-0.76), low body weight (OR: 0.08, 95% CI, 0.01-0.60), household contact with cases of TB treatment failure (OR: 0.13, 95% CI, 0.03-0.52), and exposure to cigarette smoke odor inside the home (OR: 0.17, 95% CI, 0.05-0.56). The proportion of pediatric TB in the region was lower than expected. The treatment success rate was higher than the rate defined in NTP. Special attention should be given to children aged less than five years, low body weight, contact with TB treatment failure cases, and exposure to cigarette smoke.

Taxonomy of segmental myocardial systolic dysfunction

PubMed Central

McDiarmid, Adam K.; Pellicori, Pierpaolo; Cleland, John G.; Plein, Sven

2017-01-01

The terms used to describe different states of myocardial health and disease are poorly defined. Imprecision and inconsistency in nomenclature can lead to difficulty in interpreting and applying trial outcomes to clinical practice. In particular, the terms ‘viable’ and ‘hibernating’ are commonly applied interchangeably and incorrectly to myocardium that exhibits chronic contractile dysfunction in patients with ischaemic heart disease. The range of inherent differences amongst imaging modalities used to define myocardial health and disease add further challenges to consistent definitions. The results of several large trials have led to renewed discussion about the classification of dysfunctional myocardial segments. This article aims to describe the diverse myocardial pathologies that may affect the myocardium in ischaemic heart disease and cardiomyopathy, and how they may be assessed with non-invasive imaging techniques in order to provide a taxonomy of myocardial dysfunction. PMID:27147609

Flat inferior vena cava: indicator of poor prognosis in trauma and acute care surgery patients.

PubMed

Ferrada, Paula; Vanguri, Poornima; Anand, Rahul J; Whelan, James; Duane, Therese; Wolfe, Luke; Ivatury, Rao

2012-12-01

Flat inferior vena cava (IVC) on ultrasound examination has been shown to correlate with hypovolemic status. We hypothesize that a flat IVC on limited echocardiogram (LTTE) performed in the emergency room (ER) correlates with poor prognosis in acutely ill surgical patients. We conducted a retrospective review of all patients undergoing LTTE in the ER from September 2010 until June 2011. IVC diameter was estimated by subxiphoid window. Flat IVC was defined as diameter less than 2 cm. Fat IVC was defined as diameter greater than 2 cm. Need for intensive care unit admission, blood transfusion requirement, mortality, and need for emergent operation between patients with flat versus Fat IVC were compared. One hundred one hypotensive patients had LTTE performed in the ER. Average age was 38 years. Admission diagnosis was blunt trauma (n = 80), penetrating trauma (n = 13), acute care surgery pathology (n = 7), and burn (n = 1). Seventy-four patients had flat IVC on initial LTTE. Compared with those with fat IVC, flat patients were found have higher rates of intensive care unit admission (51.3 vs 14.8%; P = 0.001), blood transfusion requirement (12.2 vs 3.7%), and mortality (13.5 vs 3.7%). This population also underwent emergent surgery on hospital Day 1 more often (16.2 vs 0%; P = 0.033). Initial flat IVC on LTTE is an indicator of hypovolemia and a predictor of poor outcome.

Copy number losses define subgroups of dedifferentiated liposarcoma with poor prognosis and genomic instability.

PubMed

Crago, Aimee M; Socci, Nicholas D; DeCarolis, Penelope; O'Connor, Rachael; Taylor, Barry S; Qin, Li-Xuan; Antonescu, Cristina R; Singer, Samuel

2012-03-01

Molecular events underlying progression of well-differentiated liposarcoma (WDLS) to dedifferentiated liposarcoma (DDLS) are poorly defined. This study sought to identify copy number alterations (CNA) associated with dedifferentiation of WDLS, with DDLS morphology, and with patient outcomes. Fifty-five WDLS and 52 DDLS were analyzed using Agilent 244K comparative genomic hybridization and Affymetrix U133A expression arrays. CNAs were identified by RAE analysis. Thirty-nine of the DDLS specimens were categorized morphologically by a single pathologist. Nine regions of CNA were identified as recurrent in DDLS but not WDLS; 79% of DDLS had at least one of these CNAs. Loss of the chromosome segment 11q23-24, the most common event, was observed only in DDLS that morphologically resembled the genomically complex sarcomas, undifferentiated pleomorphic sarcoma and myxofibrosarcoma. 11q23-24 loss was itself associated with increased genomic complexity in DDLS. Loss of 19q13, but not 11q23-24, was associated with poor prognosis. Median disease-specific survival was shorter for patients with19q13 loss (27 months) than for patients with diploid 19q13 (>90 months; P < 0.0025), and 19q13 loss was associated with local recurrence (HR, 2.86; P = 0.013). Common copy number losses were associated with transcriptional downregulation of potential tumor suppressors and adipogenesis-related genes (e.g., EI24 and CEBPA). Dedifferentiation of WDLS is associated with recurrent CNAs in 79% of tumors. In DDLS, loss of 11q23-24 is associated with genomic complexity and distinct morphology whereas loss of 19q13 predicts poor prognosis. CNAs in liposarcoma improve risk stratification for patients and will help identify potential tumor suppressors driving liposarcoma progression.

Copy number losses define subgroups of dedifferentiated liposarcoma with poor prognosis and genomic instability

PubMed Central

Crago, Aimee M.; Socci, Nicholas D.; DeCarolis, Penelope; O'Connor, Rachael; Taylor, Barry S.; Qin, Li-Xuan; Antonescu, Cristina R.; Singer, Samuel

2012-01-01

Purpose Molecular events underlying progression of well-differentiated liposarcoma (WDLS) to dedifferentiated liposarcoma (DDLS) are poorly defined. This study sought to identify copy number alterations (CNAs) associated with dedifferentiation of WDLS, with DDLS morphology, and with patient outcomes. Experimental Design 55 WDLS and 52 DDLS were analyzed using Agilent 244K comparative genomic hybridization and Affymetrix U133A expression arrays. CNAs were identified by RAE analysis. Thirty-nine of the DDLS specimens were categorized morphologically by a single pathologist. Results Nine regions of CNA were identified as recurrent in DDLS but not WDLS; 79% of DDLS had at least one of these CNAs. Loss of the chromosome segment 11q23–24, the most common event, was observed only in DDLS that morphologically resembled the genomically complex sarcomas undifferentiated pleomorphic sarcoma and myxofibrosarcoma. 11q23–24 loss was itself associated with increased genomic complexity in DDLS. Loss of 19q13, but not 11q23–24, was associated with poor prognosis. Median disease-specific survival was shorter for patients with19q13 loss (27 months) than for patients with diploid 19q13 (>90 months; p<0.0025), and 19q13 loss was associated with local recurrence (HR 2.86, p=0.013). Common copy number losses were associated with transcriptional downregulation of potential tumor suppressors and adipogenesis-related genes (e.g., EI24 and CEBPA). Conclusions Dedifferentiation of WDLS is associated with recurrent CNAs in 79% of tumors. In DDLS, loss of 11q23–24 is associated with genomic complexity and distinct morphology while loss of 19q13 predicts poor prognosis. CNAs in liposarcoma improve risk stratification for patients and will help identify potential tumor suppressors driving liposarcoma progression. PMID:22241790

Identification of novel cytogenetic markers with prognostic significance in a series of 968 patients with primary myelodysplastic syndromes.

PubMed

Solé, Francesc; Luño, Elisa; Sanzo, Carmen; Espinet, Blanca; Sanz, Guillermo F; Cervera, José; Calasanz, María José; Cigudosa, Juan Cruz; Millà, Fuensanta; Ribera, Josep Maria; Bureo, Encarna; Marquez, Maria Luisa; Arranz, Eva; Florensa, Lourdes

2005-09-01

The main prognostic factors in myelodysplastic syndromes (MDS) are chromosomal abnormalities, the proportion of blasts in bone marrow and number and degree of cytopenias. A consensus-defined International Prognostic Scoring System (IPSS) for predicting outcome and planning therapy in MDS has been developed, but its prognostic value in a large and independent series remains unproven. Furthermore, the intermediate-risk cytogenetic subgroup defined by the IPSS includes a miscellaneous number of different single abnormalities of uncertain prognostic significance at present. The main aim of the present study was to identify chromosomal abnormalities with a previously unrecognized good or poor prognosis in order to find new cytogenetic markers with predictive value. We report the cytogenetic findings in a series of 968 patients with primary MDS from the Spanish Cytogenetics Working Group, Grupo Cooperativo Español de Citogenética Hematológica (GCECGH). In this series of 968 MDS patients, we found various cytogenetic aberrations with a new prognostic impact. Complex karyotype, -7/7q- and i(17q) had a poor prognosis; normal karyotype, loss of Y chromosome, deletion 11q, deletion 12p and deletion 20q as single alterations had a good prognosis. Intermediate prognosis aberrations were rearrangements of 3q21q26, trisomy 8, trisomy 9, translocations of 11q and del(17p). Finally, a new group of single or double cytogenetic abnormalities, most of which are considered rare cytogenetic events and are usually included in the intermediate category of the IPSS, showed a trend to poor prognosis. This study suggests that some specific chromosomal abnormalities could be segregated from the IPSS intermediate-risk cytogenetic prognostic subgroup and included in the low risk or in the poor risk groups.

Systematic Therapeutic Drug Monitoring for Linezolid: Variability and Clinical Impact

PubMed Central

Valerio, Maricela; Muñoz, Patricia; Alcalá, Luis; García-González, Xandra; Burillo, Almudena; Sanjurjo, María; Grau, Santiago

2017-01-01

ABSTRACT Linezolid serum trough (Cmin) and peak (Cmax) levels were determined prospectively in 90 patients. Adequate exposure was defined as a Cmin of 2 to 8 mg/liter. Therapy was empirical (73.3%) or targeted (26.7%). Wide interindividual variability in linezolid Cmin levels was recorded (0.1 to 25.2 μg/ml). Overall, 65.5% of the patients had out-of-range, 41.1% had subtherapeutic, and 24.4% had supratherapeutic trough levels. We did not find a correlation between abnormal levels and adverse events, in-hospital mortality, or overall poor outcome. PMID:28739788

Diabetes Information Technology: Designing Informatics Systems to Catalyze Change in Clinical Care

PubMed Central

Lester, William T.; Zai, Adrian H.; Chueh, Henry C.; Grant, Richard W.

2008-01-01

Current computerized reminder and decision support systems intended to improve diabetes care have had a limited effect on clinical outcomes. Increasing pressures on health care networks to meet standards of diabetes care have created an environment where information technology systems for diabetes management are often created under duress, appended to existing clinical systems, and poorly integrated into the existing workflow. After defining the components of diabetes disease management, the authors present an eight-step conceptual framework to guide the development of more effective diabetes information technology systems for translating clinical information into clinical action. PMID:19885355

Early acute myeloblastic leukemia treatment for childhood myelodysplastic syndrome with t(3;5) (NPM/MLF1).

PubMed

Sevilla, Julián; Fernández-Plaza, Sandra; Lassaletta, Alvaro; González-Vicent, Marta; Contra, Trinidad; Madero, Luis

2007-12-01

Myelodysplastic syndromes (MDS) in childhood are rare hematologic diseases. MDS with t(3;5) (NPM/MLF1) is an unusual subtype without a well-defined clinical and prognostic pattern. A poor outcome has been reported, suggesting that hematopoietic transplantation is the only treatment option. Here in we described a 2-year-old child diagnosed with the disease, without a suitable hematopoietic donor, treated early in the disease with chemotherapy. He is alive and well 4 years after the end of treatment. This unusual MDS needs further studies to better understand the disease.

Principal components derived from CSF inflammatory profiles predict outcome in survivors after severe traumatic brain injury.

PubMed

Kumar, Raj G; Rubin, Jonathan E; Berger, Rachel P; Kochanek, Patrick M; Wagner, Amy K

2016-03-01

Studies have characterized absolute levels of multiple inflammatory markers as significant risk factors for poor outcomes after traumatic brain injury (TBI). However, inflammatory marker concentrations are highly inter-related, and production of one may result in the production or regulation of another. Therefore, a more comprehensive characterization of the inflammatory response post-TBI should consider relative levels of markers in the inflammatory pathway. We used principal component analysis (PCA) as a dimension-reduction technique to characterize the sets of markers that contribute independently to variability in cerebrospinal (CSF) inflammatory profiles after TBI. Using PCA results, we defined groups (or clusters) of individuals (n=111) with similar patterns of acute CSF inflammation that were then evaluated in the context of outcome and other relevant CSF and serum biomarkers collected days 0-3 and 4-5 post-injury. We identified four significant principal components (PC1-PC4) for CSF inflammation from days 0-3, and PC1 accounted for the greatest (31%) percentage of variance. PC1 was characterized by relatively higher CSF sICAM-1, sFAS, IL-10, IL-6, sVCAM-1, IL-5, and IL-8 levels. Cluster analysis then defined two distinct clusters, such that individuals in cluster 1 had highly positive PC1 scores and relatively higher levels of CSF cortisol, progesterone, estradiol, testosterone, brain derived neurotrophic factor (BDNF), and S100b; this group also had higher serum cortisol and lower serum BDNF. Multinomial logistic regression analyses showed that individuals in cluster 1 had a 10.9 times increased likelihood of GOS scores of 2/3 vs. 4/5 at 6 months compared to cluster 2, after controlling for covariates. Cluster group did not discriminate between mortality compared to GOS scores of 4/5 after controlling for age and other covariates. Cluster groupings also did not discriminate mortality or 12 month outcomes in multivariate models. PCA and cluster analysis establish that a subset of CSF inflammatory markers measured in days 0-3 post-TBI may distinguish individuals with poor 6-month outcome, and future studies should prospectively validate these findings. PCA of inflammatory mediators after TBI could aid in prognostication and in identifying patient subgroups for therapeutic interventions. Copyright © 2015 Elsevier Inc. All rights reserved.

Profile, risk factors and outcome of acute kidney injury in paediatric acute-on-chronic liver failure.

PubMed

Lal, Bikrant B; Alam, Seema; Sood, Vikrant; Rawat, Dinesh; Khanna, Rajeev

2018-01-11

There are no studies on acute kidney injury in paediatric acute-on-chronic liver failure. This study was planned with aim to describe the clinical presentation and outcome of acute kidney injury among paediatric acute-on-chronic liver failure patients. Data of all children 1-18 years of age presenting with acute chronic liver failure (Asia pacific association for the study of the liver definition) was reviewed. Acute kidney injury was defined as per Kidney Diseases-Improving Global Outcomes guidelines. Poor outcome was defined as death or need for liver transplant within 3 months of development of acute kidney injury. A total of 84 children with acute-on-chronic liver failure were presented to us in the study period. Acute kidney injury developed in 22.6% of patients with acute-on-chronic liver failure. The median duration from acute-on-chronic liver failure to development of acute kidney injury was 4 weeks (Range: 2-10 weeks). The causes of acute kidney injury were hepatorenal syndrome (31.6%), sepsis (31.6%), nephrotoxic drugs (21%), dehydration (10.5%) and bile pigment related acute tubular necrosis in one patient. On univariate analysis, higher baseline bilirubin, higher international normalized ratio, higher paediatric end stage liver disease, presence of systemic inflammatory response syndrome and presence of spontaneous bacterial peritonitis had significant association with presence of acute kidney injury. On logistic regression analysis, presence of systemic inflammatory response syndrome (adjusted OR: 8.659, 95% CI: 2.18-34.37, P = .002) and higher baseline bilirubin (adjusted OR: 1.07, 95% CI: 1.008-1.135, P = .025) were independently associated with presence of acute kidney injury. Of the patients with acute kidney injury, 5(26.3%) survived with native liver, 10(52.6%) died and 4 (21.1%) underwent liver transplantation. Acute kidney injury developed in 22.6% of children with acute-on-chronic liver failure. Bilirubin more than 17.7 mg/dL and presence of systemic inflammatory response syndrome were high risk factors for acute kidney injury. Development of acute kidney injury in a child with acute-on-chronic liver failure suggests poor outcome and need for early intervention. © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Glucocorticoid Receptor Polymorphisms and Outcomes in Pediatric Septic Shock.

PubMed

Cvijanovich, Natalie Z; Anas, Nick; Allen, Geoffrey L; Thomas, Neal J; Bigham, Michael T; Weiss, Scott L; Fitzgerald, Julie; Checchia, Paul A; Meyer, Keith; Quasney, Michael; Gedeit, Rainer; Freishtat, Robert J; Nowak, Jeffrey; Raj, Shekhar S; Gertz, Shira; Grunwell, Jocelyn R; Opoka, Amy; Wong, Hector R

2017-04-01

Polymorphisms of the glucocorticoid receptor gene are associated with outcome and corticosteroid responsiveness among patients with inflammatory disorders. We conducted a candidate gene association study to test the hypothesis that these polymorphisms are associated with outcome and corticosteroid responsiveness among children with septic shock. We genotyped 482 children with septic shock for the presence of two glucocorticoid receptor polymorphisms (rs56149945 and rs41423247) associated with increased sensitivity and one glucocorticoid receptor polymorphism (rs6198) associated with decreased sensitivity to corticosteroids. The primary outcome variable was complicated course, defined as 28-day mortality or the persistence of two or more organ failures 7 days after a septic shock diagnosis. We used logistic regression to test for an association between corticosteroid exposure and outcome, within genotype group, and adjusted for illness severity. Multiple PICUs in the United States. Standard care. There were no differences in outcome when comparing the various genotype groups. Among patients homozygous for the wild-type glucocorticoid receptor allele, corticosteroids were independently associated with increased odds of complicated course (odds ratio, 2.30; 95% CI, 1.01-5.21; p = 0.047). Based on these glucocorticoid receptor polymorphisms, we could not detect a beneficial effect of corticosteroids among any genotype group. Among children homozygous for the wild-type allele, corticosteroids were independently associated with increased odds of poor outcome.

Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board.

PubMed

Teherani, Arianne; Hodgson, Carol S; Banach, Mary; Papadakis, Maxine A

2005-10-01

In a previous study, we showed that unprofessional behavior in medical school was associated with subsequent disciplinary action. This study expands on that work by identifying the domains of unprofessional behavior that are most problematic. In this retrospective case-control study, negative comments were extracted from student files for 68 case (disciplined) and 196 matched control (nondisciplined) physicians. Comments were analyzed qualitatively and subsequently quantified. The relationship between domains of behavior and disciplinary action was established through chi-square tests and multivariate analysis of variance. Three domains of unprofessional behavior emerged that were related significantly to later disciplinary outcome: (1) poor reliability and responsibility, (2) lack of self-improvement and adaptability, and (3) poor initiative and motivation. Three critical domains of professionalism associated with future disciplinary action have been defined. These findings could lead to focused remediation strategies and policy decisions.

Health literacy and ophthalmic patient education

PubMed Central

Muir, Kelly W.; Lee, Paul P.

2010-01-01

In 1997, Ebrahimzadeh, Davalos and Lee wrote in this journal that only 32% of the ophthalmic patient educational materials reviewed were written at or below the recommended eighth grade reading level. Since that time, the National Assessment of Adult Literacy found that more than one third of adult Americans possess only basic or below basic health literacy skills, defined as the ability to understand written information in a healthcare setting. Subsequently, investigators have shown that poor health literacy skills are associated with poor prescription medication adherence, increased hospital admissions and increased mortality. We review the readability of currently available ophthalmic educational materials, with particular attention to the health literacy status of the patient population for which the materials are intended. Examples of prose at various readability levels are provided. Optimizing patient education and improving clinical outcomes requires understanding the attributes that the patient brings to the patient–physician relationship, including health literacy. PMID:20650503

Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness.

PubMed

Muszynski, Jennifer A; Spinella, Philip C; Cholette, Jill M; Acker, Jason P; Hall, Mark W; Juffermans, Nicole P; Kelly, Daniel P; Blumberg, Neil; Nicol, Kathleen; Liedel, Jennifer; Doctor, Allan; Remy, Kenneth E; Tucci, Marisa; Lacroix, Jacques; Norris, Philip J

2017-01-01

Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions. © 2016 AABB.

Linking stable and dynamic features of positive affect to sleep.

PubMed

Ong, Anthony D; Exner-Cortens, Deinera; Riffin, Catherine; Steptoe, Andrew; Zautra, Alex; Almeida, David M

2013-08-01

Poor sleep contributes to adult morbidity and mortality. The study examined the extent to which trait positive affect (PA) and PA reactivity, defined as the magnitude of change in daily PA in response to daily events, were linked to sleep outcomes. Analyses are based on data from 100 respondents selected from the National Survey of Midlife in the United States. Multilevel analyses indicated that higher levels of trait PA were associated with greater morning rest and better overall sleep quality. In contrast, PA reactivity was associated with diminished sleep efficiency. Finally, interactions between PA reactivity and trait PA emerged on all three sleep measures, such that higher event-related change in daily positive affect was associated with impaired sleep, especially among individuals high in trait PA. Results suggest that high trait PA, when coupled with high PA reactivity, may contribute to poor sleep.

Validating a pragmatic definition of shock in adult patients presenting to the ED.

PubMed

Li, Yan-ling; Chan, Cangel Pui-yee; Sin, King-keung; Chan, Stewart S W; Lin, Pei-yi; Chen, Xiao-hui; Smith, Brendan E; Joynt, Gavin M; Graham, Colin A; Rainer, Timothy H

2014-11-01

The importance of the early recognition of shock in patients presenting to emergency departments is well recognized, but at present, there is no agreed practical definition for undifferentiated shock. The main aim of this study was to validate an a priori clinical definition of shock against 28-day mortality. This prospective, observational, cross-sectional, single-center study was conducted in Hong Kong, China. Data were collected between July 1, 2012, and January 31, 2013. An a priori definition of shock was designed, whereby patients admitted to the resuscitation room or high dependency area of the emergency department were divided into 1 of 3 groups-no shock, possible shock, and shock. The primary outcome was 28-day mortality. Secondary outcomes were in-hospital mortality or admission to the intensive or coronary care unit. A total of 111 patients (mean age, 67.2 ± 17.1 years; male = 69 [62%]) were recruited, of which 22 were classified as no shock, 54 as possible shock, and 35 as shock. Systolic blood pressure, mean arterial pressure, lactate, and base deficit correlated well with shock classifications (P < .05). Patients who had 3 or more positively defined shock variables had a 100% poor composite outcome rate (5 of 5). Patients with 2 shock variables had a 66.7% (4 of 6) poor composite outcome rate. A simple, practical definition of undifferentiated shock has been proposed and validated in a group of patients presenting to an emergency department in Hong Kong. This definition needs further validation in a larger population and other settings. Copyright © 2014 Elsevier Inc. All rights reserved.

Medial medullary infarction: clinical, imaging, and outcome study in 86 consecutive patients.

PubMed

Kim, Jong S; Han, Young S

2009-10-01

Clinical-imaging correlation and long-term clinical outcomes remain to be investigated in medial medullary infarction (MMI). We studied clinical, MRI, and angiographic data of 86 consecutive MMI patients. The lesions were correlated with clinical findings, and long-term outcomes, divided into mild and severe (modified Rankin scale >3), were assessed by telephone interview. Central poststroke pain (CPSP) was defined as persistent pain with visual numeric scale > or = 4. The lesions were located mostly in the rostral medulla (rostral 76%, rostral+middle 16%), while ventro-dorsal lesion patterns include ventral (V, 20%), ventral+middle (VM, 33%), and ventral+middle+dorsal (VMD, 41%). Clinical manifestations included motor dysfunction in 78 patients (91%), sensory dysfunction in 59 (73%), and vertigo/dizziness in 51 (59%), each closely related to involvement of ventral, middle, and dorsal portions, respectively (P<0.001, each). Vertebral artery (VA) atherosclerotic disease relevant to the infarction occurred in 53 (62%) patients, mostly producing atheromatous branch occlusion (ABO). Small vessel disease (SVD) occurred in 24 (28%) patients. ABO was more closely related to VMD (versus V+VM) than was SVD (P=0.035). During follow-up (mean 71 months), 11 patients died, and recurrent strokes occurred in 11. Old age (P=0.001) and severe motor dysfunction at admission (P=0.001) were factors predicting poor prognosis. CPSP, occurring in 21 patients, was closely (P=0.013) related to poor clinical outcome. MMI usually presents with a rostral medullary lesion, with a good clinical ventro-dorsal imaging correlation, caused most frequently by ABO followed by SVD. A significant proportion of patients remain dependent or have CPSP.

Area racism and birth outcomes among Blacks in the United States.

PubMed

Chae, David H; Clouston, Sean; Martz, Connor D; Hatzenbuehler, Mark L; Cooper, Hannah L F; Turpin, Rodman; Stephens-Davidowitz, Seth; Kramer, Michael R

2018-02-01

There is increasing evidence that racism is a cause of poor health outcomes in the United States, including adverse birth outcomes among Blacks. However, research on the health consequences of racism has faced measurement challenges due to the more subtle nature of contemporary racism, which is not necessarily amenable to assessment through traditionally used survey methods. In this study, we circumvent some of these limitations by examining a previously developed Internet query-based proxy of area racism (Stephens-Davidowitz, 2014) in relation to preterm birth and low birthweight among Blacks. Area racism was measured in 196 designated market areas as the proportion of total Google searches conducted between 2004 and 2007 containing the "n-word." This measure was linked to county-level birth data among Blacks between 2005 and 2008, which were compiled by the National Center for Health Statistics; preterm birth and low birthweight were defined as <37 weeks gestation and <2500 g, respectively. After adjustment for maternal age, Census region, and county-level measures of urbanicity, percent of the Black population, education, and poverty, we found that each standard deviation increase in area racism was associated with relative increases of 5% in the prevalence of preterm birth and 5% in the prevalence of low birthweight among Blacks. Our study provides evidence for the utility of an Internet query-based measure as a proxy for racism at the area-level in epidemiologic studies, and is also suggestive of the role of racism in contributing to poor birth outcomes among Blacks. Copyright © 2017 Elsevier Ltd. All rights reserved.

Mortality determinants and prediction of outcome in high risk newborns.

PubMed

Dalvi, R; Dalvi, B V; Birewar, N; Chari, G; Fernandez, A R

1990-06-01

The aim of this study was to determine independent patient-related predictors of mortality in high risk newborns admitted at our centre. The study population comprised 100 consecutive newborns each, from the premature unit (PU) and sick baby care unit (SBCU), respectively. Thirteen high risk factors (variables) for each of the two units, were entered into a multivariate regression analysis. Variables with independent predictive value for poor outcome (i.e., death) in PU were, weight less than 1 kg, hyaline membrane disease, neurologic problems, and intravenous therapy. High risk factors in SBCU included, blood gas abnormality, bleeding phenomena, recurrent convulsions, apnea, and congenital anomalies. Identification of these factors guided us in defining priority areas for improvement in our system of neonatal care. Also, based on these variables a simple predictive score for outcome was constructed. The prediction equation and the score were cross-validated by applying them to a 'test-set' of 100 newborns each for PU and SBCU. Results showed a comparable sensitivity, specificity and error rate.

Supportive Care: Integration of Patient-Centered Kidney Care to Manage Symptoms and Geriatric Syndromes

PubMed Central

Jassal, Sarbjit Vanita

2016-01-01

Dialysis care is often associated with poor outcomes including low quality of life (QOL). To improve patient-reported outcomes, incorporation of the patient’s needs and perspective into the medical care they receive is essential. This article provides a framework to help clinicians integrate symptom assessment and other measures such as QOL and frailty scores into a clinical approach to the contemporary supportive care of patients with advanced CKD. This approach involves (1) defining our understanding of kidney supportive care, patient-centered dialysis, and palliative dialysis; (2) understanding and recognizing common symptoms associated with advanced CKD; (3) discussing the concepts of physical function, frailty, and QOL and their role in CKD; and (4) identifying the structural and process barriers that may arise when patient-centered dialysis is being introduced into clinical practice. PMID:27510454

The effectiveness and safety of acupuncture for poor semen quality in infertile males: a systematic review and meta-analysis

PubMed Central

Jerng, Ui Min; Jo, Jun-Young; Lee, Seunghoon; Lee, Jin-Moo; Kwon, Ohmin

2014-01-01

The aim of this review is to evaluate the effectiveness and safety of acupuncture for poor semen quality in infertile men. We searched for relevant trials registered up to May 2013 in 14 databases. We selected randomized controlled trials (RCTs) that compared acupuncture, with or without additional treatment, against placebo, sham, no treatment, or the same additional treatment. Two reviewers independently performed the study selection, data extraction, risk of bias and reporting quality appraisal. Risk of bias and reporting quality were appraised by the Cochrane risk of bias tool, the consolidated standards of reporting trials and Standards for Reporting Interventions in Clinical Trials of Acupuncture. The outcomes were sperm motility, sperm concentration, pregnancy rate, and adverse events. Pregnancy was defined as a positive pregnancy test. Four RCTs met the eligibility criteria. Acupuncture increased the percentage of sperm with rapid progression (mean difference - 6.35, 95% confidence interval (CI): 4.38–8.32, P< 0.00001) and sperm concentration (mean difference - 6.42, 95% CI: 4.91–7.92, P< 0.00001), but these two outcomes were substantially heterogeneous among the studies (I2 = 72% and 58%, respectively). No differences in pregnancy rate were found between acupuncture and control groups (odds ratio 1.60, 95% CI: 0.70–3.69, P= 0.27, I2 = 0%). No participants experienced adverse events. The current evidence showing that acupuncture might improve poor semen quality is insufficient because of the small number of studies, inadequacy of procedures and/or insufficient information for semen analysis, high levels of heterogeneity, high risk of bias, and poor quality of reporting. Further large, well-designed RCTs are required. PMID:25038176

The accuracy of assessment of walking distance in the elective spinal outpatients setting.

PubMed

Okoro, Tosan; Qureshi, Assad; Sell, Beulah; Sell, Philip

2010-02-01

Self reported walking distance is a clinically relevant measure of function. The aim of this study was to define patient accuracy and understand factors that might influence perceived walking distance in an elective spinal outpatients setting. A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and other measures. There are over-estimators and under-estimators. Overall, the accuracy to within 9.14 metres (m) (10 yards) was poor at only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 111 m; mean response 245 m (95% CI 176.3-314.7), Functional test 1 actual distance 29.2 m; mean response 71.7 m (95% CI 53.6-88.9) Functional test 2 actual distance 19.6 m; mean response 47.4 m (95% CI 35.02-59.95). Surprisingly patients over 60 years of age (n = 43) are twice as accurate with each test performed compared to those under 60 (n = 60) (average 70% overestimation compared to 140%; p = 0.06). Patients in social class I (n = 18) were more accurate than those in classes II-V (n = 85): There was a positive correlation between poor accuracy and increasing MZD (Pearson's correlation coefficient 0.250; p = 0.012). ODI, LBOS and other parameters measured showed no correlation. Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate but still poor.

Short-term intensive family therapy for adolescent eating disorders: 30-month outcome.

PubMed

Marzola, Enrica; Knatz, Stephanie; Murray, Stuart B; Rockwell, Roxanne; Boutelle, Kerri; Eisler, Ivan; Kaye, Walter H

2015-05-01

Family therapy approaches have generated impressive empirical evidence in the treatment of adolescent eating disorders (EDs). However, the paucity of specialist treatment providers limits treatment uptake; therefore, our group developed the intensive family therapy (IFT)-a 5-day treatment based on the principles of family-based therapy for EDs. We retrospectively examined the long-term efficacy of IFT in both single-family (S-IFT) and multi-family (M-IFT) settings evaluating 74 eating disordered adolescents who underwent IFT at the University of California, San Diego, between 2006 and 2013. Full remission was defined as normal weight (≥ 95% of expected for sex, age, and height), Eating Disorder Examination Questionnaire (EDE-Q) global score within 1 SD of norms, and absence of binge-purging behaviours. Partial remission was defined as weight ≥ 85% of expected or ≥ 95% but with elevated EDE-Q global score and presence of binge-purging symptoms (<1/week). Over a mean follow-up period of 30 months, 87.8% of participants achieved either full (60.8%) or partial remission (27%), while 12.2% reported a poor outcome, with both S-IFT and M-IFT showing comparable outcomes. Short-term, intensive treatments may be cost-effective and clinically useful where access to regular specialist treatment is limited. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.

Adverse pregnancy outcomes in women with nausea and vomiting of pregnancy.

PubMed

Temming, Lorene; Franco, Albert; Istwan, Niki; Rhea, Debbie; Desch, Cheryl; Stanziano, Gary; Joy, Saju

2014-01-01

To examine the influence of nausea and vomiting of pregnancy (NVP) on pregnancy outcomes. Outcomes were compared for primigravidas with a current singleton gestation enrolled at <20 weeks' gestation in a maternity risk screening and education program (n = 81 486). Patient-reported maternal characteristics and pregnancy outcomes were compared for women with and without NVP and within the NVP group for those with and without poor weight gain. 6.4% of women reported NVP as a pregnancy complication. Women reporting NVP were more likely to be younger, obese, single and smoke. They had higher rates of preterm delivery, pregnancy-induced hypertension and low birth weight <2500 g. Almost one-quarter of women with NVP had lower than recommended weight gain. Poor weight gain was associated with a higher incidence of adverse outcomes. Obesity, tobacco use and poor pregnancy weight gain independently increased the odds of an adverse outcome. NVP and subsequent poor weight gain may be associated with adverse pregnancy outcomes.

Advances in Risk Classification and Treatment Strategies for Neuroblastoma.

PubMed

Pinto, Navin R; Applebaum, Mark A; Volchenboum, Samuel L; Matthay, Katherine K; London, Wendy B; Ambros, Peter F; Nakagawara, Akira; Berthold, Frank; Schleiermacher, Gudrun; Park, Julie R; Valteau-Couanet, Dominique; Pearson, Andrew D J; Cohn, Susan L

2015-09-20

Risk-based treatment approaches for neuroblastoma have been ongoing for decades. However, the criteria used to define risk in various institutional and cooperative groups were disparate, limiting the ability to compare clinical trial results. To mitigate this problem and enhance collaborative research, homogenous pretreatment patient cohorts have been defined by the International Neuroblastoma Risk Group classification system. During the past 30 years, increasingly intensive, multimodality approaches have been developed to treat patients who are classified as high risk, whereas patients with low- or intermediate-risk neuroblastoma have received reduced therapy. This treatment approach has resulted in improved outcome, although survival for high-risk patients remains poor, emphasizing the need for more effective treatments. Increased knowledge regarding the biology and genetic basis of neuroblastoma has led to the discovery of druggable targets and promising, new therapeutic approaches. Collaborative efforts of institutions and international cooperative groups have led to advances in our understanding of neuroblastoma biology, refinements in risk classification, and stratified treatment strategies, resulting in improved outcome. International collaboration will be even more critical when evaluating therapies designed to treat small cohorts of patients with rare actionable mutations. © 2015 by American Society of Clinical Oncology.

Functional outcome of microsurgical clipping compared to endovascular coiling.

PubMed

Premananda, R M; Ramesh, N; Hillol, K P

2012-12-01

Endovascular coiling has been used increasingly as an alternative to neurosurgical clipping for treating subarachnoid hemorrhage secondary to aneurysm rupture. In a retrospective cohort review on the treatment methods of aneurysm rupture in Hospital Kuala Lumpur over the period of five years (2005-2009) a total of 268 patients were treated. These patients were broadly categorized into two groups based on their treatment mode for ruptured aneurysms. Statistical analysis was determined using Chi- Square tests to study these associations. In our study, 67.5% of patients presented with Good World Federation of Neurosurgical Societies (WFNS) grade (WFNS1-2) while 32.5% patients presented with Poor WFNS prior to intervention. In our outcome, it was noted that 60.4% had good functional outcome (mRS grade 0-2) as compared to 39.6% patients who had poor mRS(modified rankin scale) outcome (mRS 3-6). In the good WFNS group, 76% of patients in clipping group had a good mRS outcome while, 86.5% patients in coiling group had good mRS outcome (p=0.114). In poor WFNS presentation, it was noted that in 77.3% patients in clipping group, had poor mRS outcome. Similarly with poor WFNS presentation, 83.3% of patient in coiling group had poor outcome. (p=1.00). Hence when we control the WFNS group, there was no significant association between treatment group (clipping and coiling) and mRS outcome at 6 months. The outcome of patient is determined by initial clinical presentation (WFNS grade) and influenced by requirement of Extraventricular drain (EVD) in presence of hydrocephalus, CSF infection and pneumonia. Therefore the decision regarding treatment option needs to be individualized based on the presentation of the patient.

Conduct problems trajectories and psychosocial outcomes: a systematic review and meta-analysis.

PubMed

Bevilacqua, Leonardo; Hale, Daniel; Barker, Edward D; Viner, Russell

2017-10-06

There is increasing evidence that youth who follow the early onset persistent (EOP), adolescent-onset (AO) and childhood-limited (CL) trajectories of conduct problems show varying patterns of health, mental health, educational, and social outcomes in adulthood. However, there has been no systematic review and meta-analysis on outcomes associated with different conduct problems trajectories. We systematically reviewed the literature of longitudinal studies considering outcomes of three conduct problems trajectories: EOP, AO, and CL compared with individuals with low levels of conduct problems (low). We performed a series of meta-analyses comparing each trajectory to the low group for eight different outcomes in early adulthood or later. Thirteen studies met our inclusion criteria. Outcomes were mental health (depression), cannabis use, alcohol use, self-reported aggression, official records of antisocial behaviour, poor general health, poor education, and poor employment. Overall, EOP individuals showed significant higher risk of poor outcome followed by AO individuals, CL individuals, and finally participants in the low group. All conduct problems trajectories showed higher risk of poor psychosocial outcomes compared to the low group, but the magnitude of risk differed across trajectories, with a general trend for the EOP to perform significantly worse, followed by the AO and CL. Early intervention is recommended across domains to maximise likelihood of desistance from antisocial behaviour and improvement on several psychosocial outcomes.

Educational attainment in poor comprehenders

PubMed Central

Ricketts, Jessie; Sperring, Rachael; Nation, Kate

2014-01-01

To date, only one study has investigated educational attainment in poor (reading) comprehenders, providing evidence of poor performance on national UK school tests at age 11 years relative to peers (Cain and Oakhill, 2006). In the present study, we adopted a longitudinal approach, tracking attainment on such tests from 11 years to the end of compulsory schooling in the UK (age 16 years). We aimed to investigate the proposal that educational weaknesses (defined as poor performance on national assessments) might become more pronounced over time, as the curriculum places increasing demands on reading comprehension. Participants comprised 15 poor comprehenders and 15 controls; groups were matched for chronological age, nonverbal reasoning ability and decoding skill. Children were identified at age 9 years using standardized measures of nonverbal reasoning, decoding and reading comprehension. These measures, along with a measure of oral vocabulary knowledge, were repeated at age 11 years. Data on educational attainment were collected from all participants (n = 30) at age 11 and from a subgroup (n = 21) at 16 years. Compared to controls, educational attainment in poor comprehenders was lower at ages 11 and 16 years, an effect that was significant at 11 years. When poor comprehenders were compared to national performance levels, they showed significantly lower performance at both time points. Low educational attainment was not evident for all poor comprehenders. Nonetheless, our findings point to a link between reading comprehension difficulties in mid to late childhood and poor educational outcomes at ages 11 and 16 years. At these ages, pupils in the UK are making key transitions: they move from primary to secondary schools at 11, and out of compulsory schooling at 16. PMID:24904464

Characterization of premorbid functioning during childhood in patients with deficit vs. non-deficit schizophrenia and in their healthy siblings.

PubMed

Bucci, Paola; Mucci, Armida; Piegari, Giuseppe; Nobile, Maria; Pini, Stefano; Rossi, Alessandro; Vita, Antonio; Galderisi, Silvana; Maj, Mario

2016-07-01

Impaired premorbid adjustment has been reported in patients with schizophrenia, generally in association with unfavorable aspects of the illness (e.g., poor outcome and severe negative symptoms). Several studies attempted to define the domains of premorbid dysfunction associated with negative symptoms and poor outcome; however, most of them assessed broadly defined negative symptoms. The present study was aimed to characterize premorbid functioning in a group of patients with deficit schizophrenia (DS), characterized by the presence of at least two primary and persistent negative symptoms (PPNS), and one of patients with a diagnosis of schizophrenia who did not meet criteria for DS (NDS). The presence of emotional/behavioral problems during childhood was investigated using the Childhood Behavior Checklist (CBCL) in both patient groups and in their respective healthy siblings. The Premorbid Adjustment Scale (PAS) was also used to assess premorbid functioning during childhood in the two patient groups. PPNS were also treated as a continuous variable and correlated with the indices of premorbid functioning regardless the DS/NDS categorization. DS patients, as compared to NDS, showed higher scores on the CBCL subscale "Withdrawn". Both DS and NDS patients showed, as compared to their healthy siblings, a greater impairment on almost all CBCL subscales. PAS findings revealed that DS patients had poorer premorbid adjustment than NDS. No significant correlation between premorbid functioning and PPNS was observed. These findings support the hypothesis that DS has a different developmental trajectory with respect to NDS, and that premorbid adjustment is one of the essential aspects of its characterization. Copyright © 2016 Elsevier B.V. All rights reserved.

Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial.

PubMed

Siddiqui, Naveed; Arzola, Cristian; Friedman, Zeev; Guerina, Laarni; You-Ten, Kong Eric

2015-11-01

Misidentification of the cricothyroid membrane in a "cannot intubate-cannot oxygenate" situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy. A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1-easy = visual landmarks; 2-moderate = requires light palpation of landmarks; 3-difficult = requires deep palpation of landmarks; and 4-impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time. Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult-impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001). Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Prediction of outcome in newly diagnosed myeloma: a meta-analysis of the molecular profiles of 1905 trial patients

PubMed Central

Shah, V; Sherborne, A L; Walker, B A; Johnson, D C; Boyle, E M; Ellis, S; Begum, D B; Proszek, P Z; Jones, J R; Pawlyn, C; Savola, S; Jenner, M W; Drayson, M T; Owen, R G; Houlston, R S; Cairns, D A; Gregory, W M; Cook, G; Davies, F E; Jackson, G H; Morgan, G J; Kaiser, M F

2018-01-01

Robust establishment of survival in multiple myeloma (MM) and its relationship to recurrent genetic aberrations is required as outcomes are variable despite apparent similar staging. We assayed copy number alterations (CNA) and translocations in 1036 patients from the NCRI Myeloma XI trial and linked these to overall survival (OS) and progression-free survival. Through a meta-anlysis of these data with data from MRC Myeloma IX trial, totalling 1905 newly diagnosed MM patients (NDMM), we confirm the association of t(4;14), t(14;16), t(14;20), del(17p) and gain(1q21) with poor prognosis with hazard ratios (HRs) for OS of 1.60 (P=4.77 × 10−7), 1.74 (P=0.0005), 1.90 (P=0.0089), 2.10 (P=8.86 × 10−14) and 1.68 (P=2.18 × 10−14), respectively. Patients with ‘double-hit’ defined by co-occurrence of at least two adverse lesions have an especially poor prognosis with HRs for OS of 2.67 (P=8.13 × 10−27) for all patients and 3.19 (P=1.23 × 10−18) for intensively treated patients. Using comprehensive CNA and translocation profiling in Myeloma XI we also demonstrate a strong association between t(4;14) and BIRC2/BIRC3 deletion (P=8.7 × 10−15), including homozygous deletion. Finally, we define distinct sub-groups of hyperdiploid MM, with either gain(1q21) and CCND2 overexpression (P<0.0001) or gain(11q25) and CCND1 overexpression (P<0.0001). Profiling multiple genetic lesions can identify MM patients likely to relapse early allowing stratification of treatment. PMID:28584253

Impact of statin adherence on cardiovascular disease and mortality outcomes: a systematic review

PubMed Central

De Vera, Mary A; Bhole, Vidula; Burns, Lindsay C; Lacaille, Diane

2014-01-01

Aims While suboptimal adherence to statin medication has been quantified in real-world patient settings, a better understanding of its impact is needed, particularly with respect to distinct problems of medication taking. Our aim was to synthesize current evidence on the impacts of statin adherence, discontinuation and persistence on cardiovascular disease and mortality outcomes. Methods We conducted a systematic review of peer-reviewed studies using a mapped search of Medline, Embase and International Pharmaceutical Abstracts databases. Observational studies that met the following criteria were included: defined patient population; statin adherence exposure; defined study outcome [i.e. cardiovascular disease (CVD), mortality]; and reporting of statin-specific results. Results Overall, 28 studies were included, with 19 studies evaluating outcomes associated with statin adherence, six with statin discontinuation and three with statin persistence. Among adherence studies, the proportion of days covered was the most widely used measure, with the majority of studies reporting increased risk of CVD (statistically significant risk estimates ranging from 1.22 to 5.26) and mortality (statistically significant risk estimates ranging from 1.25 to 2.54) among non-adherent individuals. There was greater methodological variability in discontinuation and persistence studies. However, findings of increased CVD (statistically significant risk estimates ranging from 1.22 to 1.67) and mortality (statistically significant risk estimates ranging from 1.79 to 5.00) among nonpersistent individuals were also consistently reported. Conclusions Observational studies consistently report an increased risk of adverse outcomes associated with poor statin adherence. These findings have important implications for patients and physicians and emphasize the importance of monitoring and encouraging adherence to statin therapy. PMID:25364801

A literature review on self-care of chronic illness: definition, assessment and related outcomes.

PubMed

Ausili, Davide; Masotto, Matteo; Dall'Ora, Chiara; Salvini, Lorena; Di Mauro, Stefania

2014-01-01

Chronic illnesses care represents a challenging issue for people well-being and future health systems' sustainability. Promotion of self-care is considered a key point for chronically ill patients' care. The aim of this literature was to explore: how self-care of chronic illness has been theoretically defined; how self-care can be assessed in clinical and research settings; what associations exist between self-care and health outcomes of chronically ill patients. A wide range of definitions and terminologies related to self-care of chronic illness has been found in the literature. Although some common elements useful to explain the concept of self-care have been identified, the physical, cognitive, emotional and social processes underlying self-care remain controversial and poorly defined. Valid and reliable disease-specific assessment tools have been developed and used in a growing number of studies; however, the lack of utilization of standardized instruments in clinical practice has been referred by many authors. Significant correlations between self-care of chronic illness and outcome measures e.g. general health status, quality of life and healthcare costs, are reported by a limited number of studies. Supporting patient self-care is recognized as a crucial factor in chronic illness care. A deeper analysis of variables and processes influencing self-care could help for a full description of the phenomenon. A systematic evaluation of self-care in health professionals' everyday clinical practice is strongly recommended. The development of general non-disease-specific assessment tools could facilitate the evaluation of complex patients, especially those with multiple co-morbidities. Although self-care has been recognized as a vital intermediate outcome, further large-scale studies clarifying the association between self-care and patients' and health systems' outcomes are needed.

One-Year Randomized Controlled Trial and Follow-Up of Integrated Neurocognitive Therapy for Schizophrenia Outpatients

PubMed Central

Mueller, Daniel R.; Schmidt, Stefanie J.; Roder, Volker

2015-01-01

Objective: Cognitive remediation (CR) approaches have demonstrated to be effective in improving cognitive functions in schizophrenia. However, there is a lack of integrated CR approaches that target multiple neuro- and social-cognitive domains with a special focus on the generalization of therapy effects to functional outcome. Method: This 8-site randomized controlled trial evaluated the efficacy of a novel CR group therapy approach called integrated neurocognitive therapy (INT). INT includes well-defined exercises to improve all neuro- and social-cognitive domains as defined by the Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative by compensation and restitution. One hundred and fifty-six outpatients with a diagnosis of schizophrenia or schizoaffective disorder according to DSM-IV-TR or ICD-10 were randomly assigned to receive 15 weeks of INT or treatment as usual (TAU). INT patients received 30 bi-weekly therapy sessions. Each session lasted 90min. Mixed models were applied to assess changes in neurocognition, social cognition, symptoms, and functional outcome at post-treatment and at 9-month follow-up. Results: In comparison to TAU, INT patients showed significant improvements in several neuro- and social-cognitive domains, negative symptoms, and functional outcome after therapy and at 9-month follow-up. Number-needed-to-treat analyses indicate that only 5 INT patients are necessary to produce durable and meaningful improvements in functional outcome. Conclusions: Integrated interventions on neurocognition and social cognition have the potential to improve not only cognitive performance but also functional outcome. These findings are important as treatment guidelines for schizophrenia have criticized CR for its poor generalization effects. PMID:25713462

"Low Income"--Levels in the Jewish Population; The "Jewish Poor" in Los Angeles. A Summary of Findings.

ERIC Educational Resources Information Center

Massarik, Fred

The concept "Jewish Poor" is defined simply as Jewish households (viz. households containing one or more persons defined as Jewish) whose total household cash income (1969, comparable to U.S. Census) was under 4000 dollars. The data were obtained from four sources: (1) analysis of "Jewish Poor" drawn from Los Angeles phase of…

Perception of overweight is associated with poor academic performance in US adolescents.

PubMed

Florin, Todd A; Shults, Justine; Stettler, Nicolas

2011-11-01

To improve understanding of the mechanisms affecting the relationship between adolescent obesity and poor academic performance, we examined the association of overweight or perceived weight status with academic achievement. We performed a cross-sectional study of 14-17-year-olds (N = 11,012) from the nationally representative 2003 Youth Risk Behavior Survey. The main outcome measure was self-reported grades (mostly A, B, C, D, or F). The primary independent variables were medically defined overweight (body mass index [BMI] ≥ 85th percentile), obesity (BMI ≥ 95th percentile), and participants' perception of their weight status. Medically defined overweight youth were less likely to report higher grades in unadjusted analysis (OR 0.67, 95% CI: 0.60-0.76, p < .001) and after adjustment for demographics, depression, television and video game use, and physical activity (OR 0.83, 95% CI: 0.74-0.94, p = .003). Statistically significant results also were seen with medically defined obese participants. Youth who perceived themselves as overweight were less likely to report higher grades (OR 0.82, 95% CI: 0.73-0.92, p = .001) in unadjusted analysis and after adjustment for the same variables (OR 0.79, 95% CI: 0.68-0.91, p = .002). The perception of overweight was a more significant determinant of academic performance (OR 0.81, 95% CI: 0.69-0.95, p = .012) compared to medically defined obesity (OR 0.90, 95% CI: 0.77-1.05, p = .174). Perceived overweight status is negatively associated with academic performance, regardless of actual weight status. These findings suggest that perception of overweight may be a mechanism for prior results indicating a negative association of obesity and academic achievements, and have implications for the academic health of these adolescents. © 2011, American School Health Association.

Residential mobility and the association between physical environment disadvantage and general and mental health.

PubMed

Tunstall, H; Pearce, J R; Shortt, N K; Mitchell, R J

2015-12-01

Selective migration may influence the association between physical environments and health. This analysis assessed whether residential mobility concentrates people with poor health in neighbourhoods of the UK with disadvantaged physical environments. Data were from the British Household Panel Survey. Moves were over 1 year between adjacent survey waves, pooled over 10 pairs of waves, 1996-2006. Health outcomes were self-reported poor general health and mental health problems. Neighbourhood physical environment was defined using the Multiple Environmental Deprivation Index (MEDIx) for wards. Logistic regression analysis compared risk of poor health in MEDIx categories before and after moves. Analyses were stratified by age groups 18-29, 30-44, 45-59 and 60+ years and adjusted for age, sex, marital status, household type, housing tenure, education and social class. The pooled data contained 122 570 observations. 8.5% moved between survey waves but just 3.0% changed their MEDIx category. In all age groups odds ratios for poor general and mental health were not significantly increased in the most environmentally deprived neighbourhoods following moves. Over a 1-year time period residential moves between environments with different levels of multiple physical deprivation were rare and did not significantly raise rates of poor health in the most deprived areas. © The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Third-line antiepileptic therapy and outcome in status epilepticus: the impact of vasopressor use and prolonged mechanical ventilation.

PubMed

Kowalski, Robert G; Ziai, Wendy C; Rees, Richard N; Werner, J Kent; Kim, Grace; Goodwin, Haley; Geocadin, Romergryko G

2012-09-01

To characterize associations between antiepileptic drugs with sedating or anesthetic effects (third-line antiepileptic drugs) vs. other antiepileptic agents, and short-term outcomes, in status epilepticus. Furthermore, to evaluate the role of adverse hemodynamic and respiratory effects of these agents in status epilepticus treatment. Retrospective comparative analysis. Tertiary academic medical center with two emergency departments and two neurologic intensive care units. Adults admitted with a diagnosis of status epilepticus defined as seizures lasting continuously >5 mins, or for discrete periods in succession. None. Of 126 patients with 144 separate status epilepticus admissions, 57 were female (45%) with mean age 54.7 ± 15.7 yrs. Status epilepticus was convulsive in 132 cases (92%). Status epilepticus etiologies included subtherapeutic antiepileptic drugs (43%), alcohol or other nonantiepileptic drug (13%), and acute central nervous system disease (12%). Third-line antiepileptic drugs were administered in 47 cases (33%). Seventy-eight status epilepticus episodes (54%) had good outcomes (Glasgow Outcome Score = 1, 2) at the time of hospital discharge. On univariate analysis, poor outcome (Glasgow Outcome Score > 2) was associated with older age (mean 59.8 ± 15.5 vs. 50.5 ± 13.8 yrs, p < .001), acute central nervous system disease (21% vs. 4%, p = .001), mechanical ventilation (76% vs. 53%, p = .004), longer duration of ventilation (median 10 days [range 1-56] vs. 2 days [range 1-10], p < .001), treatment with vasopressors (35% vs. 5%, p < .001), and treatment with third-line antiepileptic drugs (51% vs. 17%, p < .001). Death was associated with acute central nervous system disease, prolonged ventilation, treatment with vasopressors, and treatment with third-line antiepileptic drugs. Predictors of poor outcome among all status epilepticus episodes were older age (odds ratio 1.06; 95% confidence interval 1.03-1.09; p < .001), treatment with third-line antiepileptic therapy (odds ratio 5.64; 95% confidence interval 2.31-13.75; p < .001), and first episode of status epilepticus (odds ratio 3.73; 95% confidence interval 1.38-10.10; p = .010). Among status epilepticus episodes treated by third-line antiepileptic drugs, predictors of poor outcome were older age (odds ratio, 1.09; 95% confidence interval 1.01-1.18; p = .038) and longer ventilation (odds ratio, 1.47; 95% confidence interval 1.08-2.00; p = .015). Predictors of mortality among all status epilepticus episodes were treatment with third-line antiepileptic drugs (odds ratio, 12.08; 95% confidence interval 2.30-63.39; p = .003) and older age (odds ratio, 1.06; 95% confidence interval 1.00-1.12; p = .045). Third-line antiepileptic drug therapies with sedating or anesthetic effects predicted poor outcome and death in status epilepticus. Hypotension requiring vasopressor therapy and duration of mechanical ventilation induced by these agents may be contributing factors, especially when pentobarbital is used. These findings may inform decision making on drug therapy in status epilepticus and help develop safer and more effective treatment strategies to improve outcome.

Ischemic strokes in Pakistan: observations from the national acute ischemic stroke database.

PubMed

Khealani, Bhojo A; Khan, Maria; Tariq, Muhammad; Malik, Abdul; Siddiqi, Alam I; Awan, Safia; Wasay, Mohammad

2014-07-01

The objective of this study was to establish a multicenter ischemic stroke registry, first of its kind in Pakistan, to provide insight into the epidemiology, subtypes, and risk factors of ischemic strokes in this country. Four academic centers (3 urban and 1 rural) participated in this project. The inclusion criteria for subjects included adults (>14 years) with acute neurologic deficit, consistent with clinical diagnosis of ischemic stroke and supported by neuroimaging. Data were available for 874 subjects. Mean age of the subjects was 59.7 years, 60.5% were males, and 18% were young. Large vessel strokes were the most common subtype found in 31.7% subjects, followed by small vessel disease (25.7%) and cardioembolic strokes (10.4%). Almost 32% subjects had ill-defined etiology for their ischemic stroke. Dyslipidemia was a most common risk factor present in 83% patients. Data related to in-hospital complications were available for 808 subjects, of which 233 complications were recorded. Pneumonia was the most common of these seen in 105 (13%) subjects, followed by urinary tract infection (7.2%). Outcome at discharge was recorded for 697 subjects. Ninety-two had died during their hospital stay (13.2%). Only 36% subjects had a favorable outcome at discharge defined as a modified Rankin Scale (mRS) score of 2 or less. A total of 446 of 697 subjects had poor outcome at discharge (defined as an mRS score≥3). Hypertension and dyslipidemia were the most common risk factors and large vessel atherosclerosis was the most common stroke etiology. Elderly patients were significantly more likely to have in-hospital complications, die during their hospital stay, and have a higher mRS score at discharge. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

The impact of nonsteroidal anti-inflammatory drugs on inflammatory response after aneurysmal subarachnoid hemorrhage.

PubMed

Muroi, Carl; Hugelshofer, Michael; Seule, Martin; Keller, Emanuela

2014-04-01

The degree of inflammatory response with cytokine release is associated with poor outcomes after aneurysmal subarachnoid hemorrhage (SAH). Previously, we reported on an association between systemic IL-6 levels and clinical outcome in patients with aneurysmal SAH. The intention was to assess the impact of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen on the inflammatory response after SAH. Our method involved exploratory analysis of data and samples collected within a previous study. In 138 patients with SAH, systemic interleukin (IL-6) and c-reactive protein (CRP) were measured daily up to day 14 after SAH. The correlations among the cumulatively applied amount of NSAIDs, inflammatory parameters, and clinical outcome were calculated. An inverse correlation between cumulatively applied NSAIDs and both IL-6 and CRP levels was found (r = -0.437, p < 0.001 and r = -0.369, p < 0.001 respectively). Multivariable linear regression analysis showed a cumulative amount of NSAIDs to be independently predictive for systemic IL-6 and CRP levels. The cumulative amount of NSAIDs reduced the odds for unfavorable outcome, defined as Glasgow outcome scale 1-3. The results indicate a potential beneficial effect of NSAIDs in patients with SAH in terms of ameliorating inflammatory response, which might have an impact on outcome.

Ford Class Aircraft Carrier: Poor Outcomes Are the Predictable Consequences of the Prevalent Acquisition Culture

DTIC Science & Technology

2015-10-01

FORD CLASS AIRCRAFT CARRIER Poor Outcomes Are the Predictable Consequences of the Prevalent Acquisition Culture...2. REPORT TYPE 3. DATES COVERED 00-00-2015 to 00-00-2015 4. TITLE AND SUBTITLE Ford Class Aircraft Carrier: Poor Outcomes Are the Predictable...This Study The Navy set ambitious goals for the Ford -class program, including an array of new technologies and design features that were intended

An integrated epidemiological and neural net model of the warfarin effect in managed care patients.

PubMed

Jacobs, David M; Stefanovic, Filip; Wilton, Greg; Gomez-Caminero, Andres; Schentag, Jerome J

2017-01-01

Risk assessment tools are utilized to estimate the risk for stroke and need of anticoagulation therapy for patients with atrial fibrillation (AF). These risk stratification scores are limited by the information inputted into them and a reliance on time-independent variables. The objective of this study was to develop a time-dependent neural net model to identify AF populations at high risk of poor clinical outcomes and evaluate the discriminatory ability of the model in a managed care population. We performed a longitudinal, cohort study within a health-maintenance organization from 1997 to 2008. Participants were identified with incident AF irrespective of warfarin status and followed through their duration within the database. Three clinical outcome measures were evaluated including stroke, myocardial infarction, and hemorrhage. A neural net model was developed to identify patients at high risk of clinical events and defined to be an "enriched" patient. The model defines the enrichment based on the top 10 minimum mean square error output parameters that describe the three clinical outcomes. Cox proportional hazard models were utilized to evaluate the outcome measures. Among 285 patients, the mean age was 74±12 years with a mean follow-up of 4.3±2.6 years, and 154 (54%) were treated with warfarin. After propensity score adjustment, warfarin use was associated with a slightly increased risk of adverse outcomes (including stroke, myocardial infarction, and hemorrhage), though it did not attain statistical significance (adjusted hazard ratio [aHR] =1.22; 95% confidence interval [CI] 0.75-1.97; p =0.42). Within the neural net model, subjects at high risk of adverse outcomes were identified and labeled as "enriched." Following propensity score adjustment, enriched subjects were associated with an 81% higher risk of adverse outcomes as compared to nonenriched subjects (aHR=1.81; 95% CI, 1.15-2.88; p =0.01). Enrichment methodology improves the statistical discrimination of meaningful endpoints when used in a health records-based analysis.

Factors associated with a bad functional prognosis in early inflammatory back pain: results from the DESIR cohort.

PubMed

Lukas, C; Dougados, M; Combe, B

2016-01-01

Spondyloarthritis (SpA) is a heterogeneous disease with hardly predictable potential courses. We aimed at determining prognostic factors of bad functional outcome at 2 years in patients with early inflammatory back pain (IBP). Data from patients included in the French multicentre devenir des spondylarthropathies indifférenciées récentes (DESIR) cohort, that is, suffering from IBP starting before 50 years of age and lasting for 3-36 months, were used. A bad functional outcome at 24 months was defined as an increase in bath ankylosing spondylitis functional index (BASFI), or BASFI at 2 years higher than the 75th centile in the cohort. Demographic, clinical, biological and radiological data collected at inclusion were compared in patients with bad functional outcome versus others, by χ(2) test, then by a multivariate logistic regression model with stepwise selection of relevant factors. 513 patients (54.4% females, 72.2% fulfilling ASAS criteria) were assessed. Of those, 130 (25.3%) fulfilled the aforementioned criteria of a bad functional outcome (BASFI increase ≥4 units or ≥36 at 2 years). Multivariate analysis revealed that not fulfilling ASAS criteria, female sex, age >33 years, lower educational level, active smoking status and high disease activity according to bath ankylosing spondylitis disease activity index (BASDAI) at baseline were independently associated with a bad functional outcome at 24 months. Sensitivity analyses restricted to patients fulfilling ASAS criteria for SpA resulted in similar results. We observed, in a large prospective cohort of patients with early IBP, formerly described bad prognostic factors, especially a low educational level, an older age and a high disease activity at onset, and revealed that active smoking status and female sex were also independently associated with a poor outcome. Fulfilment of ASAS criteria, on the other hand, was predictive of a better outcome, most likely due to the more consensual management of a defined disease.

Neurologic examination at 24–48 hours predicts functional outcomes in basilar artery occlusion stroke

PubMed Central

Rangaraju, Srikant; Jovin, Tudor G.; Frankel, Michael; Schonewille, Wouter J.; Algra, Ale; Kappelle, L. Jaap; Nogueira, Raul G.

2016-01-01

Background and Purpose Accurate long-term outcome prognostication in basilar artery occlusion (BAO) strokes may guide clinical management in the subacute stage. We determine the prognostic value of the follow-up neurologic examination using the NIH stroke scale (NIHSS) and identify 24–48 hours NIHSS risk categories in BAO patients. Methods Participants of an observational registry of radiologically-confirmed acute BAO (BASICS) with prospectively collected 24–48 hours NIHSS and 1-month modified Rankin Scale (mRS) scores were included. Uni- and multivariable modeling were performed to identify independent predictors of poor outcome. Predictive powers of baseline and 24–48 hour NIHSS for poor outcome (mRS 4–6) and 1-month mortality were determined by Receiver Operating Characteristic analyses. Classification and regression tree (CART) analysis was performed to identify risk groups. Results 376 of 619 BASICS participants were included of whom 65.4% had poor outcome. In multivariable analyses, 24–48 hours NIHSS (OR=1.28 [1.21–1.35]), history of minor stroke (OR=2.64 [1.04–6.74], time to treatment >6 hours (OR=3.07 [1.35–6.99]) and age (OR 1.02 [0.99–1.04] were retained in the final model as predictors of poor outcome. Prognostic power of 24–48 hours NIHSS was higher than baseline NIHSS for 1-month poor outcome (AUC 0.92 vs. 0.75) and mortality (AUC 0.85 vs. 0.72). CART analysis identified five 24–48 hour NIHSS risk categories with poor outcome rates of 9.4% (NIHSS 0–4), 36% (NIHSS 5–11), 84.3% (NIHSS 12–22), 96.1% (NIHSS 23–27) and 100% (NIHSS≥28). Conclusion 24–48 hour NIHSS accurately predicts 1-month poor outcome and mortality and represents a clinically valuable prognostic tool for the care of BAO patients. PMID:27586683

Newly arrived elderly immigrants: a concept analysis of "aging out of place".

PubMed

Sadarangani, Tina R; Jun, Jin

2015-03-01

Newcomer elderly immigrants, defined as adults older than the age of 65 who have arrived in the United States in the last 10 years, represent a growing sector of the American population. Newcomers who experience limited English proficiency, financial strain, and acculturative stress are at considerable risk of developing poor health outcomes. Nursing's focus on healthy aging and aging in place has largely ignored the experiences of these older adults, who are said to be "aging out of place." This concept analysis uses Rodgers's evolutionary method to define "aging out of place" and illustrates why existing theories of elderly migration do not necessarily apply to this population. The challenge for nurses is incorporating the family, with whom conflict may arise, into the care of these elders. Community-based strategies that enable social integration and create a greater division of labor in the care of newcomer elders are called for. © The Author(s) 2014.

Taxonomy of segmental myocardial systolic dysfunction.

PubMed

McDiarmid, Adam K; Pellicori, Pierpaolo; Cleland, John G; Plein, Sven

2017-04-01

The terms used to describe different states of myocardial health and disease are poorly defined. Imprecision and inconsistency in nomenclature can lead to difficulty in interpreting and applying trial outcomes to clinical practice. In particular, the terms 'viable' and 'hibernating' are commonly applied interchangeably and incorrectly to myocardium that exhibits chronic contractile dysfunction in patients with ischaemic heart disease. The range of inherent differences amongst imaging modalities used to define myocardial health and disease add further challenges to consistent definitions. The results of several large trials have led to renewed discussion about the classification of dysfunctional myocardial segments. This article aims to describe the diverse myocardial pathologies that may affect the myocardium in ischaemic heart disease and cardiomyopathy, and how they may be assessed with non-invasive imaging techniques in order to provide a taxonomy of myocardial dysfunction. © The Author 2016. Published by Oxford University Press on behalf of the European Society of Cardiology.

Dynamic interaction between fetal adversity and a genetic score reflecting dopamine function on developmental outcomes at 36 months

PubMed Central

Pokhvisneva, Irina; Léger, Étienne; Gaudreau, Hélène; Steiner, Meir; Kennedy, James L.; O’Donnell, Kieran J.; Diorio, Josie; Meaney, Michael J.; Silveira, Patrícia P.

2017-01-01

Background Fetal adversity, evidenced by poor fetal growth for instance, is associated with increased risk for several diseases later in life. Classical cut-offs to characterize small (SGA) and large for gestational age (LGA) newborns are used to define long term vulnerability. We aimed at exploring the possible dynamism of different birth weight cut-offs in defining vulnerability in developmental outcomes (through the Bayley Scales of Infant and Toddler Development), using the example of a gene vs. fetal adversity interaction considering gene choices based on functional relevance to the studied outcome. Methods 36-month-old children from an established prospective birth cohort (Maternal Adversity, Vulnerability, and Neurodevelopment) were classified according to birth weight ratio (BWR) (SGA ≤0.85, LGA >1.15, exploring a wide range of other cut-offs) and genotyped for polymorphisms associated with dopamine signaling (TaqIA-A1 allele, DRD2-141C Ins/Ins, DRD4 7-repeat, DAT1-10- repeat, Met/Met-COMT), composing a score based on the described function, in which hypofunctional variants received lower scores. Results There were 251 children (123 girls and 128 boys). Using the classic cut-offs (0.85 and 1.15), there were no statistically significant interactions between the neonatal groups and the dopamine genetic score. However, when changing the cut-offs, it is possible to see ranges of BWR that could be associated with vulnerability to poorer development according to the variation in the dopamine function. Conclusion The classic birth weight cut-offs to define SGA and LGA newborns should be seen with caution, as depending on the outcome in question, the protocols for long-term follow up could be either too inclusive—therefore most costly, or unable to screen true vulnerabilities—and therefore ineffective to establish early interventions and primary prevention. PMID:28505190

The prevalence of undiagnosed pre-surgical cognitive impairment and its post-surgical clinical impact in elderly patients undergoing surgery for adult spinal deformity.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Lydon, Emily; Vuong, Victoria D; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-09-01

Pre-existing cognitive impairment (CI) is emerging as a predictor of poor post-operative outcomes in elderly patients. Little is known about impaired preoperative cognition and outcomes after elective spine surgery in this patient population. The purpose of this study was to assess the prevalence of neuro CI in elderly patients undergoing deformity surgery and its impact on postoperative outcomes. Elderly subjects undergoing elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Pre-operative baseline cognition was assessed using the Saint Louis Mental Status (SLUMS) test. SLUMS consists of 11 questions, which can give a maximum of 30 points. Mild CI was defined as a SLUMS score between 21-26 points, while severe CI was defined as a SLUMS score of ≤20 points. Normal cognition was defined as a SLUMS score of ≥27 points. Complication rates, duration of hospital stay, and 30-day readmission rates were compared between patients with and without baseline CI. Eighty-two subjects were included in this study, with mean age of 73.26±6.08 years. Fifty-seven patients (70%) had impaired cognition at baseline. The impaired cognition group had the following outcomes: increased incidence of one or more postoperative complications (39% vs. 20%), higher incidence of delirium (20% vs. 8%), and higher rate of discharge institutionalization at skilled nursing or acute rehab facilities (54% vs. 30%). The length of hospital stay and 30-day hospital readmission rates were similar between both cohorts (5.33 vs. 5.48 days and 12.28% vs. 12%, respectively). CI is highly prevalent in elderly patients undergoing surgery for adult degenerative scoliosis. Impaired cognition before surgery was associated with higher rates of post-operative delirium, complications, and discharge institutionalization. CI assessments should be considered in the pre-operative evaluations of elderly patients prior to surgery.

The role of the CpG island methylator phenotype on survival outcome in colon cancer.

PubMed

Kang, Ki Joo; Min, Byung Hoon; Ryu, Kyung Ju; Kim, Kyoung Mee; Chang, Dong Kyung; Kim, Jae J; Rhee, Jong Chul; Kim, Young Ho

2015-03-01

CpG island methylator phenotype (CIMP)- high colorectal cancers (CRCs) have distinct clinicopathologi-cal features from their CIMP-low/negative CRC counterparts. However, controversy exists regarding the prognosis of CRC according to the CIMP status. Therefore, this study examined the prognosis of Korean patients with colon cancer according to the CIMP status. Among a previous cohort pop-ulation with CRC, a total of 154 patients with colon cancer who had available tissue for DNA extraction were included in the study. CIMP-high was defined as ≥3/5 methylated mark-ers using the five-marker panel (CACNA1G, IGF2, NEUROG1, RUNX3, and SOCS1). CIMP-high and CIMP-low/neg-ative cancers were observed in 27 patients (17.5%) and 127 patients (82.5%), respectively. Multivariate analysis adjust-ing for age, gender, tumor location, tumor stage and CIMP and microsatellite instability (MSI) statuses indicated that CIMP-high colon cancers were associated with a significant increase in colon cancer-specific mortality (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.20 to 8.69; p=0.02). In microsatellite stable cancers, CIMP-high cancer had a poor survival outcome compared to CIMP-low/negative cancer (HR, 2.91; 95% CI, 1.02 to 8.27; p=0.04). Re-gardless of the MSI status, CIMP-high cancers had poor sur-vival outcomes in Korean patients. (Gut Liver, 2015;9202-207).

Neurophysiological prediction of neurological good and poor outcome in post-anoxic coma.

PubMed

Grippo, A; Carrai, R; Scarpino, M; Spalletti, M; Lanzo, G; Cossu, C; Peris, A; Valente, S; Amantini, A

2017-06-01

Investigation of the utility of association between electroencephalogram (EEG) and somatosensory-evoked potentials (SEPs) for the prediction of neurological outcome in comatose patients resuscitated after cardiac arrest (CA) treated with therapeutic hypothermia, according to different recording times after CA. Glasgow Coma Scale, EEG and SEPs performed at 12, 24 and 48-72 h after CA were assessed in 200 patients. Outcome was evaluated by Cerebral Performance Category 6 months after CA. Within 12 h after CA, grade 1 EEG predicted good outcome and bilaterally absent (BA) SEPs predicted poor outcome. Because grade 1 EEG and BA-SEPs were never found in the same patient, the recording of both EEG and SEPs allows us to correctly prognosticate a greater number of patients with respect to the use of a single test within 12 h after CA. At 48-72 h after CA, both grade 2 EEG and BA-SEPs predicted poor outcome with FPR=0.0%. When these neurophysiological patterns are both present in the same patient, they confirm and strengthen their prognostic value, but because they also occurred independently in eight patients, poor outcome is predictable in a greater number of patients. The combination of EEG/SEP findings allows prediction of good and poor outcome (within 12 h after CA) and of poor outcome (after 48-72 h). Recording of EEG and SEPs in the same patients allows always an increase in the number of cases correctly classified, and an increase of the reliability of prognostication in a single patient due to concordance of patterns. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Leukoaraiosis predicts poor 90-day outcome after acute large cerebral artery occlusion.

PubMed

Henninger, Nils; Lin, Eugene; Baker, Stephen P; Wakhloo, Ajay K; Takhtani, Deepak; Moonis, Majaz

2012-01-01

To date limited information regarding outcome-modifying factors in patients with acute intracranial large artery occlusion (ILAO) in the anterior circulation is available. Leukoaraiosis (LA) is a common finding among patients with ischemic stroke and has been associated with poor post-stroke outcomes but its association with ILAO remains poorly characterized. This study sought to clarify the contribution of baseline LA and other common risk factors to 90-day outcome (modified Rankin Scale, mRS) after stroke due to acute anterior circulation ILAO. We retrospectively analyzed 1,153 consecutive patients with imaging-confirmed ischemic stroke during a 4-year period (2007-2010) at a single academic institution. The final study cohort included 87 patients with acute ILAO subjected to multimodal CT imaging within 24 h of symptom onset. LA severity was assessed using the van Swieten scale on non-contrast CT. Leptomeningeal collaterals were graded using CT angiogram source images. Hemorrhagic transformation (HT) was determined on follow-up CT. Multivariate logistic regression controlling for HT, treatment modality, demographic, as well as baseline clinical and imaging characteristics was used to identify independent predictors of a poor outcome (90-day mRS >2). The median National Institutes of Health Stroke Scale (NIHSS) at baseline was 15 (interquartile range 9-21). Twenty-four percent of the studied patients had severe LA. They were more likely to have hypertension (p = 0.028), coronary artery disease (p = 0.015), poor collaterals (p < 0.001), higher baseline NIHSS (p = 0.003), higher mRS at 90 days (p < 0.001), and were older (p = 0.002). Patients with severe LA had a uniformly poor outcome (p < 0.001) irrespective of treatment modality. Poor outcome was independently associated with higher baseline NIHSS (p < 0.001), worse LA (graded and dichotomized, p < 0.001), reduced leptomeningeal collaterals (graded and dichotomized, p < 0.001), presence of HT (p < 0.001), presence of parenchymal hemorrhages (p = 0.01), baseline mRS (p = 0.002), and older age (p = 0.043). The association between severe LA (p = 0.0056; OR 13.86; 95% CI 1.94-∞) and baseline NIHSS (p = 0.0001; OR 5.11; 95% CI 2.07-14.49 for each 10-point increase) with poor outcome maintained after adjustment for confounders in the final regression model. In this model, there was no significant association between presence of HT and poor outcome (p = 0.0572). Coexisting LA may predict poor functional outcome in patients with acute anterior circulation ILAO independent of other known important outcome predictors such as comorbid state, admission functional deficit, collateral status, hemorrhagic conversion, and treatment modality. Copyright © 2012 S. Karger AG, Basel.

Mannitol and Outcome in Intracerebral Hemorrhage: Propensity Score and Multivariable Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2 Results.

PubMed

Wang, Xia; Arima, Hisatomi; Yang, Jie; Zhang, Shihong; Wu, Guojun; Woodward, Mark; Muñoz-Venturelli, Paula; Lavados, Pablo M; Stapf, Christian; Robinson, Thompson; Heeley, Emma; Delcourt, Candice; Lindley, Richard I; Parsons, Mark; Chalmers, John; Anderson, Craig S

2015-10-01

Mannitol is often used to reduce cerebral edema in acute intracerebral hemorrhage but without strong supporting evidence of benefit. We aimed to determine the impact of mannitol on outcome among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). INTERACT2 was an international, open, blinded end point, randomized controlled trial of 2839 patients with spontaneous intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure allocated to intensive (target systolic blood pressure, <140 mm Hg within 1 hour) or guideline-recommended (target systolic blood pressure, <180 mm Hg) blood pressure-lowering treatment. Propensity score and multivariable analyses were performed to investigate the relationship between mannitol treatment (within 7 days) and poor outcome, defined by death or major disability on the modified Rankin Scale score (3-6) at 90 days. There was no significant difference in poor outcome between mannitol (n=1533) and nonmannitol (n=993) groups: propensity score-matched odds ratio of 0.90 (95% confidence interval, 0.75-1.09; P=0.30) and multivariable odds ratio of 0.87 (95% confidence interval, 0.71-1.07; P=0.18). Although a better outcome was suggested in patients with larger (≥15 mL) than those with smaller (<15 mL) baseline hematomas who received mannitol (odds ratio, 0.52 [95% confidence interval, 0.35-0.78] versus odds ratio, 0.91 [95% confidence interval, 0.72-1.15]; P homogeneity<0.03 in propensity score analyses), the association was not consistent in analyses across other cutoff points (≥10 and ≥20 mL) and for differing grades of neurological severity. Mannitol was not associated with excess serious adverse events. Mannitol seems safe but might not improve outcome in patients with acute intracerebral hemorrhage. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00716079. © 2015 American Heart Association, Inc.

Comparison of clinical outcomes between laminoplasty, posterior decompression with instrumented fusion, and anterior decompression with fusion for K-line (-) cervical ossification of the posterior longitudinal ligament.

PubMed

Koda, Masao; Mochizuki, Makondo; Konishi, Hiroaki; Aiba, Atsuomi; Kadota, Ryo; Inada, Taigo; Kamiya, Koshiro; Ota, Mitsutoshi; Maki, Satoshi; Takahashi, Kazuhisa; Yamazaki, Masashi; Mannoji, Chikato; Furuya, Takeo

2016-07-01

The K-line, which is a virtual line that connects the midpoints of the anteroposterior diameter of the spinal canal at C2 and C7 in a plain lateral radiogram, is a useful preoperative predictive indicator for sufficient decompression by laminoplasty (LMP) for ossification of the posterior longitudinal ligament (OPLL). K-line is defined as (+) when the peak of OPLL does not exceed the K-line, and is defined as (-) when the peak of OPLL exceeds the K-line. For patients with K-line (-) OPLL, LMP often results in poor outcome. The aim of the present study was to compare the clinical outcome of LMP, posterior decompression with instrumented fusion (PDF) and anterior decompression and fusion (ADF) for patients with K-line (-) OPLL. The present study included patients who underwent surgical treatment including LMP, PDF and ADF for K-line (-) cervical OPLL. We retrospectively compared the clinical outcome of those patients in terms of Japanese Orthopedic Association score (JOA score) recovery rate. JOA score recovery rate was significantly higher in the ADF group compared with that in the LMP group and the PDF group. The JOA score recovery rate in the PDF group was significantly higher than that in the LMP group. LMP should not be used for K-line (-) cervical OPLL. ADF is one of the suitable surgical treatments for K-line (-) OPLL. Both ADF and PDF are applicable for K-line (-) OPLL according to indications set by each institute and surgical decisions.

Early Versus Late Weight-Bearing Protocols for Surgically Managed Posterior Wall Acetabular Fractures.

PubMed

Heare, Austin; Kramer, Nicholas; Salib, Christopher; Mauffrey, Cyril

2017-07-01

Despite overall improved outcomes with open reduction and internal fixation of acetabular fractures, posterior wall fractures show disproportionately poor results. The effect of weight bearing on outcomes of fracture management has been investigated in many lower extremity fractures, but evidence-based recommendations in posterior wall acetabular fractures are lacking. The authors systematically reviewed the current literature to determine if a difference in outcome exists between early and late postoperative weight-bearing protocols for surgically managed posterior wall acetabular fractures. PubMed and MEDLINE were searched for posterior wall acetabular fracture studies that included weight-bearing protocols and Merle d'Aubigné functional scores. Twelve studies were identified. Each study was classified as either early or late weight bearing. Early weight bearing was defined as full, unrestricted weight bearing at or before 12 weeks postoperatively. Late weight bearing was defined as restricted weight bearing for greater than 12 weeks postoperatively. The 2 categories were then compared by functional score using a 2-tailed t test and by complication rate using chi-square analysis. Six studies (152 fractures) were placed in the early weight-bearing category. Six studies (302 fractures) were placed in the late weight-bearing category. No significant difference in Merle d'Aubigné functional scores was found between the 2 groups. No difference was found regarding heterotopic ossification, avascular necrosis, superficial infections, total infections, or osteoarthritis. This systematic review found no difference in functional outcome scores or complication rates between early and late weight-bearing protocols for surgically treated posterior wall fractures. [Orthopedics. 2017: 40(4):e652-e657.]. Copyright 2017, SLACK Incorporated.

Predicting contraceptive vigilance in adolescent females: a projective method for assessing ego development.

PubMed

Speier, P L; Mélèse-D'Hospital, I A; Tschann, J M; Moore, P J; Adler, N E

1997-01-01

To test the hypothesis that ego development would predict contraceptive use. Problems in ego development were defined in terms of three factors: (1) realism, (2) complexity, and (3) discontinuity. Forty-one respondents aged 14-17 years were selected from a group of 233 adolescents who were administered a projective pregnancy scenario and participated in a 12-month follow-up. Twenty of these adolescents were randomly selected from the group determined to be effective contraceptive users, while 21 were randomly selected from the group of poor contraceptors. Chi-square test revealed a significant association (p < .0005) between the composite ego maturity (EM) measure and contraceptive outcome (chi 2 = 13.82, with df-1). Low scores on the ego maturity measure predicted poor contraceptive use. EM was unrelated to age but was associated with race (chi 2 = 7.535, .025 < p < .05). However, EM predicted contraceptive use when controlling for the effects of race. A simple, time-efficient projective pregnancy scenario is an effective way of determining adolescent females at risk for poor contraceptive effectiveness and, therefore, untimely pregnancy. These stories are analyzed using factors related to the ego development of the adolescent. Subjects who scored lower on this measure have poor contraceptive effectiveness while subjects with higher levels demonstrated effective contraception use, at 1-year follow-up.

Serum Galectin-3 and Poor Outcomes Among Patients With Acute Ischemic Stroke.

PubMed

Wang, Aili; Zhong, Chongke; Zhu, Zhengbao; Xu, Tian; Peng, Yanbo; Xu, Tan; Peng, Hao; Chen, Chung-Shiuan; Wang, Jinchao; Ju, Zhong; Li, Qunwei; Geng, Deqin; Sun, Yingxian; Zhang, Jianhui; Yuan, Xiaodong; Chen, Jing; Zhang, Yonghong; He, Jiang

2018-01-01

Elevated galectin-3 has been associated with atherosclerosis and poor outcomes in patients with heart failure. However, it remains unclear whether galectin-3 has any effect on the poor outcomes of ischemic stroke. The aim of the present study was to examine the association between galectin-3 with poor outcomes among patients with acute ischemic stroke. Serum galectin-3 was measured in 3082 patients with acute ischemic stroke. The primary outcome was a combination of death or major disability (modified Rankin Scale score, ≥3) at 3 months after stroke. Compared with the lowest quartile of galectin-3, multivariate adjusted odds ratios (95% confidence intervals) for the highest quartile of galectin-3 were 1.55 (1.15-2.09) for composite outcome, 2.10 (0.89-4.95) for death, and 1.43 (1.05-1.93) for major disability. The addition of galectin-3 to the conventional risk factors significantly improved prediction of the combined outcome of death or major disability in patients with ischemic stroke (net reclassification index, 18.9%; P <0.001; integrated discrimination improvement, 0.4%; P =0.001). Higher levels of serum galectin-3 were independently associated with increased risk of death or major disability after stroke onset, suggesting that galectin-3 may have prognostic value in poor outcomes of ischemic stroke. © 2017 American Heart Association, Inc.

Seizure outcome after AED failure in pediatric focal epilepsy: impact of underlying etiology.

PubMed

Wirrell, Elaine C; Wong-Kisiel, Lily C; Nickels, Katherine C

2014-05-01

This study aimed to identify long-term seizure outcome in pediatric nonsyndromic focal epilepsy after failure of serial antiepileptic drugs (AEDs) due to lack of efficacy. Children (1 month-17 years) with new-onset focal epilepsy not meeting the criteria for a defined electroclinical syndrome diagnosed between 1980 and 2009 while residing in Olmsted County, MN, were retrospectively identified. Medical records of those followed for ≥2 years were reviewed to assess etiology, the number of AEDs that failed due to lack of efficacy, and seizure outcome at final follow-up. Etiology was classified into structural/metabolic, genetic, or unknown. Favorable outcome was defined as seizure freedom ≥1 year, on or off AEDs, without prior epilepsy surgery. Poor outcome was defined as ongoing seizures in the preceding year or having undergone prior epilepsy surgery. Nonsyndromic focal epilepsy accounted for 275/468 (59%) of all patients with newly diagnosed epilepsy--of these, 256 (93%) were followed for a minimum of two years and were included in the study. Median duration of follow-up was 10.0 years. At least one AED had failed due to lack of efficacy in 100 (39.1%) children. Favorable outcomes occurred in 149/156 (95.5%) children with no AED failure, 16/30 (53.3%) with one AED failure, 8/25 (32%) with two AED failures, and only 2/45 (4.4%) with three AED failures. After two AED failures, the seizures of nearly one-quarter of children who had epilepsy with an unknown cause responded favorably to the third AED compared with only 7.8% of the cohort that had epilepsy with a structural/metabolic cause. Children with a remote brain insult had a significantly higher likelihood of favorable outcome with serial AEDs than those with other structural abnormalities. Etiology is an important determinant of pharmacoresistance in nonsyndromic focal epilepsy. Surgical evaluation should be considered after failure of 1-2 AEDs in those who have epilepsy with structural causes, excluding remote brain insults. Conversely, as surgical success is lower with normal MRI or more diffuse brain insults, it appears reasonable to hold off surgical evaluation until 2-3 AEDs have failed in such children. Copyright © 2014 Elsevier Inc. All rights reserved.

Inflammatory Bowel Disease: Influence and Implications in Reproduction

PubMed Central

Glover, Louise E.; Fennimore, Blair; Wingfield, Mary

2016-01-01

The incidence and prevalence of inflammatory bowel disease (IBD) continues to rise with time, signifying its emergence as a global disease. Clinical onset of IBD, comprising Crohn’s disease and ulcerative colitis, typically occurs prior to or at peak reproductive age. Although active disease in female patients is associated with reduced fertility and adverse obstetric outcomes in pregnancy, the molecular mechanisms underlying this altered reproductive course, as well as its impact on IBD transmission to offspring, remain poorly understood. Clinical and experimental studies have now begun to elucidate the hormonal, environmental and microbial factors that modulate immune-reproductive crosstalk in IBD, and define their impact on maternal health, fetal development and heritability of disease risk. Evolving insight into maternal-fetal imprinting in IBD has important implications for patient counseling and disease management during pregnancy, and may help predict clinical outcomes for both mother and child. PMID:27537054

Resolution of alliance ruptures: The special case of animal-assisted psychotherapy.

PubMed

Zilcha-Mano, Sigal

2017-01-01

Many therapists regard alliance ruptures as one of the greatest challenges therapists face in the therapy room. Alliance ruptures has been previously defined as breakdowns in the process of negotiation of treatment tasks and goals and a deterioration in the affective bond between patient and therapist. Alliance ruptures have been found to predict premature termination of treatment and poor treatment outcomes. But ruptures can also present important opportunities for gaining insight and awareness and for facilitating therapeutic change. A process of rupture resolution may lead to beneficial outcomes and serve as a corrective emotional experience. The article describes unique processes of alliance rupture resolution inherent in animal-assisted psychotherapy (AAP). Building on Safran and Muran's model and on clinical examples, the article describes strategies for identifying ruptures in AAP and techniques for repairing them to facilitate a corrective experience in treatment. Implications for clinical practice and future research are discussed.

Maternal alcohol use disorder and child school attendance outcomes for non-Indigenous and Indigenous children in Western Australia: a population cohort record linkage study.

PubMed

Hafekost, Katherine; Lawrence, David; O'Leary, Colleen; Bower, Carol; Semmens, James; Zubrick, Stephen R

2017-07-11

Examine the relationship between maternal alcohol use disorder and child school attendance outcomes for non-Indigenous and Indigenous children in Western Australia. Population cohort study. Routinely collected linked administrative health, education and child protection data. Those in-scope for the study were women with a birth recorded on the Western Australian Midwives Notification System (1989-2007). Women who had an alcohol-related diagnosis (International Classification of Diseases Revisions 9/10) recorded on the Hospital Morbidity, Mental Health Inpatients and Outpatients, and Drug and Alcohol Office data sets formed the exposed group. The comparison cohort was frequency-matched to the exposed cohort based on maternal age within Indigenous status and child's year of birth. Child's school attendance was obtained from the Department of Education (2008-2012). Poor attendance was defined as <80% attendance for non-Indigenous children and <60% attendance for Indigenous children. 11 430 exposed children and 26 850 unexposed children had a linked attendance record. Maternal alcohol use disorder was significantly associated with increased odds of poor attendance (non-Indigenous: OR=1.61, 95% CI 1.50 to 1.74; Indigenous: OR=1.66, 95% CI 1.54 to 1.79). With adjustment for maternal and child factors, there was no significant difference between the timing of alcohol diagnosis relative to pregnancy and attendance outcomes. The population attributable fraction was higher in the Indigenous cohort than the non-Indigenous cohort (6.0% vs 1.3%). Maternal alcohol use disorder was associated with a significantly increased odds of poor school attendance for non-Indigenous and Indigenous children. There was no significant difference between the timing of diagnoses and odds of poor school attendance. This suggests that the effect of maternal alcohol use disorder may not be driven by the neurodevelopmental effects of alcohol exposure in utero, but may be mediated through family or social factors for which we were unable to adjust. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Increased household financial strain, the Great Recession and child health—findings from the UK Millennium Cohort Study

PubMed Central

Law, Catherine; Pearce, Anna

2017-01-01

Background There is a growing body of evidence associating financial strain (FS) with poor health but most of this research has been cross-sectional and adult-focused. During the ‘Great Recession’ many UK households experienced increased FS. The primary aim of this study was to determine the impact of increased FS on child health. Methods We analysed the Millennium Cohort Study, a longitudinal study of children born in the UK between 2000 and 2002. Surveys at 7 years (T1, 2008) and 11 years (T2, 2012) spanned the ‘Great Recession’. Three measures of increased FS were defined; ‘became income poor’ (self-reported household income dropped below the ‘poverty line’ between T1 and T2); ‘developed difficulty managing’ (parental report of being ‘financially comfortable’ at T1 and finding it ‘difficult to manage’ at T2); ‘felt worse off’ (parental report of feeling financially ‘worse off’ at T2 compared with T1). Poisson regression was used to estimate risk ratios (RR), adjusted risk ratios (aRR) and 95% CIs for six child health outcomes: measured overweight/obesity, problematic behaviour as scored by parents and teachers, and parental reports of fair/poor general health, long-standing illness and bedwetting at T2 (N=13 112). In subanalyses we limited our sample to those who were above the poverty line at T2. Results Compared with those who were not financially strained at both time points, children in households which experienced increased FS were at an increased risk of all unhealthy outcomes examined. In most cases, these increased risks persisted after adjustment for confounding and when limiting the sample to those above the poverty line. Conclusions FS is associated with a range of new or continued poor child health outcomes. During times of widespread economic hardship, such as the ‘Great Recession’, measures should be taken to buffer children and their families from the impact of FS, and these should not be limited to those who are income poor. PMID:28280000

[Encopresis].

PubMed

von Gontard, Alexander

2007-01-01

Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.

The influence of community and individual health literacy on self-reported health status.

PubMed

Sentell, Tetine; Zhang, Wei; Davis, James; Baker, Kathleen Kromer; Braun, Kathryn L

2014-02-01

Individual health literacy is an established predictor of individual health outcomes. Community-level health literacy may also impact individual health, yet limited research has simultaneously considered the influence of individual and community health literacy on individual health. The study goal was to determine if community health literacy had an independent relationship with individual self-reported health beyond individual health literacy. We used data from the 2008 and 2010 Hawai'i Health Survey, a representative statewide telephone survey. Multilevel models predicted individual self-reported health by both individual and community health literacy, controlling for relevant individual-level (education, race/ethnicity, gender, poverty, insurance status, age, and marital status) and community-level variables (community poverty and community education). The sample included 11,779 individuals within 37 communities. Individual health literacy was defined by validated self-reported measurement. Communities were defined by zip code combinations. Community health literacy was defined as the percentage of individuals within a community reporting low health literacy. Census data by ZIP Code Tabulation Areas provided community-level variables. In descriptive results, 18.2 % self-reported low health literacy, and 14.7 % reported self-reported poor health. Community-level low health literacy ranged from 5.37 % to 35.99 %. In final, multilevel models, both individual (OR: 2.00; 95 % CI: 1.63-2.44) and community low health literacy (OR: 1.02; 95 % CI: 1.00-1.03) were significantly positively associated with self-reported poor health status. Each percentage increase of average low health literacy within a community was associated with an approximately 2 % increase in poor self-reported health for individuals in that community. Also associated with poorer health were lower educational attainment, older age, poverty, and non-White race. Both individual and community health literacy are significant, distinct correlates of individual general health status. Primary care providers and facilities should consider and address health literacy at both community and individual levels.

Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury.

PubMed

Brenner, Megan; Stein, Deborah M; Hu, Peter F; Aarabi, Bizhan; Sheth, Kevin; Scalea, Thomas M

2012-05-01

Vital signs, particularly blood pressure, are often manipulated to maximize perfusion and optimize recovery from severe traumatic brain injury (sTBI). We investigated the utility of automated continuously recorded vital signs to predict outcomes after sTBI. Sixty patients with head Abbreviated Injury Scale score ≥ 3, age >14 years, "isolated" TBI, and need for intracranial pressure monitoring were prospectively enrolled at a single, large urban tertiary care facility. Outcome was measured by mortality and extended Glasgow Outcome Scale (GOSE) at 12 months. Continuous, automated, digital data were collected every 6 seconds for 72 hours after admission, and 5-minute means of systolic blood pressure (SBP) were recorded. We calculated SBP as pressure × time dose (PTD) to describe the cumulative amplitude and duration of episodes above and below clinical thresholds. The extent and duration of the insults were calculated as percent time (%time), PTD, and PTD per day (PTD/D) of defined thresholds (SBP: <90 mm Hg, <100 mm Hg, <110 mm Hg, and <120 mm Hg; mean arterial pressure: <60 mm Hg and <70 mm Hg; heart rate: >100 bpm and >120 bpm; and SpO(2): <88% and <92%) for the first 12 hours, 24 hours, and 48 hours of intensive care unit admission. We analyzed their ability to predict mortality and GOSE by receiver operator characteristics. Mean age was 33.9 (range, 16-83) years, mean admission Glasgow Coma Scale score 6.4 ± 3, and mean head Abbreviated Injury Scale score 4.2 ± 0.72. The 30-day mortality rate was 13.3%. Of the 45 patients in whom GOSE at 12 months was available, 28 (62%) had good neurologic outcomes (GOSE score >4). Traditional markers of poor outcome (admission SBP, admission Glasgow Coma Scale, and Marshall score) were not different between groups with good or poor outcome. PTD, PTD/D, and %time SBP <110 mm Hg and SBP <120 mm Hg predicted mortality at 12 hours, 24 hours, and 48 hours (p < 0.04). Percent time SBP <110 mm Hg in the first 24 hours was predictive of 12-month GOSE (p = 0.02). PTD/D SBP <120 mm Hg in the first 24 hours and PTD and PTD/D in the first 48 hours were also predictive of 12-month GOSE (p < 0.05). Within the first 48 hours of intensive care unit admission, hypotension was found to be predictive of mortality and functional outcomes at higher thresholds than traditionally defined. Systemic blood pressure targets closer to 120 mm Hg may be more efficacious in minimizing secondary insults and particularly useful in settings without invasive intracranial monitoring capabilities. III, prognostic study.

Self-perceived health-related quality of life of Indian children with specific learning disability.

PubMed

Karande, S; Venkataraman, R

2012-01-01

Specific learning disability (SpLD) often remains undetected, resulting in the afflicted child experiencing chronic poor school performance. To measure and analyze the self-perceived health-related quality of life (HRQoL) of children with newly-diagnosed SpLD. Cross-sectional questionnaire-based study in our clinic. From February to December 2008, 150 children consecutively diagnosed as having SpLD were enrolled and their HRQoL documented using the DISABKIDS chronic generic module self-report version instrument. Multiple regression analysis was carried out for determining the 'independent' impact that each of the clinical and socio-demographic variables had on a poor facet score outcome and on a poor total score outcome. Clinically significant deficits were detected in all 6 facets, namely: 'large deficits (effect size ≥-0.8)' in "social exclusion", "emotion", "limitation", "treatment", and "independence"; and 'medium deficit (effect size -0.5 to <-0.8)' in "social inclusion"; and 'large deficit' in "total score". Multivariate analysis revealed that: (i) not belonging to the upper socio-economic strata of society was an independent predictor of a poor "independence" facet outcome (P=0.010, OR=1.99, 95% CI: 1.18 to 3.37); (ii) not having experienced class detainment was an independent predictor of a poor "emotion" facet outcome (P=0.008, OR=3.04, 95% CI: 1.34 to 6.85); (iii) first-born status was an independent predictor of a poor "limitation" facet outcome (P=0.022, OR=2.60, 95% CI: 1.15 to 5.90); and (iv) female gender was an independent predictor of a poor "social exclusion" facet outcome (P=0.024, OR=0.28, 95% CI: 0.09 to 0.85) and a poor "overall health" outcome (P=0.025, OR=0.32, 95% CI: 0.12 to 0.87). Children with newly-diagnosed SpLD perceive their psychosocial, physical, and overall HRQoL to be significantly compromised.

Targeting aspirin in acute disabling ischemic stroke: an individual patient data meta-analysis of three large randomized trials.

PubMed

Thompson, Douglas D; Murray, Gordon D; Candelise, Livia; Chen, Zhengming; Sandercock, Peter A G; Whiteley, William N

2015-10-01

Aspirin is of moderate overall benefit for patients with acute disabling ischemic stroke. It is unclear whether functional outcome could be improved after stroke by targeting aspirin to patients with a high risk of recurrent thrombosis or a low risk of haemorrhage. We aimed to determine whether patients at higher risk of thrombotic events or poor functional outcome, or lower risk of major haemorrhage had a greater absolute risk reduction of poor functional outcome with aspirin than the average patient. We used data on individual ischemic stroke patients from three large trials of aspirin vs. placebo in acute ischemic stroke: the first International Stroke Trial (n = 18,372), the Chinese Acute Stroke Trial (n = 20,172) and the Multicentre Acute Stroke Trial (n = 622). We developed and evaluated clinical prediction models for the following: early thrombotic events (myocardial infarction, ischemic stroke, deep vein thrombosis and pulmonary embolism); early haemorrhagic events (significant intracranial haemorrhage, major extracranial haemorrhage, or haemorrhagic transformation of an infarct); and late poor functional outcome. We calculated the absolute risk reduction of poor functional outcome (death or dependence) at final follow-up in: quartiles of early thrombotic risk; quartiles of early haemorrhagic risk; and deciles of poor functional outcome risk. Ischemic stroke patients who were older, had lower blood pressure, computerized tomography evidence of infarct or more severe deficits due to stroke had increased risk of thrombotic and haemorrhagic events and poor functional outcome. Prediction models built with all baseline variables (including onset to treatment time) discriminated weakly between patients with and without recurrent thrombotic events (area under the receiver operating characteristic curve 0·56, 95% CI:0·53-0·59) and haemorrhagic events (0·57, 0·52-0·64), though well between patients with and without poor functional outcome (0·77, 0·76-0·78) in the International Stroke Trial. We found no evidence that the net benefit of aspirin increased with increasing risk of thrombosis, haemorrhage or poor functional outcome in all three trials. Using simple clinical variables to target aspirin to patients after acute disabling stroke by risk of thrombosis, haemorrhage or poor functional outcome does not lead to greater net clinical benefit. We suggest future risk stratification schemes include new risk factors for thrombosis and intracranial haemorrhage. © 2015 The Authors. International Journal of Stroke published by John Wiley & Sons Ltd on behalf of World Stroke Organization.

Clinical Efficacy and Its Prognostic Factor of Percutaneous Endoscopic Lumbar Annuloplasty and Nucleoplasty for the Treatment of Patients with Discogenic Low Back Pain.

PubMed

Lee, Jung Hwan; Lee, Sang-Ho

2017-09-01

The choice of appropriate treatment of discogenic low back pain (DLBP) frequently is difficult. This study sought to identify the clinical efficacy of percutaneous endoscopic lumbar annuloplasty and nucleoplasty (PELAN) to treat patients with DLBP and to investigate prognostic clinical or radiologic variables. Eighty-nine patients with a diagnosis of DLBP who underwent PELAN were included. Numeric Rating Scale (NRS) for back pain, Oswestry Disability Index % (ODI%), and modified Macnab criteria were measured at short-term (3-4 weeks) and long-term follow-up period (at least 12 months) to investigate clinical efficacy of PELAN. The subjects were defined as successful group in case of 50% or more reduction of NRS, 40% or more reduction of ODI%, and good or excellent response of Macnab criteria. Clinical and radiologic variables were compared between successful and unsuccessful outcomes group to determine prognostic variables. NRS and ODI% were significantly reduced at short- and long-term follow-up after PELAN. Sixty-two (69.7%) and 68 (76.4%) obtained successful NRS reduction and 59 (66.3%) and 68 (76.4%) accomplished successful ODI% reduction at short-term and long-term follow-up, respectively. Successful Mcnab response was found in 61% at short term and 65.2% at long term. Pain during waist flexion among clinical variables was significantly related to good clinical outcomes and Modic change among radiologic variables was significantly related to poor clinical outcomes. PELAN provided favorable outcomes in patients with DLBP who were refractory to conservative treatments. Flexion pain was good prognostic, and Modic change was a poor prognostic variable. Copyright © 2017 Elsevier Inc. All rights reserved.

Integrated genome-wide DNA copy number and expression analysis identifies distinct mechanisms of primary chemoresistance in ovarian carcinomas.

PubMed

Etemadmoghadam, Dariush; deFazio, Anna; Beroukhim, Rameen; Mermel, Craig; George, Joshy; Getz, Gad; Tothill, Richard; Okamoto, Aikou; Raeder, Maria B; Harnett, Paul; Lade, Stephen; Akslen, Lars A; Tinker, Anna V; Locandro, Bianca; Alsop, Kathryn; Chiew, Yoke-Eng; Traficante, Nadia; Fereday, Sian; Johnson, Daryl; Fox, Stephen; Sellers, William; Urashima, Mitsuyoshi; Salvesen, Helga B; Meyerson, Matthew; Bowtell, David

2009-02-15

A significant number of women with serous ovarian cancer are intrinsically refractory to platinum-based treatment. We analyzed somatic DNA copy number variation and gene expression data to identify key mechanisms associated with primary resistance in advanced-stage serous cancers. Genome-wide copy number variation was measured in 118 ovarian tumors using high-resolution oligonucleotide microarrays. A well-defined subset of 85 advanced-stage serous tumors was then used to relate copy number variation to primary resistance to treatment. The discovery-based approach was complemented by quantitative-PCR copy number analysis of 12 candidate genes as independent validation of previously reported associations with clinical outcome. Likely copy number variation targets and tumor molecular subtypes were further characterized by gene expression profiling. Amplification of 19q12, containing cyclin E (CCNE1), and 20q11.22-q13.12, mapping immediately adjacent to the steroid receptor coactivator NCOA3, was significantly associated with poor response to primary treatment. Other genes previously associated with copy number variation and clinical outcome in ovarian cancer were not associated with primary treatment resistance. Chemoresistant tumors with high CCNE1 copy number and protein expression were associated with increased cellular proliferation but so too was a subset of treatment-responsive patients, suggesting a cell-cycle independent role for CCNE1 in modulating chemoresponse. Patients with a poor clinical outcome without CCNE1 amplification overexpressed genes involved in extracellular matrix deposition. We have identified two distinct mechanisms of primary treatment failure in serous ovarian cancer, involving CCNE1 amplification and enhanced extracellular matrix deposition. CCNE1 copy number is validated as a dominant marker of patient outcome in ovarian cancer.

Absence of Metallothionein 3 Expression in Breast Cancer is a Rare, But Favorable Marker of Outcome that is Under Epigenetic Control

PubMed Central

Somji, Seema; Garrett, Scott H.; Zhou, Xu Dong; Zheng, Yun; Sens, Donald A.; Sens, Mary Ann

2010-01-01

Cadmium (Cd+2), a known carcinogen mimics the effects of estrogen in the uterus and mammary gland suggesting its possible involvement in the development and progression of breast cancer. This lab showed through analysis of a small set of archival human diagnostic specimens that the third isoform of the classic Cd+2 binding protein metallothionein (MT-3), is not expressed in normal breast tissue, but is expressed in some breast cancers and that expression tends to correlate with a poor disease outcome. The goals of the present study were to verify that overexpression of MT-3 in a large set of archival human diagnostic specimens tends to correlate with poor disease outcome and define the mechanism of MT-3 gene regulation in the normal breast epithelial cell. The results showed that MT-3 was expressed in approximately 90% of all breast cancers and was absent in normal breast epithelium. The lack of MT-3 staining in some cancers correlated with a favorable patient outcome. High frequency of MT-3 staining was also found for in situ breast cancer suggesting that MT-3 might be an early biomarker for breast cancer. The study also demonstrated that the MCF-10A cell line, an immortalized, non-tumorigenic model of human breast epithelial cells, displayed no basal expression of MT-3, nor was it induced by Cd+2. Treatment of the MCF-10A cells with the demethylation agent, 5-Aza-2′-deoxycytidine, or the histone deacetylase inhibitor, MS-275, restored MT-3 mRNA expression. It was also shown that the MT-3 metal regulatory elements are potentially active binders of protein factors following treatment with these inhibitors suggesting that MT-3 expression may be subject to epigenetic regulation. PMID:21170156

Centre-level variation in outcomes and treatment for otitis media with effusion and hearing loss and the association of hearing loss with developmental outcomes at ages 5 and 7 years in children with non-syndromic unilateral cleft lip and palate: The Cleft Care UK study. Part 2.

PubMed

Hall, A; Wills, A K; Mahmoud, O; Sell, D; Waylen, A; Grewal, S; Sandy, J R; Ness, A R

2017-06-01

To explore centre-level variation in otitis media with effusion (OME), hearing loss and treatments in children in Cleft Care UK (CCUK) and to examine the association between OME, hearing loss and developmental outcomes at 5 and 7 years. Two hundred and sixty-eight 5-year-old British children with non-syndromic unilateral cleft lip and palate (UCLP) recruited to CCUK. Children had air and bone conduction audiometry at age 5. Information on grommet and hearing aid treatment was obtained from parental questionnaire and medical notes. Hearing loss at age 5 was defined as >20 dB in the better ear and history of OME and hearing loss was determined from past treatment. Children with sensorineural hearing loss were excluded. Associations were examined with speech, behaviour and self-confidence at age 5 and educational attainment at age 7. Centre variation was examined using hierarchical models and associations between hearing variables and developmental outcomes were examined using logistic regression. There was centre-level variation in early grommet placement (variance partition coefficient (VPC) 18%, P=.001) and fitting of hearing aids (VPC 8%, P=.03). A history of OME and hearing loss was associated with poor intelligibility of speech (adjusted odds ratio=2.87, 95% CI 1.42-5.77) and aspects of educational attainment. Hearing loss is an important determinant of poor speech and treatment variation across centres suggest management of OME and hearing loss could be improved. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Quality of perinatal care services from the user's perspective: a Dutch study applies the World Health Organization's responsiveness concept.

PubMed

van der Kooy, Jacoba; Birnie, Erwin; Valentine, Nicole B; de Graaf, Johanna P; Denktas, Semiha; Steegers, Eric A P; Bonsel, Gouke J

2017-09-29

The concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions. The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care. The Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as 'poor' and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users' personal background characteristics in multiple logistic regression analyses to explain responsiveness. Poor responsiveness outcomes ranged from 5.9% to 31.7% for the antenatal phase and from 9.7% to 27.1% for the delivery phase. Overall for both phases, 'respect for persons' (Autonomy, Dignity, Communication and Confidentiality) domains performed better and were judged to be more important than 'client orientation' domains (Choice and Continuity, Prompt Attention, Quality of Basic Amenities, Social Consideration). On the whole, responsiveness was explained more by health-care and health related issues than personal characteristics. To improve responsiveness outcomes caregivers should focus on domains in the category 'client orientation'.

Prognostic factors for return-to-work following surgery for carpal tunnel syndrome: a systematic review.

PubMed

Peters, Susan; Johnston, Venerina; Hines, Sonia; Ross, Mark; Coppieters, Michel

2016-09-01

Carpal tunnel syndrome (CTS) is a common problem, that can be effectively managed by surgery. Screening for prognostic factors is important to identify workers who are at a greater risk of a poor work outcome in order to implement tailored interventions to facilitate their return-to-work. To synthesize the best available evidence on the association of preoperative prognostic factors with work-related outcomes in people who have undergone carpal tunnel surgery. Participants included those who were employed at the time of surgery, underwent carpal tunnel surgery and planned to return-to-work. The primary outcome was return-to-work. Quantitative studies investigating at least one prognostic factor for a work-related outcome in studies of workers who had carpal tunnel surgery were considered. Eleven electronic databases were searched from their respective inception date up to July 2015. A total of 3893 publications were reviewed. The quality of the included studies was assessed by two reviewers using a modified version of an appraisal tool (Joanna Briggs Institute Meta-analysis of Statistical Assessment and Review Instrument [JBI-MAStARI]). The following criteria were evaluated: study population representativeness, clearly defined prognostic factors and outcomes, potential confounding variables and appropriate statistical analysis. Data extraction was performed using a modified version of the standardized extraction tool from JBI-MAStARI. Statistical pooling was not possible. Findings are presented in tables and narrative format. Eleven studies (13 publications) investigating 93 prognostic factors for delayed return-to-work or prolonged work disability outcomes and 27 prognostic factors for work role functioning in 4187 participants were identified.Prognostic factors associated with workers' increased likelihood of an earlier return-to-work in a moderate-to-high-quality study included worker expected or desired fewer days off work, occupation, lower pain anxiety and if CTS had not altered their work role.Prognostic factors for a poorer work-related outcome included older age, lower household income, greater upper extremity functional limitation, greater than two musculoskeletal pain sites, lower recovery expectations, worse mental health status, job accommodation availability, high job strain, high job demands with high job control, poor co-worker relationships, poor baseline work role functioning, less-supportive workplace policies, preoperative work absence due to CTS or work disability of any cause, workers' compensation status, attorney involvement, and post-diagnosis surgical wait time. For workers who have had carpal tunnel surgery, there are a number of factors which may be modified in order to improve return-to-work times.

Therapy was not what I expected: a preliminary qualitative analysis of concordance between client expectations and experience of cognitive-behavioural therapy.

PubMed

Westra, Henny Alice; Aviram, Adi; Barnes, Marissa; Angus, Lynne

2010-07-01

Expectancy violations have generally been neglected in psychotherapy research but may have important implications for therapy process and outcome. A qualitative approach was used to examine discrepancies between actual experience and expectations in client posttreatment accounts of cognitive-behavioural therapy. Nine good- and nine poor-outcome cases were included. Good-outcome clients frequently reported disconfirmation of process expectations, including surprise that therapy was collaborative, that they had the freedom to direct therapy, and that they were comfortable and could trust the process. Poor-outcome clients generally failed to report such experiences. Good-outcome clients also reported gaining more from treatment than expected, whereas poor-outcome clients reported being disappointed. These findings suggest an important role for expectancy disconfirmation in therapy.

Trends in 'poor responder' research: lessons learned from RCTs in assisted conception.

PubMed

Papathanasiou, Athanasios; Searle, Belinda J; King, Nicole M A; Bhattacharya, Siladitya

2016-04-01

A substantial minority of women undergoing IVF will under-respond to controlled ovarian hyperstimulation. These women-so-called 'poor responders'-suffer persistently reduced success rates after IVF. Currently, no single intervention is unanimously accepted as beneficial in overcoming poor ovarian response (POR). This has been supported by the available research on POR, which consists mainly of randomized controlled trials (RCTs ) with an inherent high-risk of bias. The aim of this review was to critically appraise the available experimental trials on POR and provide guidance towards more useful-less wasteful-future research. A comprehensive review was undertaken of RCTs on 'poor responders' published in the last 15 years. Data on various methodological traits as well as important clinical characteristics were extracted from the included studies and summarized, with a view to identifying deficiencies from which lessons can be learned. Based on this analysis, recommendations were provided for further research in this field of assisted conception. We selected and analysed 75 RCTs. A valid, 'low-risk' randomization method was reported in three out of four RCTs. An improving trend in reporting concealment of patient allocation was also evident over the 15-year period. In contrast, <1 in 10 RCTs 'blinded' patients and <1 in 5 RCTs 'blinded' staff to the proposed intervention. Only 1 in 10 RCTs 'blinded' ultrasound practitioners to patient allocation, when assessing the outcome of early pregnancy. The majority of trials reported an intention-to-treat analysis for at least one of their outcomes, with an improving trend in the recent years. Substantial variation was noted in the definitions used for 'poor responders', the most popular being 'low ovarian response at previous stimulation'. The preferred cut-off value for defining previous low response has been 'less or equal to three retrieved oocytes'. The most popular tests used for diagnosing diminished ovarian reserve have been antral follicle count and FSH. Although the Bologna criteria for POR were only recently introduced, they are expected to become a popular definition in future 'poor responder' trials. Numerous interventions have been studied on 'poor responders'. Most of these have been applied before/during controlled ovarian hyperstimulation. The antagonist protocol, the microdose flare protocol and the long down-regulation protocol have been among the most popular interventions. The analysis of outcomes revealed a clear improving trend in reporting live birth. In contrast, only 10% of RCTs reported significant improvement in reproductive outcomes among tested interventions. Twelve 'significant' interventions were reported, each supported by a single 'positive' RCT. Finally, trials of higher methodological quality were more likely to have been published in a high-impact journal. Overall, the majority of published trials on POR suffer from methodological flaws and are, thus, regarded as being high-risk for bias. The same trials have used a variety of definitions for their poor responders and a variety of interventions for their head-to-head comparisons. Not surprisingly, discrepancies are also evident in the findings of trials comparing similar interventions. Based on the identified deficiencies, this novel type of 'methodology and clinical' review has introduced custom recommendations on how to improve future experimental research in the 'poor responder' population. © The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

The design briefing process matters: a case study on telehealthcare device providers in the UK.

PubMed

Yang, Fan; Renda, Gianni

2018-01-23

The telehealthcare sector has been expanding steadily in the UK. However, confusing, complex and unwieldy designs of telehealthcare devices are at best, less effective than they could be, at worst, they are potentially dangerous to the users. This study investigated the factors within the new product development process that hindered satisfactory product design outcomes, through working collaboratively with a leading provider based in the UK. This study identified that there are too many costly late-stage design changes; a critical and persistent problem area ripe for improvement. The findings from analyzing 30 recent devices, interviewing key stakeholders and observing on-going projects further revealed that one major cause of the issue was poor practice in defining and communicating the product design criteria and requirements. Addressing the characteristics of the telehealthcare industry, such as multiple design commissioners and frequent deployment of design subcontracts, this paper argues that undertaking a robust process of creating the product design brief is the key to improving the outcomes of telehealthcare device design, particularly for the small and medium-sized enterprises dominating the sector. Implications for rehabilitation Product design criteria and requirements are frequently ill-defined and ineffectively communicated to the designers within the processes of developing new telehealthcare devices. The absence of a (robust) process of creating the design brief is the root cause of the identified issues in defining and communicating the design task. Deploying a formal process of creating the product design brief is particularly important for the telehealthcare sector.

Oxidative stress balance is dysregulated and represents an additional target for treating cholangiocarcinoma.

PubMed

Uchida, Daisuke; Takaki, Akinobu; Ishikawa, Hisashi; Tomono, Yasuko; Kato, Hironari; Tsutsumi, Koichiro; Tamaki, Naofumi; Maruyama, Takayuki; Tomofuji, Takaaki; Tsuzaki, Ryuichiro; Yasunaka, Tetsuya; Koike, Kazuko; Matsushita, Hiroshi; Ikeda, Fusao; Miyake, Yasuhiro; Shiraha, Hidenori; Nouso, Kazuhiro; Yoshida, Ryuichi; Umeda, Yuzo; Shinoura, Susumu; Yagi, Takahito; Fujiwara, Toshiyoshi; Morita, Manabu; Fukushima, Masaki; Yamamoto, Kazuhide; Okada, Hiroyuki

2016-07-01

Pancreatico-biliary malignancies exhibit similar characteristics, including obesity-related features and poor prognosis, and require new treatment strategies. Oxidative stress is known to induce DNA damage and carcinogenesis, and its reduction is viewed as being favorable. However, it also has anti-infection and anti-cancer functions that need to be maintained. To reveal the effect of oxidative stress on cancer progression, we evaluated oxidative stress and anti-oxidative balance in pancreatic cancer (PC) and cholangiocarcinoma (CC) patients, as well as the effect of add-on antioxidant treatment to chemotherapy in a mouse cholangiocarcinoma model. We recruited 84 CC and 80 PC patients who were admitted to our hospital. Serum levels of reactive oxygen metabolites (ROM) and the anti-oxidative OXY-adsorbent test were determined and the balance of these tests was defined as an oxidative index. A diabetic mouse-based cholangiocarcinoma model was utilized to evaluate the effects of add-on antioxidant therapy on cholangiocarcinoma chemotherapy. Serum ROM was higher and anti-oxidant OXY was lower in CC patients with poor outcomes. These parameters were not significantly different in PC patients. In mice, vitamin E administration induced antioxidant hemeoxygenase (HO)-1 protein expression in cancer tissue, while the number of stem-like cells increased. l-carnitine administration improved intestinal microbiome and biliary acid balance, upregulated the hepatic mitochondrial membrane uptake related gene Cpt1 in non-cancerous tissue, and did not alter stem-like cell numbers. Oxidative stress balance was dysregulated in cholangiocarcinoma with poor outcome. The mitochondrial function-supporting agent l-carnitine is a good candidate to control oxidative stress conditions.

Primary tumor location predicts poor clinical outcome with cetuximab in RAS wild-type metastatic colorectal cancer.

PubMed

Kim, Dalyong; Kim, Sun Young; Lee, Ji Sung; Hong, Yong Sang; Kim, Jeong Eun; Kim, Kyu-Pyo; Kim, Jihun; Jang, Se Jin; Yoon, Young-Kwang; Kim, Tae Won

2017-11-23

In metastatic colorectal cancer, the location of the primary tumor has been suggested to have biological significance. In this study, we investigated whether primary tumor location affects cetuximab efficacy in patients with RAS wild-type metastatic colorectal cancer. Genotyping by the SequenomMassARRAY technology platform (OncoMap) targeting KRAS, NRAS, PIK3CA, and BRAF was performed in tumors from 307 patients who had been given cetuximab as salvage treatment. Tumors with mutated RAS (KRAS or NRAS; n = 127) and those with multiple primary location (n = 10) were excluded. Right colon cancer was defined as a tumor located in the proximal part to splenic flexure. A total of 170 patients were included in the study (right versus left, 23 and 147, respectively). Patients with right colon cancer showed more mutated BRAF (39.1% vs. 5.4%), mutated PIK3CA (13% vs. 1.4%), poorly differentiated tumor (17.4% vs. 3.4%), and peritoneal involvement (26.1% vs. 8.8%) than those with left colon and rectal cancer. Right colon cancer showed poorer progression-free survival (2.0 vs.5.0 months, P = 0.002) and overall survival (4.1 months and 13.0 months, P < 0.001) than the left colon and rectal cancer. By multivariable analysis, BRAF mutation, right colon primary, poorly differentiated histology, and peritoneal involvement were associated with risk of death. In RAS wild-type colon cancer treated with cetuximab as salvage treatment, right colon primary was associated with poorer survival outcomes than left colon and rectal cancer.

The Difference Between the Healing and the Nonhealing Diabetic Foot Ulcer: A Review of the Role of the Microcirculation.

PubMed

Lowry, Danielle; Saeed, Mujahid; Narendran, Parth; Tiwari, Alok

2017-09-01

Diabetic foot disease carries a high morbidity and is a leading cause of lower limb amputation. This may in part be due to the effect diabetes mellitus (DM) has on the microcirculation including in the skin. We conducted a review of studies that have examined the relationship between microcirculatory function and wound healing in patients with DM. A search of the Medline, Embase, and Web of Science databases was performed coupled with a review of references for the period 1946 to March 2015. Nineteen studies of diverse methodology and cohort selection were identified. Poor function of the microcirculation was related to poor outcome. Transcutaneous oxygen pressure (TcPO 2 ) was the most commonly used method to measure the microcirculation and thresholds for poor outcome proposed ranged from 10 mmHg to <34 mmHg. Two studies reexamined microcirculatory function following revascularization. Both found an increase in TcPO 2 , however only 1 reached statistical significance. No significant difference in the results of microcirculation tests was found between diabetic and nondiabetic patients. While it is not possible to draw firm conclusions from the evidence currently available there are clear areas that warrant research. Good microcirculation unsurprisingly appears to associate with better wound healing. The influence of DM is not clear, and neither is the degree of improvement required to achieve healing. Studies that examine a clearly defined cohort both with and without DM are urgently required. Accurate quantitative assessment of microcirculation will aid prediction of wound healing identifying those at greatest risk of amputation.

Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study.

PubMed

Singh, Swaran P; Paul, Moli; Ford, Tamsin; Kramer, Tami; Weaver, Tim; McLaren, Susan; Hovish, Kimberly; Islam, Zoebia; Belling, Ruth; White, Sarah

2010-10-01

Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS. We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced. Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health. For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

[Clinical evaluation of open and close treatment in pediatric condylar fractures].

PubMed

Han, Jing; Li, Zhi; Zhou, Haihua; Yang, Rongtao; Xiong, Guizhong; Li, Zubing

2014-08-01

To evaluate the long-term clinical and radiographic outcomes of open and close treatment of condylar fractures of mandible in children. A total of 78 cases (105 mandibular condylar fractures) were included in this study. All patients (younger than 12 years at the time of injury were followed up for at least 3 years. According to the classification of the condylar fractures, open or close treatment was chosen. Clinical outcomes were classified as favorable or unfavorable depending on the mouth opening, pattern of mouth opening, occlusion, facial symmetry. Condylar remodeling was defined as complete, moderate, or poor based on the radiographic findings. Depending on the classification, 14 sides of type I, 48 sides of type II and 43 sides of type III were included in this study. Open treatment was chosen in 51 sides and close treatment was chosen in 54 sides. Most of the patients acquired satisfactory clinical outcomes. Better radiologic remodeling of the condylar process was found in the patients treated by open treatment. Favorable long-term clinical outcomes were obtained in both open and close treatment of mandibular condylar fractures. A better morphological remodeling of condylar process was found in patients with open treatment.

Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

PubMed Central

Hilberman, M; Kutner, J; Parsons, D; Murphy, D J

1997-01-01

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp good clinical judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated. PMID:9451605

A Propensity Score Analysis of the Impact of Dexamethasone Use on Delayed Cerebral Ischemia and Poor Functional Outcomes After Subarachnoid Hemorrhage.

PubMed

Mohney, Nathaniel; Williamson, Craig A; Rothman, Edward; Ball, Ron; Sheehan, Kyle M; Pandey, Aditya S; Fletcher, Jeffrey J; Jacobs, Teresa L; Thompson, B Gregory; Rajajee, Venkatakrishna

2018-01-01

An inflammatory response occurs after aneurysmal subarachnoid hemorrhage (aSAH) and predicts poor outcomes. Glucocorticoids suppress inflammation and promote fluid retention. Dexamethasone is often administered after aSAH for postoperative cerebral edema and refractory headache. Our objective was to examine the impact of dexamethasone use on functional outcomes and delayed cerebral ischemia (DCI) after aSAH. Patients with aSAH admitted between 2010 and 2015 were included; the data source was a single-center subarachnoid hemorrhage registry. The intervention of interest was a dexamethasone taper used <7 days from ictus. The primary outcome was poor discharge functional outcome, with a modified Rankin Scale score >3. Other outcomes included DCI and infection. A propensity score for use of dexamethasone was calculated using a logistic regression model that included potential predictors of dexamethasone use and outcome. The impact of dexamethasone on outcomes of interest was calculated and the propensity score was controlled for. A total of 440 patients with subarachnoid hemorrhage were admitted during the study period and 309 met eligibility criteria. Dexamethasone was administered in 101 patients (33%). A total of 127 patients (41%) had a discharge modified Rankin Scale score >3, 105 (34%) developed DCI, and 94 (30%) developed an infection. After propensity score analysis, dexamethasone use was associated with a significant reduction in poor functional outcomes (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.19-0.66) but showed no significant association with DCI (OR, 0.93; 95% CI, 0.53-1.64) or infection (OR, 0.60; 95% CI, 0.34-1.06). Dexamethasone use after aSAH was associated with a reduction in poor functional outcomes at discharge but not DCI, controlling for predictors of dexamethasone use. Copyright © 2017 Elsevier Inc. All rights reserved.

The Balance Between Stress and Personal Capital during Pregnancy and the Relationship with Adverse Obstetric Outcomes: Findings from the 2007 Los Angeles Mommy and Baby (LAMB) Study

PubMed Central

Wakeel, Fathima; Wisk, Lauren E.; Gee, Rebekah; Chao, Shin M.; Witt, Whitney P.

2013-01-01

Purpose Stress during pregnancy is a salient risk factor for adverse obstetric outcomes. Personal capital during pregnancy, defined as internal and social resources that help women cope with or decrease their exposure to stress, may reduce the risk of poor obstetric outcomes. Methods Using data from the 2007 Los Angeles Mommy and Baby (LAMB) survey (N=3,353), we examined the relationships between the balance of stress and personal capital during pregnancy, or the Stress-to-Capital Ratio (SCR), and adverse obstetric outcomes ((i.e., pregnancy complications, preterm birth (PTB), low birthweight (LBW), and small-for-gestational-age (SGA)). Results Women with a higher SCR (i.e. greater stress relative to personal capital during pregnancy) were significantly more likely to experience at least one pregnancy complication, PTB, and lower gestational age, but not LBW or SGA. Accounting for pregnancy complications completely mediated the association between the SCR and PTB. Conclusions Our findings indicate that experiencing greater stress relative to personal capital during pregnancy is associated with an increased risk for pregnancy complications, PTB, and lower gestational age and that pregnancy complications may be a mechanism by which the SCR is related to adverse obstetric outcomes. PMID:23812738

Creating a Novel Video Vignette Stroke Preparedness Outcome Measure Using a Community-Based Participatory Approach.

PubMed

Skolarus, Lesli E; Murphy, Jillian B; Dome, Mackenzie; Zimmerman, Marc A; Bailey, Sarah; Fowlkes, Sophronia; Morgenstern, Lewis B

2015-07-01

Evaluating the efficacy of behavioral interventions for rare outcomes is a challenge. One such topic is stroke preparedness, defined as inteventions to increase stroke symptom recognition and behavioral intent to call 911. Current stroke preparedness intermediate outcome measures are centered on written vignettes or open-ended questions and have been shown to poorly reflect actual behavior. Given that stroke identification and action requires aural and visual processing, video vignettes may improve on current measures. This article discusses an approach for creating a novel stroke preparedness video vignette intermediate outcome measure within a community-based participatory research partnership. A total of 20 video vignettes were filmed of which 13 were unambiguous (stroke or not stroke) as determined by stroke experts and had test discrimination among community participants. Acceptable reliability, high satisfaction, and cultural relevance were found among the 14 community respondents. A community-based participatory approach was effective in creating a video vignette intermediate outcome. Future projects should consider obtaining expert and community feedback prior to filming all the video vignettes to improve the proportion of vignettes that are usable. While content validity and preliminary reliability were established, future studies are needed to confirm the reliability and establish construct validity. © 2014 Society for Public Health Education.

Creating a Novel Video Vignette Stroke Preparedness Outcome Measure using a Community Based Participatory Approach

PubMed Central

Skolarus, Lesli E.; Murphy, Jillian B.; Dome, Mackenzie; Zimmerman, Marc A.; Bailey, Sarah; Fowlkes, Sophronia; Morgenstern, Lewis B.

2015-01-01

Evaluating the efficacy of behavioral interventions for rare outcomes is a challenge. One such topic is stroke preparedness, defined as inteventions to increase stroke symptom recognition and behavioral intent to call 911. Current stroke preparedness intermediate outcome measures are centered on written vignettes or open ended questions and have been shown to poorly reflect actual behavior. Given that stroke identification and action requires aural and visual processing, video vignettes may improve upon current measures. This article discusses an approach for creating a novel stroke preparedness video vignette intermediate outcome measure within a community based participatory research partnership. A total of 20 video vignettes were filmed of which 13 were unambiguous (stroke or not stroke) as determined by stroke experts and had test discrimination among community participants. Acceptable reliability, high satisfaction and cultural relevance were found among the 14 community respondents. A community based participatory approach was effective in creating a video vignette intermediate outcome. Future projects should consider obtaining expert and community feedback prior to filming all the video vignettes to improve the proportion of vignettes that are usable. While content validity and preliminary reliability were established, future studies are needed to confirm the reliability and establish construct validity. PMID:25367896

Making parks make a difference: poor alignment of policy, planning and management with protected-area impact, and ways forward

PubMed Central

Pressey, Robert L.; Visconti, Piero; Ferraro, Paul J.

2015-01-01

Policy and practice around protected areas are poorly aligned with the basic purpose of protection, which is to make a difference. The difference made by protected areas is their impact, defined in program evaluation as the outcomes arising from protection relative to the counterfactual of no protection or a different form of protection. Although impact evaluation of programs is well established in fields such as medicine, education and development aid, it is rare in nature conservation. We show that the present weak alignment with impact of policy targets and operational objectives for protected areas involves a great risk: targets and objectives can be achieved while making little difference to the conservation of biodiversity. We also review potential ways of increasing the difference made by protected areas, finding a poor evidence base for the use of planning and management ‘levers’ to better achieve impact. We propose a dual strategy for making protected areas more effective in their basic role of saving nature, outlining ways of developing targets and objectives focused on impact while also improving the evidence for effective planning and management. PMID:26460132

When is a research question not a research question?

PubMed

Mayo, Nancy E; Asano, Miho; Barbic, Skye Pamela

2013-06-01

Research is undertaken to answer important questions yet often the question is poorly expressed and lacks information on the population, the exposure or intervention, the comparison, and the outcome. An optimal research question sets out what the investigator wants to know, not what the investigator might do, nor what the results of the study might ultimately contribute. The purpose of this paper is to estimate the extent to which rehabilitation scientists optimally define their research questions. A cross-sectional survey of the rehabilitation research articles published during 2008. Two raters independently rated each question according to pre-specified criteria; a third rater adjudicated all discrepant ratings. The proportion of the 258 articles with a question formulated as methods or expected contribution and not as what knowledge was being sought was 65%; 30% of questions required reworking. The designs which most often had poorly formulated research questions were randomized trials, cross-sectional and measurement studies. Formulating the research question is not purely a semantic concern. When the question is poorly formulated, the design, analysis, sample size calculations, and presentation of results may not be optimal. The gap between research and clinical practice could be bridged by a clear, complete, and informative research question.

Chronic Wound Repair and Healing in Older Adults: Current Status and Future Research

PubMed Central

Gould, Lisa; Abadir, Peter; Brem, Harold; Carter, Marissa; Conner-Kerr, Teresa; Davidson, Jeff; DiPietro, Luisa; Falanga, Vincent; Fife, Caroline; Gardner, Sue; Grice, Elizabeth; Harmon, John; Hazzard, William R.; High, Kevin P.; Houghton, Pamela; Jacobson, Nasreen; Kirsner, Robert S.; Kovacs, Elizabeth J.; Margolish, David; McFarland Horne, Frances; Reed, May J.; Sullivan, Dennis H.; Thom, Stephen; Tomic-Canic, Marjana; Walston, Jeremy; Whitney, JoAnne; Williams, John; Zieman, Susan; Schmader, Kenneth

2014-01-01

The incidence of chronic wounds is increased among older adults, and the impact of chronic wounds on quality of life is particularly profound in this population. It is well established that wound healing slows with age. However, the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The impact of age and accompanying multi-morbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables, lack of standardization in data collection, and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this paper, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify key research questions to guide future study of age-associated changes in chronic wound healing. PMID:25486905

Chronic Wound Repair and Healing in Older Adults: Current Status and Future Research

PubMed Central

Gould, Lisa; Abadir, Peter; Brem, Harold; Carter, Marissa; Conner-Kerr, Teresa; Davidson, Jeff; DiPietro, Luisa; Falanga, Vincent; Fife, Caroline; Gardner, Sue; Grice, Elizabeth; Harmon, John; Hazzard, William R.; High, Kevin P.; Houghton, Pamela; Jacobson, Nasreen; Kirsner, Robert S.; Kovacs, Elizabeth J.; Margolis, David; Horne, Frances McFarland; Reed, May J.; Sullivan, Dennis H.; Thom, Stephen; Tomic-Canic, Marjana; Walston, Jeremy; Whitney, Jo Anne; Williams, John; Zieman, Susan; Schmader, Kenneth

2015-01-01

Older adults are more likely to have chronic wounds than younger people, and the effect of chronic wounds on quality of life is particularly profound in this population. Wound healing slows with age, but the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The effect of age and accompanying multimorbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables; lack of standardization in data collection; and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this article, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify research questions to guide future study of age-associated changes in chronic wound healing. PMID:25753048

Measuring the success of occupational alcoholism programs.

PubMed

Kurtz, N R; Googins, B; Howard, W C

1984-01-01

The research on the success of occupational alcoholism programs (OAPs) was reviewed. One measure of the success of OAPs has been a change in drinking behavior. This may seem like the most relevant measure but there are questions about its reliability because researchers usually depend on subjects' self-reports and do not define their criteria for successful outcome well. In addition, attempts by employers to dictate the drinking habits of their employees may be difficult to justify. Varying rates of success on this measure have been reported. Subjects have generally been able to control drinking in the long term, but it is suggested that their control erodes over time. A second measure of the success of OAPs has been work performance, as revealed by absenteeism, disciplinary actions, accidents, sick and injured days taken, turnover rate and job efficiency. Studies of this measure have been hindered by employers' poor record keeping and by the difficulty of developing standard measures of outcome success. In general, studies with weaker research designs have shown more improvement on this measure. A third measure has been the cost efficiency of OAPs, as revealed by direct savings for employers resulting from OAPs such as decreases in absenteeism and indirect savings such as increased accuracy of work. This measure seems to be the one most relevant to employers' profit motives. Studies of cost efficiency have had ambiguous findings. A fourth measure has been the penetration rate--the extent to which an OAP reaches its target population. This measure has never been studied successfully. A problem with all the studies reviewed has been their poor design (a lack of control groups, follow-up periods that were too brief and problems with selection of subjects), which raises serious questions about their validity. The obstacles to measuring outcome success were also discussed--poor documentation by employers, lack of access to subjects and reluctance on the part of employers and treatment staff to allow studies.

Retrospective study of long-term outcome after brain arteriovenous malformation rupture: the RAP score.

PubMed

Shotar, Eimad; Debarre, Matthieu; Sourour, Nader-Antoine; Di Maria, Federico; Gabrieli, Joseph; Nouet, Aurélien; Chiras, Jacques; Degos, Vincent; Clarençon, Frédéric

2018-01-01

OBJECTIVE The authors aimed to design a score for stratifying patients with brain arteriovenous malformation (BAVM) rupture, based on the likelihood of a poor long-term neurological outcome. METHODS The records of consecutive patients with BAVM hemorrhagic events who had been admitted over a period of 11 years were retrospectively reviewed. Independent predictors of a poor long-term outcome (modified Rankin Scale score ≥ 3) beyond 1 year after admission were identified. A risk stratification scale was developed and compared with the intracranial hemorrhage (ICH) score to predict poor outcome and inpatient mortality. RESULTS One hundred thirty-five patients with 139 independent hemorrhagic events related to BAVM rupture were included in this analysis. Multivariate logistic regression followed by stepwise analysis showed that consciousness level according to the Glasgow Coma Scale (OR 6.5, 95% CI 3.1-13.7, p < 10 -3 ), hematoma volume (OR 1.8, 95% CI 1.2-2.8, p = 0.005), and intraventricular hemorrhage (OR 7.5, 95% CI 2.66-21, p < 10 -3 ) were independently associated with a poor outcome. A 12-point scale for ruptured BAVM prognostication was constructed combining these 3 factors. The score obtained using this new scale, the ruptured AVM prognostic (RAP) score, was a stronger predictor of a poor long-term outcome (area under the receiver operating characteristic curve [AUC] 0.87, 95% CI 0.8-0.92, p = 0.009) and inpatient mortality (AUC 0.91, 95% CI 0.85-0.95, p = 0.006) than the ICH score. For a RAP score ≥ 6, sensitivity and specificity for predicting poor outcome were 76.8% (95% CI 63.6-87) and 90.8% (95% CI 81.9-96.2), respectively. CONCLUSIONS The authors propose a new admission score, the RAP score, dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy-to-use scoring system may help to improve communication between health care providers and consistency in clinical research. Only external prospective cohorts and population-based studies will ensure full validation of the RAP scores' capacity to predict outcome after BAVM rupture.

Chronic urinary retention in men: how we define it, and how does it affect treatment outcome.

PubMed

Negro, Carlo L A; Muir, Gordon H

2012-12-01

What's known on the subject? and What does the study add? Chronic urinary retention (CUR) is a poorly defined entity, as the key element of definition, significant postvoid residual urine volume (PVR), has not a worldwide and moreover evidenced-based definition. There is no agreement on which is the threshold value to define a significant PVR and different society produced guidelines with different thresholds ranging from 300 mL to 1000 mL. Diagnosis is difficult, and management has not been defined yet. There is a lack of studies on the best management of these patients, as this group of patients has always been considered at high risk of failure. Only one study compares conservative with the surgical management but it is not a randomised controlled trail. This review offers a systematic appraisal of the most recent publications on CUR. It indicates the absence of a real worldwide agreed definition, as the two keys element of it are not satisfactorily defined yet: significant PVR, is suffering from a lack of evidenced-based definition, and percussable or palpable bladder is a very nebulous concept as it is not a criteria of certainty as different individual variables affect it. This has an important effect on management which is not structured. Most of the trials involving benign prostatic hyperplasia treatments (either medical or surgical) tend to exclude this group of patients, which is a clinically important group, comprising up to a quarter of men undergoing TURP in the UK. Urinary retention describes a bladder that does not empty completely or does not empty at all. Historically, urinary retention has been classified as either acute or chronic the latter is generally classified as high pressure or low pressure according to the bladder filling pressure on urodynamic. A MEDLINE® search for articles written in English and published before January 2010 was done using a list of terms related to urinary retention: 'urinary retention', 'chronic urinary retention' and 'PVR'. Chronic urinary retention (CUR) is defined by the International Continence Society as 'a non-painful bladder, which remains palpable or percussable after the patient has passed urine'. Abrams was the first to choose a residual urine volume >300 mL to define CUR as he considered it the minimum volume at which the bladder becomes palpable suprapubically. The UK National Institute for Health and Clinical Excellence lower urinary tract symptoms (LUTS) guidelines define CUR as a postvoid residual urine volume (PVR) of >1000 mL. No studies have specifically addressed the problem of quantifying the minimum amount of urine present in the bladder to define CUR. Nor did we find any publications objectively assessing at what amount of urine a bladder can be palpable. The ability to feel a bladder may rely on variables (i.e. medical skills and patient habitus). There is a marked variability of PVR, so the test should be repeated to improve precision. As defining CUR is difficult, structured management is challenging. Nearly all prospective trials exclude men with CUR from analysis, possibly anticipating a poor outcome and a high risk of complications. However, men with CUR are a clinically important group, comprising up to 25% of men undergoing transurethral resection of the prostate. Definition of CUR is imprecise and arbitrary. Most studies seem to describe the condition as either a PVR of >300 mL in men who are voiding, or >1000 mL in men who are unable to void. This confusion leads to an inability to design and interpret studies; indeed most prospective trials simply exclude these patients. There is a clear need for internationally accepted definitions of retention to allow both treatment and reporting of outcomes in men with LUTS, and for such definitions to be used by all investigators in future trials. © 2012 BJU INTERNATIONAL.

The burden of surgical diseases on critical care services at a tertiary hospital in sub-Saharan Africa.

PubMed

Tomlinson, Jared; Haac, Bryce; Kadyaudzu, Clement; Samuel, Jonathan C; Campbell, Emilia L P; Lee, Clara N; Charles, Anthony G

2013-01-01

In many developing countries, including those of sub-Saharan Africa, care of the critically ill is poorly developed. We sought to elucidate the characteristics and outcomes of critically ill patients in order to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographics, patient characteristics, clinical specialty and outcome data was collected for the 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynaecology patients. Use of the ventilator and transfusions were not associated with increased mortality. Patients with head injuries had the highest mortality rate. Rationing of critical care resources, using admitting diagnosis or scoring tools, can maximize access to critical care services in resource-limited settings. Furthermore, improvements of critical care services will be central to future efforts to reduce surgical morbidity and mortality and improving outcomes in all critically ill patients.

Using risk adjustment approaches in child welfare performance measurement: Applications and insights from health and mental health settings

PubMed Central

Raghavan, Ramesh

2014-01-01

Federal policymaking in the last decade has dramatically expanded performance measurement within child welfare systems, and states are currently being fiscally penalized for poor performance on defined outcomes. However, in contrast to performance measurement in health settings, current policy holds child welfare systems solely responsible for meeting outcomes, largely without taking into account the effects of factors at the level of the child, and his or her social ecology, that might undermine the performance of child welfare agencies. Appropriate measurement of performance is predicated upon the ability to disentangle individual, as opposed to organizational, determinants of outcomes, which is the goal of risk adjustment methodologies. This review briefly conceptualizes and examines risk adjustment approaches in health and child welfare, suggests approaches to expanding its use to appropriately measure the performance of child welfare agencies, and highlights research gaps that diminish the appropriate use of risk adjustment approaches – and which consequently suggest the need for caution – in policymaking around performance measurement of child welfare agencies. PMID:25253917

Toward a neuroimaging treatment selection biomarker for major depressive disorder.

PubMed

McGrath, Callie L; Kelley, Mary E; Holtzheimer, Paul E; Dunlop, Boadie W; Craighead, W Edward; Franco, Alexandre R; Craddock, R Cameron; Mayberg, Helen S

2013-08-01

Currently, fewer than 40% of patients treated for major depressive disorder achieve remission with initial treatment. Identification of a biological marker that might improve these odds could have significant health and economic impact. To identify a candidate neuroimaging "treatment-specific biomarker" that predicts differential outcome to either medication or psychotherapy. Brain glucose metabolism was measured with positron emission tomography prior to treatment randomization to either escitalopram oxalate or cognitive behavior therapy for 12 weeks. Patients who did not remit on completion of their phase 1 treatment were offered enrollment in phase 2 comprising an additional 12 weeks of treatment with combination escitalopram and cognitive behavior therapy. Mood and anxiety disorders research program at an academic medical center. Men and women aged 18 to 60 years with currently untreated major depressive disorder. Randomized assignment to 12 weeks of treatment with either escitalopram oxalate (10-20 mg/d) or 16 sessions of manual-based cognitive behavior therapy. Remission, defined as a 17-item Hamilton depression rating scale score of 7 or less at both weeks 10 and 12, as assessed by raters blinded to treatment. Positive and negative predictors of remission were identified with a 2-way analysis of variance treatment (escitalopram or cognitive behavior therapy) × outcome (remission or nonresponse) interaction. Of 65 protocol completers, 38 patients with clear outcomes and usable positron emission tomography scans were included in the primary analysis: 12 remitters to cognitive behavior therapy, 11 remitters to escitalopram, 9 nonresponders to cognitive behavior therapy, and 6 nonresponders to escitalopram. Six limbic and cortical regions were identified, with the right anterior insula showing the most robust discriminant properties across groups (effect size = 1.43). Insula hypometabolism (relative to whole-brain mean) was associated with remission to cognitive behavior therapy and poor response to escitalopram, while insula hypermetabolism was associated with remission to escitalopram and poor response to cognitive behavior therapy. If verified with prospective testing, the insula metabolism-based treatment-specific biomarker defined in this study provides the first objective marker, to our knowledge, to guide initial treatment selection for depression. Registered at clinicaltrials.gov (NCT00367341).

Improving the Rank Precision of Population Health Measures for Small Areas with Longitudinal and Joint Outcome Models

PubMed Central

Athens, Jessica K.; Remington, Patrick L.; Gangnon, Ronald E.

2015-01-01

Objectives The University of Wisconsin Population Health Institute has published the County Health Rankings since 2010. These rankings use population-based data to highlight health outcomes and the multiple determinants of these outcomes and to encourage in-depth health assessment for all United States counties. A significant methodological limitation, however, is the uncertainty of rank estimates, particularly for small counties. To address this challenge, we explore the use of longitudinal and pooled outcome data in hierarchical Bayesian models to generate county ranks with greater precision. Methods In our models we used pooled outcome data for three measure groups: (1) Poor physical and poor mental health days; (2) percent of births with low birth weight and fair or poor health prevalence; and (3) age-specific mortality rates for nine age groups. We used the fixed and random effects components of these models to generate posterior samples of rates for each measure. We also used time-series data in longitudinal random effects models for age-specific mortality. Based on the posterior samples from these models, we estimate ranks and rank quartiles for each measure, as well as the probability of a county ranking in its assigned quartile. Rank quartile probabilities for univariate, joint outcome, and/or longitudinal models were compared to assess improvements in rank precision. Results The joint outcome model for poor physical and poor mental health days resulted in improved rank precision, as did the longitudinal model for age-specific mortality rates. Rank precision for low birth weight births and fair/poor health prevalence based on the univariate and joint outcome models were equivalent. Conclusion Incorporating longitudinal or pooled outcome data may improve rank certainty, depending on characteristics of the measures selected. For measures with different determinants, joint modeling neither improved nor degraded rank precision. This approach suggests a simple way to use existing information to improve the precision of small-area measures of population health. PMID:26098858

Fluid Overload is Associated with Late Poor Outcomes in Neonates Following Cardiac Surgery

PubMed Central

Wilder, Nicole S; Yu, Sunkyung; Donohue, Janet E; Goldberg, Caren S; Blatt, Neal B

2016-01-01

Objective Acute kidney injury (AKI) is a severe complication of cardiac surgery associated with increased morbidity and mortality, yet AKI classification for neonates remains challenging. We characterized patterns of post-operative fluid overload (FO) as a surrogate marker for AKI and as a risk factor of poor post-operative outcomes in neonates undergoing cardiac surgery. Design Retrospective cohort study. Setting Single, congenital heart center destination program. Patients 435 neonates undergoing cardiac surgery with cardiopulmonary bypass from January 2006 through December 2010. Interventions None Measurements and Main Results Demographics, diagnosis, and perioperative clinical variables were collected, including daily weights and serum creatinine (SCr) levels. A composite poor clinical outcome (death, need for renal replacement therapy (RRT), or extracorporeal life support (ECLS) within 30 post-operative days) was considered the primary outcome measure. Twenty-one neonates (5%) had a composite poor outcome with 7 (2%) requiring RRT, 8 (2%) requiring ECLS, and 14 (3%) dying between 3 and 30 days post-surgery. Neonates with a composite poor outcome had significantly higher maximum FO (>20%) and were slower to diurese. A receiver-operating characteristic curve determined that FO ≥ 16% and SCr ≥ 0.9 on post-operative day 3 were the optimal cutoffs for significant discrimination on the primary outcome (area under the curve = 0.71 and 0.76, respectively). In multivariable analysis, FO ≥ 16% (adjusted odds ratio [AOR] = 3.7) and SCr ≥ 0.9 (AOR = 6.6) on post-operative day 3 remained an independent risk factor for poor outcome. FO ≥ 16% was also significantly associated with cardiac arrest requiring cardiopulmonary resuscitation, prolonged intensive care unit stay, and chest re-exploration. Conclusions This study highlights the importance of monitoring fluid balance in the neonatal cardiac surgical population, and suggests that daily FO, a readily-available, non-invasive marker of renal function, may be a sensitive and specific predictor of adverse outcomes. PMID:27028790

Impact of the revised International Prognostic Scoring System, cytogenetics and monosomal karyotype on outcome after allogeneic stem cell transplantation for myelodysplastic syndromes and secondary acute myeloid leukemia evolving from myelodysplastic syndromes: a retrospective multicenter study of the European Society of Blood and Marrow Transplantation

PubMed Central

Koenecke, Christian; Göhring, Gudrun; de Wreede, Liesbeth C.; van Biezen, Anja; Scheid, Christof; Volin, Liisa; Maertens, Johan; Finke, Jürgen; Schaap, Nicolaas; Robin, Marie; Passweg, Jakob; Cornelissen, Jan; Beelen, Dietrich; Heuser, Michael; de Witte, Theo; Kröger, Nicolaus

2015-01-01

The aim of this study was to determine the impact of the revised 5-group International Prognostic Scoring System cytogenetic classification on outcome after allogeneic stem cell transplantation in patients with myelodysplastic syndromes or secondary acute myeloid leukemia who were reported to the European Society for Blood and Marrow Transplantation database. A total of 903 patients had sufficient cytogenetic information available at stem cell transplantation to be classified according to the 5-group classification. Poor and very poor risk according to this classification was an independent predictor of shorter relapse-free survival (hazard ratio 1.40 and 2.14), overall survival (hazard ratio 1.38 and 2.14), and significantly higher cumulative incidence of relapse (hazard ratio 1.64 and 2.76), compared to patients with very good, good or intermediate risk. When comparing the predictive performance of a series of Cox models both for relapse-free survival and for overall survival, a model with simplified 5-group cytogenetics (merging very good, good and intermediate cytogenetics) performed best. Furthermore, monosomal karyotype is an additional negative predictor for outcome within patients of the poor, but not the very poor risk group of the 5-group classification. The revised International Prognostic Scoring System cytogenetic classification allows patients with myelodysplastic syndromes to be separated into three groups with clearly different outcomes after stem cell transplantation. Poor and very poor risk cytogenetics were strong predictors of poor patient outcome. The new cytogenetic classification added value to prediction of patient outcome compared to prediction models using only traditional risk factors or the 3-group International Prognostic Scoring System cytogenetic classification. PMID:25552702

Effect of early trauma on the sleep quality of euthymic bipolar patients.

PubMed

Aubert, E; Jaussent, I; Olié, E; Ducasse, D; Azorin, J M; Bellivier, F; Belzeaux, R; Bougerol, T; Etain, B; Gard, S; Henry, C; Kahn, J P; Leboyer, M; Loftus, J; Passerieux, C; Lopez-Castroman, J; Courtet, Ph

2016-12-01

Poor quality of sleep is frequent in euthymic bipolar patients and conveys worse clinical outcomes. We investigated the features of euthymic bipolar patients associated with poor sleep quality, with a focus on the effect of childhood trauma. 493 euthymic patients with DSM-IV-defined bipolar disorders were recruited in FondaMental Advanced Centers of Expertize for Bipolar Disorders (FACE-BD) between 2009 and 2014. Clinical variables were recorded. Subjective sleep quality and history of childhood trauma were respectively measured by the Pittsburgh Sleep Quality Index (PSQI) and the Childhood Trauma Questionnaire (CTQ). Poor sleepers were older, less professionally active, had significantly higher anxiety levels, took more anxiolytic drugs and did endorse more suicide attempts and suicidal ideas than good sleepers after adjusting for anxiety levels and age. Emotional abuse was associated with poor sleep quality after adjustment for BMI, age, professional activity, and bipolar disorders (BD) type (OR=1.83; 95% CI [1.30; 3.10]; p=0.02). However, this association was lost after adjustment for anxiety levels, anxiolytic treatment and suicide ideation/attempts. The main limitation was the type of sleep assessment, which only measured the subjective part of sleep complaints. A history of emotional abuse might underlie sleep problems in many bipolar patients but anxiety seems to act as a confounding factor in this relationship. New studies are needed to elucidate the role of childhood maltreatment on poor sleep among bipolar patients. Copyright © 2016 Elsevier B.V. All rights reserved.

What counts: outcome assessment after distal radius fractures in aged patients.

PubMed

Goldhahn, Jörg; Angst, Felix; Simmen, Beat R

2008-09-01

Outcome of surgical interventions at the distal radius does not only depend on the type of intervention used, it also depends on the way the outcome is measured. Substantial differences in outcome assessment between different measurement tools and poor correlation among them result in the question about the best instrument for the evaluation of treatment after distal radius fractures. The aim of the review is to discuss pros and cons of the parameters that are available to assess the outcome after distal radius fractures. The review should help to choose the appropriate instruments for a given research question in aged patients with distal radius fractures. Objective and subjective measures were reviewed with respect to their suitability in outcome assessment. Radiological parameters like inclination, palmar slope, and length of the radius are most common and used to determine especially surgical success. Grip strength and range of motion are considered objective and used as study endpoints in many studies. Functional tests like the Jebsen test provide a realistic feedback about disability but require special skills and resources of the testing personnel. Patient self-assessment adds perceived patient benefit. The patient-rated wrist evaluation (PRWE) provides a reliable and valid instrument for subjective outcome assessment. A combination of objective and subjective parameters should be used to assess the outcome of different treatment strategies due to the known discrepancies. Objective parameters like shortening, radial shift, or others should be clearly defined in the study methodology.

A Summary of the Biological Basis of Frailty.

PubMed

Fielding, Roger A

2015-01-01

Frailty has been defined as a geriatric syndrome that is characterized by a reduction in the physiological reserve required for an individual to respond to endogenous and exogenous stressors. Using a discrete definition of frailty that includes sedentariness, involuntary weight loss, fatigue, poor muscle strength, and slow gait speed, 'frailty' has been associated with increased disability, postsurgical complications, and increased mortality. Despite the strong associations between frailty and subsequent poor outcomes, limited attention to this common geriatric condition has been paid in clinical settings. A more fundamental basic understanding of the biological factors that contribute to the frailty phenotype has begun to emerge. Multiple underlying biological factors such as dysregulation of inflammatory processes, genomic instability, oxidative stress, mitochondrial dysfunction, and cellular senescence appear to contribute to the clinical presentation of frailty. This chapter summarizes the papers presented on the biological basis of frailty from the 83rd Nestlé Nutrition Institute Workshop on 'Frailty, Pathophysiology, Phenotype and Patient Care' held in Barcelona, Spain, in March 2014. © 2015 Nestec Ltd., Vevey/S. Karger AG, Basel.

Survival analysis, long-term outcomes, and percentage of recovery up to 8 years post-infection among the Houston West Nile virus cohort.

PubMed

Murray, Kristy O; Garcia, Melissa N; Rahbar, Mohammad H; Martinez, Diana; Khuwaja, Salma A; Arafat, Raouf R; Rossmann, Susan

2014-01-01

In 2012, we witnessed a resurgence of West Nile virus (WNV) in the United States, with the largest outbreak of human cases reported since 2003. WNV is now endemic and will continue to produce epidemics over time, therefore defining the long-term consequences of WNV infection is critical. Over a period of eight years, we prospectively followed a cohort of 157 WNV-infected subjects in the Houston metropolitan area to observe recovery over time and define the long-term clinical outcomes. We used survival analysis techniques to determine percentage of recovery over time and the effects of demographic and co-morbid conditions on recovery. We found that 40% of study participants continued to experience symptoms related to their WNV infection up to 8 years later. Having a clinical presentation of encephalitis and being over age 50 were significantly associated with prolonged or poor recovery over time. Since the health and economic impact as a result of prolonged recovery, continued morbidity, and related disability is likely substantial in those infected with WNV, future research should be aimed at developing effective vaccines to prevent illness and novel therapeutics to minimize morbidity, mortality, and long-term complications from infection.

Survival Analysis, Long-Term Outcomes, and Percentage of Recovery up to 8 Years Post-Infection among the Houston West Nile Virus Cohort

PubMed Central

Murray, Kristy O.; Garcia, Melissa N.; Rahbar, Mohammad H.; Martinez, Diana; Khuwaja, Salma A.; Arafat, Raouf R.; Rossmann, Susan

2014-01-01

In 2012, we witnessed a resurgence of West Nile virus (WNV) in the United States, with the largest outbreak of human cases reported since 2003. WNV is now endemic and will continue to produce epidemics over time, therefore defining the long-term consequences of WNV infection is critical. Over a period of eight years, we prospectively followed a cohort of 157 WNV-infected subjects in the Houston metropolitan area to observe recovery over time and define the long-term clinical outcomes. We used survival analysis techniques to determine percentage of recovery over time and the effects of demographic and co-morbid conditions on recovery. We found that 40% of study participants continued to experience symptoms related to their WNV infection up to 8 years later. Having a clinical presentation of encephalitis and being over age 50 were significantly associated with prolonged or poor recovery over time. Since the health and economic impact as a result of prolonged recovery, continued morbidity, and related disability is likely substantial in those infected with WNV, future research should be aimed at developing effective vaccines to prevent illness and novel therapeutics to minimize morbidity, mortality, and long-term complications from infection. PMID:25054656

Can somatosensory and visual evoked potentials predict neurological outcome during targeted temperature management in post cardiac arrest patients?

PubMed

Choi, Seung Pill; Park, Kyu Nam; Wee, Jung Hee; Park, Jeong Ho; Youn, Chun Song; Kim, Han Joon; Oh, Sang Hoon; Oh, Yoon Sang; Kim, Soo Hyun; Oh, Joo Suk

2017-10-01

In cardiac arrest patients treated with targeted temperature management (TTM), it is not certain if somatosensory evoked potentials (SEPs) and visual evoked potentials (VEPs) can predict neurological outcomes during TTM. The aim of this study was to investigate the prognostic value of SEPs and VEPs during TTM and after rewarming. This retrospective cohort study included comatose patients resuscitated from cardiac arrest and treated with TTM between March 2007 and July 2015. SEPs and VEPs were recorded during TTM and after rewarming in these patients. Neurological outcome was assessed at discharge by the Cerebral Performance Category (CPC) Scale. In total, 115 patients were included. A total of 175 SEPs and 150 VEPs were performed. Five SEPs during treated with TTM and nine SEPs after rewarming were excluded from outcome prediction by SEPs due to an indeterminable N20 response because of technical error. Using 80 SEPs and 85 VEPs during treated with TTM, absent SEPs yielded a sensitivity of 58% and a specificity of 100% for poor outcome (CPC 3-5), and absent VEPs predicted poor neurological outcome with a sensitivity of 44% and a specificity of 96%. The AUC of combination of SEPs and VEPs was superior to either test alone (0.788 for absent SEPs and 0.713 for absent VEPs compared with 0.838 for the combination). After rewarming, absent SEPs and absent VEPs predicted poor neurological outcome with a specificity of 100%. When SEPs and VEPs were combined, VEPs slightly increased the prognostic accuracy of SEPs alone. Although one patient with absent VEP during treated with TTM had a good neurological outcome, none of the patients with good neurological outcome had an absent VEP after rewarming. Absent SEPs could predict poor neurological outcome during TTM as well as after rewarming. Absent VEPs may predict poor neurological outcome in both periods and VEPs may provide additional prognostic value in outcome prediction. Copyright © 2017 Elsevier B.V. All rights reserved.

The neural basis of risky choice with affective outcomes.

PubMed

Suter, Renata S; Pachur, Thorsten; Hertwig, Ralph; Endestad, Tor; Biele, Guido

2015-01-01

Both normative and many descriptive theories of decision making under risk are based on the notion that outcomes are weighted by their probability, with subsequent maximization of the (subjective) expected outcome. Numerous investigations from psychology, economics, and neuroscience have produced evidence consistent with this notion. However, this research has typically investigated choices involving relatively affect-poor, monetary outcomes. We compared choice in relatively affect-poor, monetary lottery problems with choice in relatively affect-rich medical decision problems. Computational modeling of behavioral data and model-based neuroimaging analyses provide converging evidence for substantial differences in the respective decision mechanisms. Relative to affect-poor choices, affect-rich choices yielded a more strongly curved probability weighting function of cumulative prospect theory, thus signaling that the psychological impact of probabilities is strongly diminished for affect-rich outcomes. Examining task-dependent brain activation, we identified a region-by-condition interaction indicating qualitative differences of activation between affect-rich and affect-poor choices. Moreover, brain activation in regions that were more active during affect-poor choices (e.g., the supramarginal gyrus) correlated with individual trial-by-trial decision weights, indicating that these regions reflect processing of probabilities. Formal reverse inference Neurosynth meta-analyses suggested that whereas affect-poor choices seem to be based on brain mechanisms for calculative processes, affect-rich choices are driven by the representation of outcomes' emotional value and autobiographical memories associated with them. These results provide evidence that the traditional notion of expectation maximization may not apply in the context of outcomes laden with affective responses, and that understanding the brain mechanisms of decision making requires the domain of the decision to be taken into account.

The Association of CHA2DS2-VASc Score and Blood Biomarkers with Ischemic Stroke Outcomes: The Belgrade Stroke Study

PubMed Central

Potpara, Tatjana S.; Polovina, Marija M.; Djikic, Dijana; Marinkovic, Jelena M.; Kocev, Nikola; Lip, Gregory Y. H.

2014-01-01

Background Many blood biomarkers have a positive association with stroke outcome, but adding blood biomarkers to the National Institutes of Health Stroke Scale (NIHSS) did not significantly improve its discriminatory ability. We investigated the association of the CHA2DS2-VASc score with unfavourable functional outcome (defined as a 30-day modified Rankin Scale [mRS] ≥3) in patients presenting with acute ischemic stroke (AIS), and examined whether the addition of blood biomarkers (troponin I [TnI], fibrinogen, C-reactive protein [CRP]) affects the model discriminatory ability. Methods We conducted an observational single-centre study of consecutive patients with AIS. All patients were admitted to hospital within 24 hours from the neurological symptoms onset. Results Of 240 patients (mean age 70.0±8.9 years), unfavourable 30-day outcome occurred in 92 (38.3%). Patients with mRS≥3 were older and more likely to have atrial fibrillation or other comorbidities (all p<0.001). They had higher levels of CRP, fibrinogen, TnI and higher CHA2DS2-VASc and CHADS2 scores (all p<0.05). The adjusted CHA2DS2-VASc score had excellent predictive ability for poor stroke outcome (c-statistic 0.982;95%CI,0.964–1.000, p<0.001). Whilst CRP had the highest sensitivity (83.7%), cardiac TnI was the most specific (97.3%) for prediction of poor stroke outcome (cut-off: >0.09µg/L). Compared with each of these biomarkers, CHA2DS2-VASc score had significantly better predictive ability for poor stroke outcome (c-statistic for CRP, Fibrinogen and TnI was 0.853;95%CI,0.802–0.895, 0.848;95%CI,0.796–0.891, and 0.792;95%CI,0.736–0.842, all p<0.001, respectively, versus 0.932;95%CI,0.892–0.960, p<0.001 for the CHA2DS2-VASc, all p for the comparisons<0.01). There was no significant difference in the predictive ability of the CHA2DS2-VASc score vs. combinations of the CHA2DS2-VASc and TnI or TnI, fibrinogen and CRP (z statistic 0.369, p = 0.7119; integrated discrimination index 0.00801 and 0.00172, respectively, both p>0.05). Conclusions The CHA2DS2-VASc score alone reliably predicts 30-day unfavourable outcome of stroke. Adding blood biomarkers to the CHA2DS2-VASc score did not significantly increase the predictive ability of the model. PMID:25184809

Increased Trunk Extension Endurance is Associated with Meaningful Improvement in Balance among Older Adults with Mobility Problems

PubMed Central

Suri, Pradeep; Kiely, Dan K.; Leveille, Suzanne G.; Frontera, Walter R.; Bean, Jonathan. F.

2011-01-01

Objective To determine if trunk extension endurance changes with training are associated with clinically meaningful improvements in balance among mobility-limited older adults. Design Longitudinal data from a randomized clinical trial. Setting Outpatient rehabilitation research center. Participants Community-dwelling older adults (N=64; mean age 75.9 y) with mobility limitations as defined by a score of 4 to 10 on the Short Physical Performance Battery. Interventions 16 weeks of progressive resistance training. Main Outcome Measures Outcomes were the Berg Balance Scale (BBS) and the Unipedal Stance Test (UST). Predictors included leg strength, leg power, trunk extension endurance and the product of heart rate and blood pressure (RPP) at the final stage of an exercise tolerance test. We performed an analysis of data from participants who completed 16 weeks of training using binary outcomes defined by a clinically meaningful change from baseline to completion of the intervention (CMC) (BBS= 4 units; UST= 5 seconds). The association of predictor variables with balance outcomes was examined separately and together in multivariate adjusted logistic regression models. Results Trunk extension endurance in seconds (1.04 [1.00– 1.09]) was independently associated with CMC on the BBS. Trunk extension endurance (1.02 [1.00– 1.03]) was independently associated with CMC on the UST. Other physical attributes were not associated with meaningful change in balance. Conclusions Improvements in trunk extension endurance were independently associated with clinically meaningful changes in balance in older adults. Leg strength, leg power, and RPP were not associated with CMC in balance. Poor trunk extension endurance may be a rehabilitative impairment worthy of further study as a modifiable factor linked to balance among older adults. PMID:21636073

Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery.

PubMed

Kaw, Roop; Pasupuleti, Vinay; Deshpande, Abhishek; Hamieh, Tarek; Walker, Esteban; Minai, Omar A

2011-04-01

Perioperative risk associated with pulmonary hypertension (PH) in patients undergoing non-cardiac surgery (NCS) remains poorly defined. We report perioperative outcomes in a large cohort of patients undergoing NCS, comparing those with and without PH. Patients undergoing NCS at our institution between January 2002 and December 2006, were cross matched with a Right Heart Catheterization (RHC) database for the same period. Patients were excluded if they were <18 years old and if they underwent cardiac surgery prior to NCS or minor procedures using local anesthesia or sedation. Controls were defined as patients who underwent similar NCS with mean pulmonary arterial pressure (MPAP) ≤ 25 mmHg. 173 patients underwent RHC and NCS during the specified period and were included in the analysis. Of these 96 (55%) had PH. Mean pulmonary arterial pressure (p = 0.001), American Association of Anesthesiology Class (p = 0.02), and chronic renal insufficiency (p = 0.03) were determined as independent risk factors for post-operative morbidity. Patients with PH were more likely to develop congestive heart failure (p < 0.001; OR: 11.9), hemodynamic instability (p < 0.002), sepsis (p < 0.0005), and respiratory failure (p < 0.004). Patients with PH needed longer ventilatory support (p < 0.002), stayed longer in the ICU (p < 0.04), and were more frequently readmitted to the hospital within 30 days (p < 008; OR 2.4). In addition to the traditionally known risk factors for outcomes after NCS such as coronary artery disease, diabetes mellitus, chronic renal insufficiency, American Society of Anesthesiology class, the presence of underlying PH can have a significant negative impact on perioperative outcomes. Copyright © 2010 Elsevier Ltd. All rights reserved.

Major depressive episodes are associated with poor concordance with therapy in rheumatoid arthritis patients: the impact on disease outcomes.

PubMed

Cabrera-Marroquín, Ricardo; Contreras-Yáñez, Irazú; Alcocer-Castillejos, Natasha; Pascual-Ramos, Virginia

2014-01-01

Our objective was to investigate associations between major depressive episodes (MDE), concordance with therapy (CwT) and disease outcomes in rheumatoid arthritis patients. Seventy-eight outpatients receiving ≥1 disease modifying anti-rheumatic drug and without significant comorbidity had concomitant rheumatic and psychiatric evaluations. CwT was defined according to a questionnaire. MDE was defined using the Mini International Neuropsychiatric Interview and the severity of depressive symptoms was assessed with the Beck Depression Inventory (BDI-II). Appropriated statistic was used. IRB approval was obtained. Patients included (73 ♀) had (mean±SD) age of 44±10 years and (median, range) disease duration of 10 years (5.2-15.8). Current MDE were diagnosed in 24 patients (30.8%); 60 patients (76.9%) were CwT. Patient-non-CwT were more frequently diagnosed with MDE and tend to have higher BDI scores. They had significantly more disease activity according to patient-pain VAS and swollen joint counts. Both groups were similar regarding demographic variables, treatment and comorbid conditions. Forty-one patients (53%) had clinically important depressive symptoms (BDI≥10), among them 20 had mild depression, 14 moderate and 7 severe depression. Patient-non-CwT had more frequently moderate depression (according to BDI score) than their counterparts and similar tendency was found regarding severe depression. Patient-CwT who additionally had lower BDI scores had better disease outcomes than concordant patients with higher BDI scores. Similar results were found in non-CwT patients but statistical significance was limited to disease activity. Prevalence of current MDE in RA patients was of 31%; those patients had poorer CwT and worse outcomes than mentally healthy patients.

Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making.

PubMed

Mijderwijk, Herjan; Stolker, Robert Jan; Duivenvoorden, Hugo J; Klimek, Markus; Steyerberg, Ewout W

2016-09-01

Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters. We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R (2) ). In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R (2)  = 30% and ORC = 0.76 after correction for optimism. This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare professionals the opportunity to identify vulnerable patients in ambulatory surgery, although additional modification and validation are needed. (ClinicalTrials.gov number, NCT01441843).

Prophylactic Antiepileptic Drug Use and Outcome in the Ethnic/Racial Variations of Intracerebral Hemorrhage Study.

PubMed

Sheth, Kevin N; Martini, Sharyl R; Moomaw, Charles J; Koch, Sebastian; Elkind, Mitchell S V; Sung, Gene; Kittner, Steven J; Frankel, Michael; Rosand, Jonathan; Langefeld, Carl D; Comeau, Mary E; Waddy, Salina P; Osborne, Jennifer; Woo, Daniel

2015-12-01

The role of antiepileptic drug (AED) prophylaxis after intracerebral hemorrhage (ICH) remains unclear. This analysis describes prevalence of prophylactic AED use, as directed by treating clinicians, in a prospective ICH cohort and tests the hypothesis that it is associated with poor outcome. Analysis included 744 patients with ICH enrolled in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study before November 2012. Baseline clinical characteristics and AED use were recorded in standardized fashion. ICH location and volume were recorded from baseline neuroimaging. We analyzed differences in patient characteristics by AED prophylaxis, and we used logistic regression to test whether AED prophylaxis was associated with poor outcome. The primary outcome was 3-month modified Rankin Scale score, with 4 to 6 considered poor outcome. AEDs were used for prophylaxis in 289 (39%) of the 744 subjects; of these, levetiracetam was used in 89%. Patients with lobar ICH, craniotomy, or larger hematomas were more likely to receive prophlyaxis. Although prophylactic AED use was associated with poor outcome in an unadjusted model (odds ratio, 1.40; 95% confidence interval, 1.04-1.88; P=0.03), this association was no longer significant after adjusting for clinical and demographic characteristics (odds ratio, 1.11; 95% confidence interval, 0.74-1.65; P=0.62). We found no evidence that AED use (predominantly levetiracetam) is independently associated with poor outcome. A prospective study is required to assess for a more modest effect of AED use on outcome after ICH. © 2015 American Heart Association, Inc.

Self-competence Among Early and Middle Adolescents Affected by Maternal HIV/AIDS

PubMed Central

Marelich, William D.; Murphy, Debra A.; Payne, Diana L.; Herbeck, Diane M.; Schuster, Mark A.

2012-01-01

Adolescent children of mothers with HIV face a host of stressors that place them at increased risk for poor outcomes. Using covariance structure analysis, this study examines adolescent risk outcomes and their relationships to maternal health, as well as the potentially protective factors of family environment and self-competence. The final model indicated that poor maternal health was negatively related to a protective family environment, which in turn was negatively related to adolescent risk outcomes. A protective family environment was also positively related to adolescent self-competence, which was negatively related to adolescent risk outcomes. Implications of the study are discussed, including how these findings can influence interventions aimed at reducing the risk for poor outcomes among adolescent youth with HIV-infected mothers. PMID:22485061

Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry.

PubMed

Linfante, Italo; Starosciak, Amy K; Walker, Gail R; Dabus, Guilherme; Castonguay, Alicia C; Gupta, Rishi; Sun, Chung-Huan J; Martin, Coleman; Holloway, William E; Mueller-Kronast, Nils; English, Joey D; Malisch, Tim W; Marden, Franklin A; Bozorgchami, Hormozd; Xavier, Andrew; Rai, Ansaar T; Froehler, Michael T; Badruddin, Aamir; Nguyen, Thanh N; Taqi, M Asif; Abraham, Michael G; Janardhan, Vallabh; Shaltoni, Hashem; Novakovic, Roberta; Yoo, Albert J; Abou-Chebl, Alex; Chen, Peng R; Britz, Gavin W; Kaushal, Ritesh; Nanda, Ashish; Issa, Mohammad A; Nogueira, Raul G; Zaidat, Osama O

2016-03-01

Mechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70-83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40-55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Logistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0-2 (good outcome) vs 3-6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power. Of 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80). Age, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Somatic mutation load of estrogen receptor-positive breast tumors predicts overall survival: an analysis of genome sequence data.

PubMed

Haricharan, Svasti; Bainbridge, Matthew N; Scheet, Paul; Brown, Powel H

2014-07-01

Breast cancer is one of the most commonly diagnosed cancers in women. While there are several effective therapies for breast cancer and important single gene prognostic/predictive markers, more than 40,000 women die from this disease every year. The increasing availability of large-scale genomic datasets provides opportunities for identifying factors that influence breast cancer survival in smaller, well-defined subsets. The purpose of this study was to investigate the genomic landscape of various breast cancer subtypes and its potential associations with clinical outcomes. We used statistical analysis of sequence data generated by the Cancer Genome Atlas initiative including somatic mutation load (SML) analysis, Kaplan-Meier survival curves, gene mutational frequency, and mutational enrichment evaluation to study the genomic landscape of breast cancer. We show that ER(+), but not ER(-), tumors with high SML associate with poor overall survival (HR = 2.02). Further, these high mutation load tumors are enriched for coincident mutations in both DNA damage repair and ER signature genes. While it is known that somatic mutations in specific genes affect breast cancer survival, this study is the first to identify that SML may constitute an important global signature for a subset of ER(+) tumors prone to high mortality. Moreover, although somatic mutations in individual DNA damage genes affect clinical outcome, our results indicate that coincident mutations in DNA damage response and signature ER genes may prove more informative for ER(+) breast cancer survival. Next generation sequencing may prove an essential tool for identifying pathways underlying poor outcomes and for tailoring therapeutic strategies.

Body temperature and response to thrombolytic therapy in acute ischaemic stroke.

PubMed

Millán, M; Grau, L; Castellanos, M; Rodríguez-Yáñez, M; Arenillas, J F; Nombela, F; Pérez de la Ossa, N; López-Manzanares, L; Serena, J; Castillo, J; Dávalos, A

2008-12-01

To determine the relationship between body temperature (BT), arterial recanalization, functional outcome, and hemorrhagic transformation (HT) of cerebral infarction in patients treated with i.v. tissue plasminogen activator (tPA). We studied 254 patients treated with tPA within 3 h from stroke onset. National Institute of Health Stroke Scale score, BT, and transcranial Doppler ultrasound (n = 99) on admission and at 24 h were recorded. Hypodensity volume and HT were evaluated on CT at 24-36 h. Poor outcome (Rankin Scale > 2) was evaluated at 3 months. Arterial recanalization at 24 h was found in 70.7% of patients, HT in 24.8% (symptomatic in 4.7%) and poor outcome in 44.1%. Baseline BT was not associated with greater stroke severity at admission or at 24 h, HT or poor outcome. However, BT at 24 h correlated to stroke severity (P < 0.001) and hypodensity volume (P < 0.001) at 24 h, and was higher in patients who did not recanalize (P = 0.001), had symptomatic HT (P = 0.063) and poor outcome (P < 0.001). The adjusted odds ratio of poor outcome for patients with BT at 24 h > or = 37 degrees C was 2.56 (1.19-5.50, P = 0.016). Body temperature > or =37 degrees C at 24 h, but not at baseline, is associated with a lack of recanalization, greater hypodensity volume and worse outcome in stroke patients treated with tPA.

Klebsiella pneumoniae Infection Leads to a Poor Visual Outcome in Endogenous Endophthalmitis: A 12-year Experience in Southern Taiwan.

PubMed

Chen, Shih-Chou; Lee, Ying-Yen; Chen, Ya-Hsin; Lin, Huey-Shyan; Wu, Tsung-Tien; Sheu, Shwu-Jiuan

2017-12-01

To compare the characteristics, visual outcome, and prognostic factors of patients with endogenous endophthalmitis and to determine the association of endophthalmitis with Klebsiella pneumoniae infection. We retrospectively analyzed records of patients diagnosed with endogenous endophthalmitis from January 2002 to August 2013. A total of 86 patients were diagnosed with endogenous endophthalmitis; 48 patients were infected with K. pneumoniae, 28 patients were infected with other pathogens, and 10 were culture-negative. Diabetes mellitus was more prevalent among patients infected with K. pneumoniae. Liver abscess and urinary tract infection were the leading sources of infection in patients with and without a K. pneumoniae infection, respectively. In patients with endogenous endophthalmitis, poor initial vision (p<0.001) and K. pneumoniae infection (p = 0.048) were significantly associated with a poor visual outcome. Poor initial vision and K. pneumoniae infection were significantly associated with poorer visual outcome for patients with endogenous endophthalmitis.

Predictors of Positive Outcomes in Offspring of Depressed Parents and Non-depressed Parents Across 20 Years

PubMed Central

Verdeli, Helen; Wickramaratne, Priya; Warner, Virginia; Mancini, Anthony; Weissman, Myrna

2014-01-01

Understanding differences in factors leading to positive outcomes in high-risk and low-risk offspring has important implications for preventive interventions. We identified variables predicting positive outcomes in a cohort of 235 offspring from 76 families in which one, both, or neither parent had major depressive disorder. Positive outcomes were termed resilient in offspring of depressed parents, and competent in offspring of non-depressed parents, and defined by two separate criteria: absence of psychiatric diagnosis and consistently high functioning at 2, 10, and 20 years follow-up. In offspring of depressed parents, easier temperament and higher self-esteem were associated with greater odds of resilient outcome defined by absence of diagnosis. Lower maternal overprotection, greater offspring self-esteem, and higher IQ were associated with greater odds of resilient outcome defined by consistently high functioning. Multivariate analysis indicated that resilient outcome defined by absence of diagnosis was best predicted by offspring self-esteem; resilient outcome defined by functioning was best predicted by maternal overprotection and self-esteem. Among offspring of non-depressed parents, greater family cohesion, easier temperament and higher self-esteem were associated with greater odds of offspring competent outcome defined by absence of diagnosis. Higher maternal affection and greater offspring self-esteem were associated with greater odds of competent outcome, defined by consistently high functioning. Multivariate analysis for each criterion indicated that competent outcome was best predicted by offspring self-esteem. As the most robust predictor of positive outcomes in offspring of depressed and non-depressed parents, self-esteem is an important target for youth preventive interventions. PMID:25374449

Risk factors for work-related stress and health in head teachers.

PubMed

Phillips, Samantha J; Sen, Dil; McNamee, Roseanne

2008-12-01

Work-related stress (WRS) is known to cause ill-health and decreased productivity. Work in the education sector is thought to be particularly stressful. Few studies have considered risk factors for WRS and health in head teachers. To investigate health in head teachers in West Sussex. To determine personal risk factors most likely to predict cases of WRS and of poor health in head teachers. A cross-sectional study, in a population of 290 head teachers and principals of colleges of further education, using a validated questionnaire, 'a short stress evaluation tool' (ASSET) and additional questions derived from earlier studies. Results were compared with the ASSET database 'norm' groups: a general population of workers (GPN) group and a group of managers and professionals (MPN). 'Caseness' was defined as respondents who felt work was 'very or extremely stressful'. Head teachers had poor physical and mental health compared to the GPN group. Psychological well-being, particularly of females and primary head teachers was worse than a comparative group of managers and professionals. Teaching<5 h/week was a significant predictor of caseness and being female was the main risk factor for poor psychological well-being. Prevalence of self-reported stress in head teachers in West Sussex is high. Female head teachers had worse health outcomes. Our study identified possible personal risk factors predicting WRS and/or poor health in head teachers.

High Tumor Volume to Fetal Weight Ratio Is Associated with Worse Fetal Outcomes and Increased Maternal Risk in Fetuses with Sacrococcygeal Teratoma.

PubMed

Gebb, Juliana S; Khalek, Nahla; Qamar, Huma; Johnson, Mark P; Oliver, Edward R; Coleman, Beverly G; Peranteau, William H; Hedrick, Holly L; Flake, Alan W; Adzick, N Scott; Moldenhauer, Julie S

2018-03-01

Tumor volume to fetal weight ratio (TFR) > 0.12 before 24 weeks has been associated with poor outcome in fetuses with sacrococcygeal teratoma (SCT). We evaluated TFR in predicting poor fetal outcome and increased maternal operative risk in our cohort of SCT pregnancies. This is a retrospective, single-center review of fetuses seen with SCT from 1997 to 2015. Patients who chose termination of pregnancy (TOP), delivered elsewhere, or had initial evaluation at > 24 weeks were excluded. Receiver operating characteristic (ROC) analysis determined the optimal TFR to predict poor fetal outcome and increased maternal operative risk. Poor fetal outcome included fetal demise, neonatal demise, or fetal deterioration warranting open fetal surgery or delivery < 32 weeks. Increased maternal operative risk included cases necessitating open fetal surgery, classical cesarean delivery, or ex utero intrapartum treatment (EXIT). Of 139 pregnancies with SCT, 27 chose TOP, 14 delivered elsewhere, and 40 had initial evaluation at > 24 weeks. Thus, 58 fetuses were reviewed. ROC analysis revealed that at ≤24 weeks, TFR > 0.095 was predictive of poor fetal outcome and TFR > 0.12 was predictive of increased maternal operative risk. This study supports the use of TFR at ≤24 weeks for risk stratification of pregnancies with SCT. © 2018 S. Karger AG, Basel.

Higher leukocyte count predicts 3-month poor outcome of ruptured cerebral aneurysms.

PubMed

Yao, Pei-Sen; Chen, Guo-Rong; Xie, Xue-Ling; Shang-Guan, Huang-Cheng; Gao, Jin-Zhen; Lin, Yuan-Xiang; Zheng, Shu-Fa; Lin, Zhang-Ya; Kang, De-Zhi

2018-04-11

It is not fully established whether leukocyte can predict the poor outcome for ruptured cerebral aneurysms (CA) or not. Here, we retrospectively analyzed the clinical data of 428 patients with ruptured CA between 2010 and 2015. Patients' demographic data, including gender, age, history of smoking, alcohol, hypertension, diabetes and hypercholesterolemia, Hunt-Hess and Fisher grade, occurrence of hydrocephalus, aneurysm location, time to surgery, delayed ischemic neurological deficit (DIND) and peak leukocyte of blood test from day 1 to 3 after aneurysmal rupture were recorded and analyzed. In the multivariable analysis model, gender, Fisher grade, time to surgery and hydrocephalus were not relevant to poor outcome. However, Hunt-Hess grade, DIND and preoperative leukocyte count (>13.84 × 10 9 /L) were significantly associated with adverse outcome. The respective increased risks were 5.2- (OR5.24, 95% CI 1.67-16.50, p = 0.005), 6.2-(OR 6.24, 95% CI 3.55-10.99, p < 0.001) and 10.9-fold (OR 9.35, 95% CI 5.98-19.97, p < 0.001). The study revealed that Hunt-Hess grade, DIND and preoperative leukocyte count (>13.84 × 10 9 /L) were independent risk factors for poor outcome of ruptured CA at 3 months. Higher leukocyte count is a convenient and useful marker to predict 3-month poor outcome for ruptured CA.

Poor oral status is associated with rehabilitation outcome in older people.

PubMed

Shiraishi, Ai; Yoshimura, Yoshihiro; Wakabayashi, Hidetaka; Tsuji, Yuri

2017-04-01

Poor oral status is associated with increased physical dependency and cognitive decline. Malnutrition, a potential result of poor oral status, is associated with poorer rehabilitation outcome and physical function. However, the association between oral status and rehabilitation outcome is not fully understood. The present study investigated the association of poor oral status with rehabilitation outcome in older patients. A retrospective cohort study was carried out of 108 consecutive patients (mean age 80.5 ± 6.8 years; 50.9% men) who were admitted to convalescent rehabilitation wards. The Revised Oral Assessment Guide was used to evaluate oral status. Rehabilitation outcome was evaluated by the Functional Independence Measure (FIM) on discharge. Multivariate analyses were applied to examine the associations between poor oral status and motor-FIM on discharge. According to the Revised Oral Assessment Guide score, 14.8% of participants had normal oral status, 52.8% had slight to moderate oral problems and 32.4% had severe oral problems. The median scores of motor-FIM on admission and on discharge were 52 (interquartile range 25-70) and 75 (interquartile range 51-89), respectively. Multivariate analysis showed that the Revised Oral Assessment Guide score and the motor-/cognitive-FIM scores on admission were significant independent factors for motor-FIM on discharge, after adjusted for sex, age, length of stay, nutritional status, handgrip and causative diseases (P < 0.001). Poor oral status is associated with rehabilitation outcome in older people. Geriatr Gerontol Int 2017; 17: 598-604. © 2016 Japan Geriatrics Society.

The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health.

PubMed

Fink, Per; Ørnbøl, Eva; Christensen, Kaj Sparle

2010-03-24

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs. 1785 consecutive primary care patients aged 18-65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41-78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition. Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.

The Outcome of Health Anxiety in Primary Care. A Two-Year Follow-up Study on Health Care Costs and Self-Rated Health

PubMed Central

Fink, Per; Ørnbøl, Eva; Christensen, Kaj Sparle

2010-01-01

Background Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs. Methodology/Principal Findings 1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition. Conclusions/Significance Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety. PMID:20352043

Comparison of Spot Sign, Blend Sign and Black Hole Sign for Outcome Prediction in Patients with Intracerebral Hemorrhage

PubMed Central

Sporns, Peter B.; Schwake, Michael; Kemmling, André; Minnerup, Jens; Schwindt, Wolfram; Niederstadt, Thomas; Schmidt, Rene; Hanning, Uta

2017-01-01

Background and Purpose Blend sign (BS) and black hole sign (BHS) on non-contrast computed tomography (NCCT) and spot sign (SS) on CT-angiography (CTA) are indicators of early hematoma expansion in spontaneous intracerebral hemorrhage (ICH). However, their independent contributions to outcome have not been well explored. Methods In this retrospective study, inclusion criteria were: 1) spontaneous ICH and 2) NCCT and CTA performed on admission within 6 hours after onset of symptoms. Discharge outcome was dichotomized as good (modified Rankin Scale [mRS] 0-3) and poor (mRS 4-6) outcomes. The impacts of BHS, BS and SS on outcome were assessed in univariate and multivariable logistic regression models. Results Of 182 patients with spontaneous ICH, 26 (14.3%) presented with BHS, 37 (20.3%) with BS and 39 (21.4%) with SS. There was a substantial correlation between SS and BS (κ=0.701) and a moderate correlation between SS and BHS (κ=0.424). In univariable logistic regression, higher baseline hematoma volume (P<0.001), intraventricular hemorrhage (P=0.002) and the presence of BHS/BS/SS (all P<0.001) on admission CT scan were associated with poor outcome. Multivariable analysis identified intraventricular haemorrhage (odds ratio [OR] 2.22 per mL, P=0.022), baseline hematoma volume (OR 1.03 per mL, P<0.001) and SS on CTA (OR 11.43, P<0.001) as independent predictors of poor outcome, showing that SS compared to BS and BHS was more powerful to predict poor outcome. Conclusions The NCCT BHS and BS are correlated with the CTA SS and are reliable predictors of poor outcome in patients with ICH. Of the CT variables indicating early hematoma expansion, SS on CTA was the most reliable outcome predictor. However, given their correlation with SS on CTA, BS and BHS on NCCT can be useful for predicting outcome if CTA is not obtainable. PMID:29037015

Comparison of Spot Sign, Blend Sign and Black Hole Sign for Outcome Prediction in Patients with Intracerebral Hemorrhage.

PubMed

Sporns, Peter B; Schwake, Michael; Kemmling, André; Minnerup, Jens; Schwindt, Wolfram; Niederstadt, Thomas; Schmidt, Rene; Hanning, Uta

2017-09-01

Blend sign (BS) and black hole sign (BHS) on non-contrast computed tomography (NCCT) and spot sign (SS) on CT-angiography (CTA) are indicators of early hematoma expansion in spontaneous intracerebral hemorrhage (ICH). However, their independent contributions to outcome have not been well explored. In this retrospective study, inclusion criteria were: 1) spontaneous ICH and 2) NCCT and CTA performed on admission within 6 hours after onset of symptoms. Discharge outcome was dichotomized as good (modified Rankin Scale [mRS] 0-3) and poor (mRS 4-6) outcomes. The impacts of BHS, BS and SS on outcome were assessed in univariate and multivariable logistic regression models. Of 182 patients with spontaneous ICH, 26 (14.3%) presented with BHS, 37 (20.3%) with BS and 39 (21.4%) with SS. There was a substantial correlation between SS and BS (κ=0.701) and a moderate correlation between SS and BHS (κ=0.424). In univariable logistic regression, higher baseline hematoma volume ( P <0.001), intraventricular hemorrhage ( P =0.002) and the presence of BHS/BS/SS (all P <0.001) on admission CT scan were associated with poor outcome. Multivariable analysis identified intraventricular haemorrhage (odds ratio [OR] 2.22 per mL, P =0.022), baseline hematoma volume (OR 1.03 per mL, P <0.001) and SS on CTA (OR 11.43, P <0.001) as independent predictors of poor outcome, showing that SS compared to BS and BHS was more powerful to predict poor outcome. The NCCT BHS and BS are correlated with the CTA SS and are reliable predictors of poor outcome in patients with ICH. Of the CT variables indicating early hematoma expansion, SS on CTA was the most reliable outcome predictor. However, given their correlation with SS on CTA, BS and BHS on NCCT can be useful for predicting outcome if CTA is not obtainable.

Adoptive immunotherapy for the treatment of glioblastoma: progress and possibilities.

PubMed

Kuramitsu, Shunichiro; Yamamichi, Akane; Ohka, Fumiharu; Motomura, Kazuya; Hara, Masahito; Natsume, Atsushi

2016-12-01

Patients with glioblastoma have a very poor prognosis. Adoptive cellular therapy (ACT) is defined as the collection of circulating or tumor-infiltrating lymphocytes, their selection, modification, expansion and activation, and their re-administration to patients in order to induce antitumor activity. Although various ACTs have been attempted, most failed to improve the outcome. Immune checkpoint blockade antibodies and T cell engineering with tumor-specific chimeric antigen receptors suggest the emergence of a new era of immunotherapy. Here, we summarize approaches with ACTs using genetically modified T cells, which have been improved by enhancing their antitumor activity, and discuss strategies to develop these therapies. The mechanisms by which gliomas modulate and evade the immune system are also discussed.

Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study.

PubMed

Dasgupta, Monidipa; Brymer, Chris; Elsayed, Sameer

2017-09-01

Despite clinical practice guidelines, asymptomatic bacteriuria (ASB) in older people is frequently treated. A common reason for treating ASB is a change in mental status. To determine how often asymptomatic UTI is treated in older medically ill delirious individuals and its association with functional recovery. Consecutive older medical in-patients were screened for delirium, and followed in hospital. Treatment for asymptomatic UTI was defined as documented treatment for a possible urinary tract infection with antibiotics, without concurrent infectious or urinary symptoms. The primary outcome was functional recovery at discharge or 3 months post-discharge. Poor functional recovery was defined by any one of death, new permanent long-term institutionalization or decreased ability to perform activities of daily living. The study sample comprised 343 delirious in-patients, of which 237 (69%) had poor functional recovery. Ninety two (27%) delirious in-patients were treated for asymptomatic UTI. Treatment for asymptomatic UTI was associated with poor functional recovery compared to other delirious in-patients (RR 1.30, 95% CI: 1.14-1.48 overall). Similar results were seen when the analysis was restricted to only bacteriuric delirious individuals. Seven (7.5%) individuals treated for asymptomatic UTI developed Clostridium difficile infection compared to eight (3.2%) in the remainder of the delirious cohort (OR 2.45, 95% CI: 0.86-6.96). These results suggest that treatment of asymptomatic UTI in older medical in-patients with delirium is common, and of questionable benefit. Further research is needed to establish guidelines to minimize over-treatment of UTI in older delirious in-patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Psychosocial risk factors, job characteristics and self-reported health in the Paris Military Hospital Group (PMHG): a cross-sectional study

PubMed Central

Verret, Catherine; Trichereau, Julie; Rondier, Jean-Philippe; Viance, Patrice; Migliani, René

2012-01-01

Objectives To investigate the associations between psychosocial risk factors and self-reported health, taking into account other occupational risk factors. Design Cross-sectional survey using a self-administered questionnaire. Setting The three military hospitals in Paris, France. Participants Surveys were distributed to 3173 employees (1807 military and 1336 civilian), a total of 1728 employees completed surveys. Missing data prohibited the use of 26 surveys. Primary and secondary outcome measures The authors used Karasek's model in order to identify psychosocial factors (psychological demands, decisional latitude, social support) in the workplace. The health indicator studied was self-reported health. Adjustments were made for covariates: age, gender, civil or military status, work injury, ergonomic score, physical and chemical exposures, and occupational profile. Occupational profile was defined by professional category, department, work schedule, supervisor status and service-related length in the hospital. Results Job strain (defined as high psychological demands and low decisional latitude) (adjusted OR 2.1, 95% CI 1.5 to 2.8, p<0.001) and iso-strain (job strain with low social support) were significantly associated with moderate or poor self-reported health. Among covariates, occupational profile (p<0.001) and an unsatisfactory ergonomic score (adjusted OR 2.3 95% CI 1.6 to 3.2, p<0.001) were also significantly associated with moderate or poor self-reported health. Conclusions The results support findings linking moderate or poor self-reported health to psychosocial risk factors. The results of this study suggest that workplace interventions that aim to reduce exposure to psychological demands as well as to increase decisional latitude and social support could help improve self-reported health. PMID:22855624

Unbiased and automated identification of a circulating tumour cell definition that associates with overall survival.

PubMed

Ligthart, Sjoerd T; Coumans, Frank A W; Attard, Gerhardt; Cassidy, Amy Mulick; de Bono, Johann S; Terstappen, Leon W M M

2011-01-01

Circulating tumour cells (CTC) in patients with metastatic carcinomas are associated with poor survival and can be used to guide therapy. Classification of CTC however remains subjective, as they are morphologically heterogeneous. We acquired digital images, using the CellSearch™ system, from blood of 185 castration resistant prostate cancer (CRPC) patients and 68 healthy subjects to define CTC by computer algorithms. Patient survival data was used as the training parameter for the computer to define CTC. The computer-generated CTC definition was validated on a separate CRPC dataset comprising 100 patients. The optimal definition of the computer defined CTC (aCTC) was stricter as compared to the manual CellSearch CTC (mCTC) definition and as a consequence aCTC were less frequent. The computer-generated CTC definition resulted in hazard ratios (HRs) of 2.8 for baseline and 3.9 for follow-up samples, which is comparable to the mCTC definition (baseline HR 2.9, follow-up HR 4.5). Validation resulted in HRs at baseline/follow-up of 3.9/5.4 for computer and 4.8/5.8 for manual definitions. In conclusion, we have defined and validated CTC by clinical outcome using a perfectly reproducing automated algorithm.

Early EEG for outcome prediction of postanoxic coma: prospective cohort study with cost-minimization analysis.

PubMed

Sondag, Lotte; Ruijter, Barry J; Tjepkema-Cloostermans, Marleen C; Beishuizen, Albertus; Bosch, Frank H; van Til, Janine A; van Putten, Michel J A M; Hofmeijer, Jeannette

2017-05-15

We recently showed that electroencephalography (EEG) patterns within the first 24 hours robustly contribute to multimodal prediction of poor or good neurological outcome of comatose patients after cardiac arrest. Here, we confirm these results and present a cost-minimization analysis. Early prognosis contributes to communication between doctors and family, and may prevent inappropriate treatment. A prospective cohort study including 430 subsequent comatose patients after cardiac arrest was conducted at intensive care units of two teaching hospitals. Continuous EEG was started within 12 hours after cardiac arrest and continued up to 3 days. EEG patterns were visually classified as unfavorable (isoelectric, low-voltage, or burst suppression with identical bursts) or favorable (continuous patterns) at 12 and 24 hours after cardiac arrest. Outcome at 6 months was classified as good (cerebral performance category (CPC) 1 or 2) or poor (CPC 3, 4, or 5). Predictive values of EEG measures and cost-consequences from a hospital perspective were investigated, assuming EEG-based decision- making about withdrawal of life-sustaining treatment in the case of a poor predicted outcome. Poor outcome occurred in 197 patients (51% of those included in the analyses). Unfavorable EEG patterns at 24 hours predicted a poor outcome with specificity of 100% (95% CI 98-100%) and sensitivity of 29% (95% CI 22-36%). Favorable patterns at 12 hours predicted good outcome with specificity of 88% (95% CI 81-93%) and sensitivity of 51% (95% CI 42-60%). Treatment withdrawal based on an unfavorable EEG pattern at 24 hours resulted in a reduced mean ICU length of stay without increased mortality in the long term. This gave small cost reductions, depending on the timing of withdrawal. Early EEG contributes to reliable prediction of good or poor outcome of postanoxic coma and may lead to reduced length of ICU stay. In turn, this may bring small cost reductions.

Biopsychosocial factors associated with non-recovery after a minor transport-related injury: A systematic review.

PubMed

Samoborec, Stella; Ruseckaite, Rasa; Ayton, Darshini; Evans, Sue

2018-01-01

Globally, road transport accidents contribute significantly to mortality and burden of disability. Up to 50 million people suffer a transport-related non-fatal injury each year, which often leads to long-term disability. A substantial number of people with minor injuries struggle to recover and little is known about the factors leading to poor or non-recovery. The aim of this paper is to present a systematic review of biopsychosocial factors related to poor or non-recovery after a minor transport-related injury. Studies were selected through searches of PubMed, Medline, Embase, and Cochrane library. Methodological quality was assessed using a Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklist for quantitative cohort studies and Standards for Reporting Qualitative Research (SRQR) checklist for qualitative articles. Data were extracted using the Cochrane data extraction tool based on the biopsychosocial model of health (BPS). In total, there were 37 articles included. However, heterogeneity of the techniques and tools used to assess factors and outcomes across studies meant that pooling of results to determine biopsychosocial factors most predictive of poor or non-recovery was not possible. Hence, a narrative synthesis was conducted and shown multiple factors to be associated with poorer outcomes or non-recovery, most being identified in the biological and psychological domain of the BPS model. Factors that were the most representative across studies and have shown to have the strongest associations with poor or non-recovery were high initial pain intensity, pain duration and severity, pre-accident physical and mental health status and pain catastrophising. This review demonstrates the complexity of recovery and a challenge in reporting on predictors of recovery. It is evident that a range of multi-factorial biopsychosocial factors impact recovery. These factors are often inter-connected and multi-faceted and therefore, it was not feasible to select or focus on one single factor. In defining the most predictive factors, further research is required, yet the consensus around which tools to use to measure recovery outcomes is needed and is highly recommended. Regardless of the descriptive nature, the review demonstrated that high levels of post-injury pain are associated with poorer outcomes such as chronic pain and physical and mental disability. Therefore, early targeting of modifiable factors such as pain, pain catastrophizing and arising comorbidities such as PTSD, depression and anxiety may assist in reducing chronic pain and ongoing related disabilities. Systematic review protocol was registered in International Prospective Register for Systematic Reviews (PROSPERO) on 14 December 2016. Registration number CRD42016052276.

Conventional MRI features for predicting the clinical outcome of patients with invasive placenta

PubMed Central

Chen, Ting; Xu, Xiao-Quan; Shi, Hai-Bin; Yang, Zheng-Qiang; Zhou, Xin; Pan, Yi

2017-01-01

PURPOSE We aimed to evaluate whether morphologic magnetic resonance imaging (MRI) features could help to predict the maternal outcome after uterine artery embolization (UAE)-assisted cesarean section (CS) in patients with invasive placenta previa. METHODS We retrospectively reviewed the MRI data of 40 pregnant women who have undergone UAE-assisted cesarean section due to suspected high risk of massive hemorrhage caused by invasive placenta previa. Patients were divided into two groups based on the maternal outcome (good-outcome group: minor hemorrhage and uterus preserved; poor-outcome group: significant hemorrhage or emergency hysterectomy). Morphologic MRI features were compared between the two groups. Multivariate logistic regression analysis was used to identify the most valuable variables, and predictive value of the identified risk factor was determined. RESULTS Low signal intensity bands on T2-weighted imaging (P < 0.001), placenta percreta (P = 0.011), and placental cervical protrusion sign (P = 0.002) were more frequently observed in patients with poor outcome. Low signal intensity bands on T2-weighted imaging was the only significant predictor of poor maternal outcome in multivariate analysis (P = 0.020; odds ratio, 14.79), with 81.3% sensitivity and 84.3% specificity. CONCLUSION Low signal intensity bands on T2-weighted imaging might be a predictor of poor maternal outcome after UAE-assisted cesarean section in patients with invasive placenta previa. PMID:28345524

The influence of childhood sexual abuse on adolescent outcomes: the roles of gender, poverty, and revictimization.

PubMed

Matta Oshima, Karen M; Jonson-Reid, Melissa; Seay, Kristen D

2014-01-01

Research on child sexual abuse has focused on adult revictimization and outcomes. This article examines the rate of child maltreatment revictimization among male and female children reported to child protective services for child sexual abuse and whether revictimization impacts outcomes. Using longitudinal administrative data, Cox regressions were used to examine relationships between initial report of child sexual abuse, maltreatment revictimization, and adolescent outcomes among children from poor and nonpoor families. Despite no significant differences in child sexual abuse rates between poor and nonpoor families, poor child sexual abuse victims were significantly more likely to have re-reports for maltreatment. Children with multiple reports were more likely to have negative outcomes. Interventions for child sexual abuse survivors should focus on preventing maltreatment recurrence generally and not ignore needs of male victims.

Economic inequality increases risk taking.

PubMed

Payne, B Keith; Brown-Iannuzzi, Jazmin L; Hannay, Jason W

2017-05-02

Rising income inequality is a global trend. Increased income inequality has been associated with higher rates of crime, greater consumer debt, and poorer health outcomes. The mechanisms linking inequality to poor outcomes among individuals are poorly understood. This research tested a behavioral account linking inequality to individual decision making. In three experiments ( n = 811), we found that higher inequality in the outcomes of an economic game led participants to take greater risks to try to achieve higher outcomes. This effect of unequal distributions on risk taking was driven by upward social comparisons. Next, we estimated economic risk taking in daily life using large-scale data from internet searches. Risk taking was higher in states with greater income inequality, an effect driven by inequality at the upper end of the income distribution. Results suggest that inequality may promote poor outcomes, in part, by increasing risky behavior.

Interictal scalp electroencephalography and intraoperative electrocorticography in magnetic resonance imaging-negative temporal lobe epilepsy surgery.

PubMed

Burkholder, David B; Sulc, Vlastimil; Hoffman, E Matthew; Cascino, Gregory D; Britton, Jeffrey W; So, Elson L; Marsh, W Richard; Meyer, Fredric B; Van Gompel, Jamie J; Giannini, Caterina; Wass, C Thomas; Watson, Robert E; Worrell, Gregory A

2014-06-01

Scalp electroencephalography (EEG) and intraoperative electrocorticography (ECoG) are routinely used in the evaluation of magnetic resonance imaging-negative temporal lobe epilepsy (TLE) undergoing standard anterior temporal lobectomy with amygdalohippocampectomy (ATL), but the utility of interictal epileptiform discharge (IED) identification and its role in outcome are poorly defined. To determine whether the following are associated with surgical outcomes in patients with magnetic resonance imaging-negative TLE who underwent standard ATL: (1) unilateral-only IEDs on preoperative scalp EEG; (2) complete resection of tissue generating IEDs on ECoG; (3) complete resection of opioid-induced IEDs recorded on ECoG; and (4) location of IEDs recorded on ECoG. Data were gathered through retrospective medical record review at a tertiary referral center. Adult and pediatric patients with TLE who underwent standard ATL between January 1, 1990, and October 15, 2010, were considered for inclusion. Inclusion criteria were magnetic resonance imaging-negative TLE, standard ECoG performed at the time of surgery, and a minimum follow-up of 12 months. Univariate analysis was performed using log-rank time-to-event analysis. Variables reaching significance with log-rank testing were further analyzed using Cox proportional hazards. Excellent or nonexcellent outcome at time of last follow-up. An excellent outcome was defined as Engel class I and a nonexcellent outcome as Engel classes II through IV. Eighty-seven patients met inclusion criteria, with 48 (55%) achieving an excellent outcome following ATL. Unilateral IEDs on scalp EEG (P = .001) and complete resection of brain regions generating IEDs on baseline intraoperative ECoG (P = .02) were associated with excellent outcomes in univariate analysis. Both were associated with excellent outcomes when analyzed with Cox proportional hazards (unilateral-only IEDs, relative risk = 0.31 [95% CI, 0.16-0.64]; complete resection of IEDs on baseline ECoG, relative risk = 0.39 [95% CI, 0.20-0.76]). Overall, 25 of 35 patients (71%) with both unilateral-only IEDs and complete resection of baseline ECoG IEDs had an excellent outcome. Unilateral-only IEDs on preoperative scalp EEG and complete resection of IEDs on baseline ECoG are associated with better outcomes following standard ATL in magnetic resonance imaging-negative TLE. Prospective evaluation is needed to clarify the use of ECoG in tailoring temporal lobectomy.

Comparison of the survival between coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with poor left ventricular function (ejection fraction <30%): a propensity-matched analysis.

PubMed

Shah, Shaneel; Benedetto, Umberto; Caputo, Massimo; Angelini, Gianni D; Vohra, Hunaid A

2018-06-22

Existing evidence comparing the outcomes of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with poor left ventricular function (LVF) is sparse and flawed. This is largely due to patients with poor LVF being underrepresented in major research trials and the outdated nature of some studies that do not consider drug-eluting stent PCI. Following strict inclusion criteria, 717 patients who underwent revascularization by CABG or PCI between 2002 and 2015 were enrolled. All patients had poor LVF (defined by ejection fraction <30%). By employing a propensity score analysis, 134 suitable matches (67 CABG and 67 PCI) were identified. Several outcomes were evaluated, in the matched population, using data extracted from national registry databases. CABG patients required a longer length of hospital stay post-revascularization compared to PCI in the propensity-matched population, 7 days (lower-upper quartile; 6-12) and 2 days (lower-upper quartile; 1-6), respectively (Mood's median test, P = 0.001). Stratified Cox-regression proportional-hazards analysis of the propensity-matched population found that PCI patients experienced a higher adjusted 8-year mortality rate (hazard ratio 3.291, 95% confidence interval 1.776-6.101; P < 0.001). This trend was consistent amongst urgent cases of revascularization: patients with 3 or more vessels with coronary artery disease and patients where complete revascularization was achieved. Although sub-analyses found no difference between survival distributions of on-pump versus off-pump CABG (log-rank P = 0.726), both modes of CABG were superior to PCI (stratified log-rank P = 0.002). Despite a longer length of hospital stay, patients with impaired LVF requiring intervention for coronary artery disease experienced a greater post-procedural survival benefit if they received CABG compared to PCI. We have demonstrated this at 30 days, 90 days, 1 year, 3 years, 5 years and 8 years following revascularization. At present, CABG remains a superior revascularization modality to PCI in patients with poor LVF.

Progressive disability and prefrontal shrinkage in schizophrenia patients with poor outcome: A 3-year longitudinal study.

PubMed

Dusi, N; Bellani, M; Perlini, C; Squarcina, L; Marinelli, V; Finos, L; Altamura, C A; Ruggeri, M; Brambilla, P

2017-01-01

Schizophrenia is a severe disabling disorder with heterogeneous illness courses. In this longitudinal study we characterized schizophrenia patients with poor and good outcome (POS, GOS), using functional and imaging metrics. Patients were defined in accordance to Keefe's criteria (i.e. Kraepelinian and non-Kraepelinian patients). 35 POS patients, 35 GOS patients and 76 healthy controls (H) underwent clinical, functioning and magnetic resonance imaging (MRI) assessments twice over three years of follow-up. Information on psychopathology, treatment, disability (using the World Health Organization Disability Assessment Scale II, WHO-DAS-2) and prefrontal morphology was collected. Dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex (OFC) were manually traced. At baseline, subjects with POS showed significantly decreased right dorsolateral prefrontal cortex (DLPFC) white matter volumes (WM) compared to healthy controls and GOS patients (POS VS HC, p<0.001; POS vs GOS, p=0.03), with shrinkage of left DLPFC WM volumes at follow up (t=2.66, p=0.01). Also, POS patients had higher disability in respect to GOS subjects both at baseline and after 3years at the WHO-DAS-2 (p<0.05). Our study supports the hypothesis that POS is characterized by progressive deficits in brain structure and in "real-life" functioning. These are particularly notable in the DLPFC. Copyright © 2016 Elsevier B.V. All rights reserved.

APPETITE PREDICTS INTAKE AND NUTRITIONAL STATUS IN PATIENTS RECEIVING PERITONEAL DIALYSIS.

PubMed

Young, Valerie; Balaam, Sarah; Orazio, Linda; Bates, Annerley; Badve, Sunil V; Johnson, David W; Campbell, Katrina L

2016-06-01

Sub-optimal nutrition status is common amongst patients receiving peritoneal dialysis (PD) and leads to poor clinical outcome. This population experiences multi-factorial challenges to achieving optimal nutritional status, particularly driven by inadequate intake. The aim of this investigation was to identify factors associated with inadequate protein intake and sub-optimal nutritional status in patients undergoing PD. This was a cross-sectional study of 67 adult patients receiving PD (mean age 59 ± 14 years; 57% male) within a single centre. Participants were consecutively recruited and interviewed by renal dietitians, collecting: Subjective Global Assessment (SGA); quality of life (using EQ-5D); dietary intake (via dietary interview); and appetite (using Appetite and Diet Assessment Tool). Participant demographics were obtained via survey or medical charts. Main outcome measures were inadequate dietary protein intake (<1.1 g/kg adjusted body weight/day) and malnutrition (as defined by SGA rating B or C). Overall, 15 (22%) patients were malnourished and 29 (43%) had inadequate protein intake. Poor appetite (anorexia) was reported in 62% (18/29) of participants with inadequate protein malnourished patients reported anorexia versus 12 (23%) of the well-nourished patients (p = 0.0001). Anorexia was a key risk factor for inadequate protein intake and malnutrition in patients undergoing PD. These findings highlight a need to closely monitor patients with appetite disturbances. © 2016 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Effects of different nitrogen sources on the biogas production - a lab-scale investigation.

PubMed

Wagner, Andreas Otto; Hohlbrugger, Peter; Lins, Philipp; Illmer, Paul

2012-12-20

For anaerobic digestion processes nitrogen sources are poorly investigated although they are known as possible process limiting factors (in the hydrolysis phase) but also as a source for fermentations for subsequent methane production by methanogenic archaea. In the present study different complex and defined nitrogen sources were investigated in a lab-scale experiment in order to study their potential to build up methane. The outcome of the study can be summarised as follows: from complex nitrogen sources yeast extract and casamino acids showed the highest methane production with approximately 600 ml methane per mole of nitrogen, whereas by the use of skim milk no methane production could be observed. From defined nitrogen sources L-arginine showed the highest methane production with almost 1400 ml methane per mole of nitrogen. Moreover it could be demonstrated that the carbon content and therefore C/N-ratio has only minor influence for the methane production from the used substrates. Copyright © 2011 Elsevier GmbH. All rights reserved.

Rationale, design, and preliminary results of the Quebec Warfarin Cohort Study.

PubMed

Perreault, Sylvie; Shahabi, Payman; Côté, Robert; Dumas, Stéphanie; Rouleau-Mailloux, Étienne; Feroz Zada, Yassamin; Provost, Sylvie; Mongrain, Ian; Dorais, Marc; Huynh, Thao; Kouz, Simon; Diaz, Ariel; Blostein, Mark; de Denus, Simon; Turgeon, Jacques; Ginsberg, Jeffrey; Lelorier, Jacques; Lalonde, Lyne; Busque, Lambert; Kassis, Jeannine; Talajic, Mario; Tardif, Jean-Claude; Dubé, Marie-Pierre

2018-05-01

Over- and undercoagulation with warfarin are associated with hemorrhagic and thromboembolic events, respectively. Genetic and clinical factors affect warfarin response, and the causes of this variability remain unclear. We present descriptive statistics and test for predictors of poor anticoagulation control. The Quebec Warfarin Cohort (QWC) comprises 1059 new warfarin users, with prospective follow-up using telephone questionnaires every 3 months for 1 year, and using healthcare administrative databases (RAMQ and Med-Echo) for 5 years prior to cohort entry and up to 10 years following active patient participation. Genetic material was collected, and genotyping of CYP2C9 and VKORC1 genes was conducted. Measured outcomes included the percentage of time patients spent within therapeutic range, anticoagulation control, warfarin dose, bleeding, and thromboembolic events. We report baseline characteristics and outcomes after 1 year of follow-up. Poor anticoagulation control was defined as time in therapeutic range <60% in the 3- to 12-month interval. Participants had a mean age of 71 years, and 62% were men. The most common indication for warfarin was atrial fibrillation (87%). Mean time in therapeutic range was 56% (±25%) in the 3 months following warfarin initiation, and 70% (±21%) in the 3- to 12-month interval. During follow-up, the rate of stroke or systemic embolism was 1.8 events per 100 person-years; for major bleeding events, 3.3 events per 100 person-years. Independent predictors of poor anticoagulation control were chronic kidney disease, heart failure, dyslipidemia, and age. The QWC represents a good research cohort to investigate clinical and genetic factors in a warfarin-anticoagulated population. © 2018 Wiley Periodicals, Inc.

The incidence, risk factors, and outcomes of primary poor graft function after unmanipulated haploidentical stem cell transplantation.

PubMed

Sun, Yu-Qian; He, Gan-Lin; Chang, Ying-Jun; Xu, Lan-Ping; Zhang, Xiao-Hui; Han, Wei; Chen, Huan; Chen, Yu-Hong; Wang, Yu; Wang, Feng-Rong; Wang, Jing-Zhi; Liu, Kai-Yan; Huang, Xiao-Jun

2015-10-01

Primary poor graft function (PGF) is a severe complication after allogeneic stem cell transplantation (SCT). The incidence, risk factors, and outcomes of PGF have not been well described, especially in the haploidentical SCT setting. We retrospectively reviewed patients who received haploidentical SCT at Peking University Institute of Hematology between January 1, 2011, and December 31, 2012. PGF was defined as persistent neutropenia (≤0.5 × 10(9) L(-1)), thrombocytopenia (platelets ≤20 × 10(9) L(-1)), and/or hemoglobin ≤70 g L(-1) after engraftment with hypocellular bone marrow and full donor chimerism, without concurrent graft-versus-host disease or disease relapse. Incidence was calculated from all patients. Of the 464 total patients, 26 (5.6 %) developed primary PGF. The risk factors were analyzed and compared with control patients with good graft function who were selected using the case-pair method. Finally, 104 patients were selected as a control group according to the matching conditions: (1) the type (acute leukemia, myelodysplastic syndrome (MDS), chronic myelogenous leukemia (CML)) and status (standard risk, high risk) of underlying disease, (2) sex, (3) year in which the transplantation was received, and (4) a 1:4 ratio of case-control. No factors were found to be associated with primary PGF. Compared to cases with good graft function, patients with primary PGF experienced poor overall survival (34.6 vs. 82.7 %, p < 0.001). Of the 26 primary PGF patients, only nine achieved hematopoietic recovery and survived. In conclusion, primary PGF is a rare but life-threatening complication after haploidentical SCT, and effective therapies need to be explored.

Effects of anticoagulant therapy on pregnancy outcomes in patients with thrombophilia and previous poor obstetric history.

PubMed

Mutlu, Ilknur; Mutlu, Mehmet Firat; Biri, Aydan; Bulut, Berk; Erdem, Mehmet; Erdem, Ahmet

2015-04-01

This study investigates the effects of anticoagulant therapy on pregnancy outcomes in 204 patients with thrombophilia and previous poor obstetric outcomes. Patients with poor obstetric history (pre-eclampsia, intrauterine growth retardation, fetal death, placental abruption, recurrent pregnancy loss) and having hereditary thrombophilia were included in this study. Poor obstetric outcomes were observed more frequently in patients who had not taken anticogulant therapy compared with treated group. Live birth rate, gestational age at birth and Apgar scores were significantly higher in the treated group when compared with the untreated group. There were no significant differences in terms of birthweight, mode of delivery and admission rates to the neonatal intensive care unit (NICU). Low-molecular-weight heparin (LMWH) plus acetylsalicylic acid (ASA) had higher gestational age at birth, Apgar scores, live birth rate and a lower abortion rates when compared with controls; in contrast, no significant difference was observed in terms of birthweight, mode of delivery, obstetric complications and admission rates to NICU. There were no significant differences between control group and both LMWH only and ASA only groups in terms of gestational age at birth, Apgar scores, birthweight, mode of delivery, obstetric complications and admission rates to NICU. Only LMWH group had higher live birth rate as compared with control group. The use of only ASA did not seem to affect the perinatal complication rates and outcomes. In conclusion, anticoagulant therapy with both LMWH and ASA seems to provide better obstetric outcomes in pregnant women with thrombophilia and previous poor obstetric outcomes.

Early Elevations of the Complement Activation Fragment C3a and Adverse Pregnancy Outcomes

PubMed Central

Lynch, Anne M.; Gibbs, Ronald S.; Murphy, James R.; Giclas, Patricia C.; Salmon, Jane E.; Holers, V. Michael

2016-01-01

OBJECTIVE To estimate whether elevations of complement C3a early in pregnancy are predictive of the subsequent development of adverse pregnancy outcomes. METHODS A plasma sample was obtained from each enrolled pregnant woman before 20 weeks of gestation. The cohort (n=1,002) was evaluated for the development of adverse pregnancy outcomes defined as hypertensive diseases of pregnancy (gestational hypertension or preeclampsia), preterm birth (before 37 weeks of gestation), premature rupture of the membranes, pregnancy loss (during the embryonic and fetal period), intrauterine growth restriction, and the composite outcome of any adverse outcome. RESULTS One or more adverse pregnancy outcomes occurred in 211 (21%) of the cohort. The mean levels (ng/mL) of C3a in early pregnancy were significantly (P=<.001) higher among women with one or more adverse outcomes (858±435) compared with women with an uncomplicated pregnancy (741±407). Adjusted for parity and prepregnancy body mass index, women with levels of C3a in the upper quartile in early pregnancy were three times more likely to have an adverse outcome later in pregnancy compared with women in the lowest quartile (95% confidence interval, 1.8–4.8; P<.001). The link between early elevated C3a levels and adverse pregnancy outcomes was driven primarily by individual significant (P<.05) associations of C3a with hypertensive diseases of pregnancy, preterm birth, and premature rupture of the membranes. CONCLUSION Elevated C3a as early as the first trimester of pregnancy is an independent predictive factor for adverse pregnancy outcomes, suggesting that complement-related inflammatory events in pregnancy contribute to the subsequent development of poor outcomes at later stages of pregnancy. PMID:21173647

Impact of worsening renal function related to medication in heart failure.

PubMed

Brunner-La Rocca, Hans-Peter; Knackstedt, Christian; Eurlings, Luc; Rolny, Vinzent; Krause, Friedemann; Pfisterer, Matthias E; Tobler, Daniel; Rickenbacher, Peter; Maeder, Micha T

2015-02-01

Renal failure is a major challenge in treating heart failure (HF) patients. HF medication may deteriorate renal function, but the impact thereof on outcome is unknown. We investigated the effects of HF medication on worsening renal function (WRF) and the relationship to outcome. This post-hoc analysis of TIME-CHF (NT-proBNP-guided vs. symptom-guided management in chronic HF) included patients with LVEF ≤45% and ≥1 follow-up visit (n = 462). WRF III was defined as a rise in serum creatinine ≥0.5 mg/dL (i.e. 44.2 µmol/L) at any time during the first 6 months. Four classes of medication were considered: loop diuretics, beta-blockers, renin-angiotensin system (RAS)-blockers, and spironolactone. Functional principal component analysis of daily doses was used to comprehend medication over time. All-cause mortality after 18 months was the primary outcome. Interactions between WRF, medication, and outcome were tested. Patients with WRF III received on average higher loop diuretic doses (P = 0.0002) and more spironolactone (P = 0.02), whereas beta-blockers (P = 0.69) did not differ and lower doses of RAS-blockers were given (P = 0.09). There were significant interactions between WRF III, medicationn and outcome. Thus, WRF III was associated with poor prognosis if high loop diuretic doses were given (P = 0.001), but not with low doses (P = 0.29). The opposite was found for spironolactone (poor prognosis in the case of WRF III with no spironolactone, P <0.0001; but not with spironolactone, P = 0.31). Beta-blockers were protective in all patients (P <0.001), but most in those with WRF III (P <0.05 for interaction). RAS-blockade was associated with improved outcome (P = 0.006), irrespective of WRF III. Based on this analysis, it may be hypothesized that high doses of loop diuretics might have detrimental effects, particularly in combination with significant WRF, whereas spironolactone and beta-blockers might be protective in patients with WRF. © 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.

Asymmetric and Symmetric Dimethylarginines are Markers of Delayed Cerebral Ischemia and Neurological Outcome in Patients with Subarachnoid Hemorrhage.

PubMed

Appel, Daniel; Seeberger, Miriam; Schwedhelm, Edzard; Czorlich, Patrick; Goetz, Alwin E; Böger, Rainer H; Hannemann, Juliane

2018-03-20

Delayed cerebral ischemia (DCI) is the major cause of lethality and neuronal damage in patients who survived the primary subarachnoid hemorrhage (SAH). Asymmetric and symmetric dimethylarginines (ADMA and SDMA) inhibit nitric oxide production from L-arginine via distinct mechanisms. Elevated ADMA levels are associated with vasospasm after SAH. We aimed to study the time course of ADMA and SDMA in plasma and ventricular cerebrospinal fluid (CSF) and their associations with DCI and outcome. We measured ADMA and SDMA in 34 SAH patients with an external ventricular drain at admission and on days 3, 6, 8, 12, and 15 and followed them up for clinical status and neurological outcome until 30 days post-discharge. DCI was defined as the appearance of new infarctions on cerebral computed tomography or magnetic resonance imaging. ADMA and SDMA plasma concentrations did not differ significantly at baseline between patients who suffered DCI (N = 14; 41%) and not; however, plasma ADMA reached a peak on days 8 and 15 after hemorrhage in patients with DCI (0.81-0.91 µmol/l). Baseline plasma L-arginine/ADMA ratio was significantly lower in patients with DCI (57.1 [34.3; 70.8] vs. 68.7 [55.7; 96.2]; p < 0.05). ADMA and SDMA concentrations in CSF were significantly higher in patients with DCI than without. In multivariable-adjusted linear regression models, CSF ADMA was negatively associated with the incidence of DCI (OR 0.03 [0.02-0.70]; p = 0.04), whereas CSF SDMA on the day of hemorrhage predicted poor neurological outcome until 30 days after discharge (OR 22.4 [1.21-416.02]; p = 0.04). Our study shows that ADMA and the L-arginine/ADMA ratio are associated with the incidence of DCI after SAH. By contrast, SDMA was associated with initial neuronal damage and poor neurological outcome after SAH. These data support the hypothesis that ADMA and L-arginine affect the pathophysiology of cerebral ischemia after SAH, while SDMA is a biomarker of neurological outcome after SAH.

Effect of Intra- and Extrauterine Growth on Long-Term Neurologic Outcomes of Very Preterm Infants.

PubMed

Guellec, Isabelle; Lapillonne, Alexandre; Marret, Stephane; Picaud, Jean-Charles; Mitanchez, Delphine; Charkaluk, Marie-Laure; Fresson, Jeanne; Arnaud, Catherine; Flamand, Cyril; Cambonie, Gilles; Kaminski, Monique; Roze, Jean-Christophe; Ancel, Pierre-Yves

2016-08-01

To determine whether extrauterine growth is associated with neurologic outcomes and if this association varies by prenatal growth profile. For 1493 preterms from the EPIPAGE (Étude Épidémiologique sur les Petits Âges Gestationnels [Epidemiological Study on Small Gestational Ages]) cohort, appropriate for gestational-age (AGA) was defined by birth weight >-2 SD and small for gestational-age (SGA) by birth weight ≤-2 SD. Extra-uterine growth was defined by weight gain or loss between birth and 6 months by z-score change. Growth following-the-curve (FTC) was defined as weight change -1 to +1 SD, catch-down-growth (CD) as weight loss ≥1 SD, and catch-up-growth (CU) as weight gain ≥1 SD. At 5 years, a complete medical examination (n = 1305) and cognitive evaluation with the Kauffman Assessment Battery for Children (n = 1130) were performed. Behavioral difficulties at 5 years and school performance at 8 years were assessed (n = 1095). Overall, 42.5% of preterms were AGA-FTC, 20.2% AGA-CD, 17.1% AGA-CU, 5.6% SGA-FTC, and 14.5% SGA-CU. Outcomes did not differ between CU and FTC preterm AGA infants. Risk of cerebral palsy was greater for AGA-CD compared with AGA-FTC (aOR 2.26 [95% CI 1.37-3.72]). As compared with children with SGA-CU, SGA-FTC children showed no significant increased risk of cognitive deficiency (aOR 1.41[0.94-2.12]) or school difficulties (aOR 1.60 [0.84-3.03]). Compared with AGA-FTC, SGA showed increased risk of cognitive deficiency (SGA-FTC aOR 2.19 [1.25-3.84]) and inattention-hyperactivity (SGA-CU aOR 1.65 [1.05-2.60]). Deficient postnatal growth was associated with poor neurologic outcome for AGA and SGA preterm infants. CU growth does not add additional benefits. Regardless of type of postnatal growth, SGA infants showed behavioral problems and cognitive deficiency. Copyright © 2016 Elsevier Inc. All rights reserved.

Diagnosing obesity by body mass index in chronic kidney disease: an explanation for the "obesity paradox?".

PubMed

Agarwal, Rajiv; Bills, Jennifer E; Light, Robert P

2010-11-01

Although obesity is associated with poor outcomes, among patients with chronic kidney disease (CKD), obesity is related to improved survival. These results may be related to poor diagnostic performance of body mass index (BMI) in assessing body fat content. Accordingly, among 77 patients with CKD and 20 controls, body fat percentage was estimated by air displacement plethysmography (ADP), skinfold thickness, and body impedance analysis. Defined by BMI ≥30 kg/m(2), the prevalence of obesity was 20% in controls and 65% in patients with CKD. Defined by ADP, the prevalence increased to 60% among controls and to 90% among patients with CKD. Although sensitivity and positive predictive value of BMI to diagnose obesity were 100%, specificity was 72%, but the negative predictive value was only 30%. BMI correctly classified adiposity in 75%. Regardless of the presence or absence of CKD, subclinical obesity (defined as BMI <30 kg/m(2) but excess body fat by ADP) was often missed in people with low lean body mass. The adjusted odds ratio for subclinical obesity per 1 kg of reduced lean body mass by ADP was 1.14 (95% CI: 1.06 to 1.23; P<0.001). Skinfold thickness measurements correctly classified 94% of CKD patients, but bioelectrical impedance analyzer-assessed body fat estimation did so in only 65%. Air displacement plethysmography-, skinfold thickness-, and bioelectrical impedance analyzer-assessed body fat all provided reproducible estimates of adiposity. Skinfold thickness measurements may be a better test to classify obesity among those with CKD. Given the low negative predictive value of BMI for obesity, our study may provide an explanation of the "obesity paradox."

An audit of diabetes care at 3 centres in Alexandria.

PubMed

Abou El-Enein, N Y; Abolfotouh, M A

2008-01-01

Selected indicators for structure, process and outcome of care were used to audit diabetes care in 3 centres in Alexandria. Structure was poor: main problems included absence of appointment and recall system, deficiencies in laboratory resources and lack of educational material. Process of care was poor for 69.2% of patients: deficiencies included absence of essential information in records and missing some essential clinical examinations. Degree of control was poor for 49.2% of patients and only 30.6% had no complications. Compliance to appointment was good for about 80% of patients. Better outcome (fewer complications and higher compliance) was significantly associated with poor process of care. This cannot, however, be considered a valid predictor of outcome as good care might be initiated by the presence of complications.

The Neural Basis of Risky Choice with Affective Outcomes

PubMed Central

Suter, Renata S.; Pachur, Thorsten; Hertwig, Ralph; Endestad, Tor; Biele, Guido

2015-01-01

Both normative and many descriptive theories of decision making under risk are based on the notion that outcomes are weighted by their probability, with subsequent maximization of the (subjective) expected outcome. Numerous investigations from psychology, economics, and neuroscience have produced evidence consistent with this notion. However, this research has typically investigated choices involving relatively affect-poor, monetary outcomes. We compared choice in relatively affect-poor, monetary lottery problems with choice in relatively affect-rich medical decision problems. Computational modeling of behavioral data and model-based neuroimaging analyses provide converging evidence for substantial differences in the respective decision mechanisms. Relative to affect-poor choices, affect-rich choices yielded a more strongly curved probability weighting function of cumulative prospect theory, thus signaling that the psychological impact of probabilities is strongly diminished for affect-rich outcomes. Examining task-dependent brain activation, we identified a region-by-condition interaction indicating qualitative differences of activation between affect-rich and affect-poor choices. Moreover, brain activation in regions that were more active during affect-poor choices (e.g., the supramarginal gyrus) correlated with individual trial-by-trial decision weights, indicating that these regions reflect processing of probabilities. Formal reverse inference Neurosynth meta-analyses suggested that whereas affect-poor choices seem to be based on brain mechanisms for calculative processes, affect-rich choices are driven by the representation of outcomes’ emotional value and autobiographical memories associated with them. These results provide evidence that the traditional notion of expectation maximization may not apply in the context of outcomes laden with affective responses, and that understanding the brain mechanisms of decision making requires the domain of the decision to be taken into account. PMID:25830918

Does semiology of status epilepticus have an impact on treatment response and outcome?

PubMed

Baysal-Kirac, Leyla; Feddersen, Berend; Einhellig, Marion; Rémi, Jan; Noachtar, Soheyl

2018-06-01

This study investigated whether there is an association between semiology of status epilepticus (SE) and response to treatment and outcome. Two hundred ninety-eight consecutive adult patients (160 females, 138 males) with SE at the University of Munich Hospital were prospectively enrolled. Mean age was 63.2±17.5 (18-97) years. Patient demographics, SE semiology and electroencephalography (EEG) findings, etiology, duration of SE, treatment, and outcome measures were investigated. Status epilepticus semiology was classified according to a semiological status classification. Patient's short-term outcome was determined by Glasgow Outcome Scale (GOS). The most frequent SE type was nonconvulsive SE (NCSE) (39.2%), mostly associated with cerebrovascular etiology (46.6%). A potentially fatal etiology was found in 34.8% of the patients. More than half (60.7%) of the patients had poor short-term outcome (GOS≤3) with an overall mortality of 12.4%. SE was refractory to treatment in 21.5% of the patients. Older age, potentially fatal etiology, systemic infections, NCSE in coma, refractory SE, treatment with anesthetics, long SE duration (>24h), low Glasgow Coma Scale (GCS) (≤8) at onset, and high Status Epilepticus Severity Score (STESS-3) (≥3) were associated with poor short-term outcome and death (p<0.05). Potentially fatal etiology and low GCS were the strongest predictors of poor outcome (Exp [b]: 4.74 and 4.10 respectively, p<0.05). Status epilepticus semiology has no independent association with outcome, but potentially fatal etiology and low GCS were strong predictive factors for poor short-term outcome of SE. Copyright © 2018 Elsevier Inc. All rights reserved.

Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Preoperative Factors Associated With Outcome Deterioration Over 2 Years.

PubMed

Shon, Min Soo; Koh, Kyoung Hwan; Lim, Tae Kang; Kim, Won Ju; Kim, Kyung Cheon; Yoo, Jae Chul

2015-08-01

Arthroscopic partial repair is a treatment option in irreparable large-to-massive rotator cuff tears without arthritic changes. However, there are indications that arthroscopic partial repair does not yield satisfactory outcomes. To report the clinical and radiographic results of arthroscopic partial repairs in patients with irreparable large-to-massive cuff tears. In addition, an analysis was performed regarding preoperative factors that may influence patient outcomes and patient-rated satisfaction over time. Case series; Level of evidence, 4. From 2005 to 2011, a total of 31 patients who underwent arthroscopic partial repair for irreparable large-to-massive cuff tears were retrospectively evaluated. Partial repair was defined as posterior cuff tissue repair with or without subscapularis tendon repair to restore the transverse force couple of the cuff. Pain visual analog scale (PVAS), questionnaire results (American Shoulder and Elbow Surgeons [ASES] and Simple Shoulder Test [SST]), and radiographic changes (acromiohumeral distance and degenerative change) were assessed preoperatively, at first follow-up (roughly 1 year postoperatively), and at final follow-up (>2 years postoperatively). Patients rated their satisfaction level at each postoperative follow-up as well. Preoperative factors that might influence outcomes, such as patient demographics, tear size, and fatty infiltration, were investigated. The preoperative, first follow-up, and final follow-up results for mean PVAS (5.13, 2.13, and 3.16, respectively) and questionnaires (ASES: 41.97, 76.37, and 73.78; SST: 3.61, 6.33, and 6.07, respectively) improved significantly (all P < .05). Radiographic evaluation showed no difference compared with preoperative status. Nevertheless, patient-rated satisfaction at final evaluation was inferior: 16 good responses ("very satisfied" and "satisfied") and 15 poor responses ("rather the same" and "dissatisfied"). Despite initial improvements in both groups (P < .05), patients with poor satisfaction demonstrated statistically significant deterioration in mean PVAS (from 2.07 to 4.67), questionnaire scores (ASES: from 74.56 to 59.80; SST: from 5.11 to 3.81), and acromiohumeral distance (from 7.19 to 5.06 mm) between the first and final follow-up (all P < .05). Patients with good satisfaction showed no significant difference or they improved (P > .05) from the first to the final follow-up. Among preoperative factors, fatty infiltration of the teres minor was identified as the only statistically significant factor affecting patient-rated satisfaction (P = .007). This study showed that arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up. However, about half of the patients in the study were not satisfied with their outcomes, which had deteriorated over time. Preoperative fatty infiltration of the teres minor was the only factor that correlated with worse final outcomes and poor satisfaction after arthroscopic partial repair. © 2015 The Author(s).

Divorce and health: current trends and future directions.

PubMed

Sbarra, David A

2015-04-01

Social relationships play a vital role in health and well-being, and it follows that loss experiences can be highly stressful for some people. This article reviews what is known about the association between marital separation, divorce, and health outcomes. Key findings in the area of divorce and health are discussed, and the review outlines a series of specific questions for future research. In particular, the article integrates research in social epidemiology with research in social psychophysiology. The former approach provides a broad-based estimate of the association between marital status and health outcomes, whereas the latter approach studies mechanisms of action and individual differences associated with increased risk for poor outcomes. The experience of separation or divorce confers risk for poor health outcomes, including a 23% higher mortality rate. However, most people cope well and are resilient after their marriage or long-term relationship ends. Despite the fact that resilience is the most common response, a small percentage of people (approximately 10%-15%) struggle quite substantially, and it seems that the overall elevated adverse health risks are driven by the poor functioning of this group. Several candidate mechanisms and novel (ambulatory) assessment techniques that may elucidate the poor outcomes among people who adapt poorly to separation are discussed. To increase knowledge on the association between divorce and health, three primary areas require more research: a) genetic and third variable explanations for divorce-related health outcomes, (b) better studies of objective social behavior after separation, and (c) increased attention to interventions targeting high-risk adults.

Prevalence and risk factors of poor immune recovery among adult HIV patients attending care and treatment centre in northwestern Tanzania following the use of highly active antiretroviral therapy: a retrospective study.

PubMed

Gunda, Daniel W; Kilonzo, Semvua B; Kamugisha, Erasmus; Rauya, Engelbert Z; Mpondo, Bonaventura C

2017-06-08

Highly Active Antiretroviral therapy (HAART) reverses the effect of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) by durably suppressing viral replication. This allows CD4 gain to levels that are adequate enough to restore the body's capability to fight against opportunistic infections (OIs). Patients with poor immune recovery have been shown to have higher risk of developing both AIDS and non AIDS related clinical events. This study aimed at assessing the proportions and risk factors of poor immune recovery in adult HIV-infected patients on 48 months of HAART attending care and treatment center (CTC) in northwestern Tanzania. A retrospective analysis of adult HIV patients' data attending CTC at Sekou Toure hospital and who initiated HAART between February 2004 and January 2008 was done. Poor immune recovery was defined as a CD4 count less than 350 cells/µl on follow up as used in other studies. A total of 734 patients were included in the study. In this study 50.25% of patients attending CTC at Sekou Toure hospital were found to have poor immune recovery. The risk of developing inadequate immune recovery was independently associated with male gender, age older than 50 years, low baseline CD4 counts, and advanced World Health Organization (WHO) clinical stage. Poor immune recovery is prevalent among adult HIV patients attending CTC at Sekou Toure hospital in Northwestern part of Tanzania and opportunistic infections are common in this sub group of patients. Clinicians in resource limited countries need to identify these patients timely and plan them for targeted viral assessment and close clinical follow up to improve their long term clinical outcome.

Hardiness, depression, and emotional well-being and their association with appetite in older adults.

PubMed

Engel, Julia H; Siewerdt, Frank; Jackson, Robert; Akobundu, Ucheoma; Wait, Carolyn; Sahyoun, Nadine

2011-03-01

To examine the associations between hardiness (defined as the ability to manage stress), depression, and emotional well-being and appetite in older adults. Cross-sectional. Assisted-living facilities and senior centers in the Washington/Baltimore area. Two hundred ninety-two adults aged 60 and older. Depressive symptoms assessed using the 5-item Geriatric Depression Scale and categorized as 0 to 1 (normal, referent group) versus 2 to 5 (depressive symptoms present). Hardiness was measured using the 18-item Dispositional Resilience Scale II modified based on interviews with older adults and categorized as 67 or less (low hardiness) versus greater than 67 (normal, referent group). Appetite was measured using the Simplified Nutritional Appetite Questionnaire and categorized as 4 to 14 (poor appetite) versus 15 to 20 (normal, referent group). Emotional well-being was measured using a single question. Depression, hardiness, and emotional well-being were all significantly associated with appetite. In models controlling for confounders (data collection site, age, educational attainment, self-reported health, race, presence of chronic disease), fair to poor emotional well-being was most significantly associated with poor appetite (odds ratio (OR)=5.60, 95% confidence interval (CI)=2.60-12.07) and low commitment (a component of hardiness that indicates an individual's involvement in life) was also significantly associated with poor appetite (OR=1.35, 95% CI=1.13-1.61). These associations further elucidate the components of mental health that contribute to poor appetite in this population. Simple measures of self-reported mental health administered to older adults may predict poor appetite and lend themselves to potential interventions to prevent malnutrition and negative health outcomes. © 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.

Preoperative and perioperative factors effect on adolescent idiopathic scoliosis surgical outcomes.

PubMed

Sanders, James O; Carreon, Leah Y; Sucato, Daniel J; Sturm, Peter F; Diab, Mohammad

2010-09-15

Prospective multicenter database. To identify factors associated with outcomes from adolescent idiopathic scoliosis (AIS) surgery outcomes and especially poor results. Because AIS is rarely symptomatic during adolescence, excellent surgical results are expected. However, some patients have poor outcomes. This study seeks to identify factors correlating with results and especially those making poor outcomes more likely. Demographic, surgical, and radiographic parameters were compared to 2-year postoperative Scoliosis Research Society (SRS) scores in 477 AIS surgical patients using stepwise linear regression to identify factors predictive of 2-year domain and total scores. Poor postoperative score patients (>2 SD below mean) were compared using t tests to those with better results. The SRS instrument exhibited a strong ceiling effect. Two-year scores showed more improvement with greater curve correction (self-image, pain, and total), and were worse with larger body mass index (pain, mental, total), larger preoperative trunk shift (mental and total), larger preoperative Cobb (self-image), and preoperative symptoms (function). Poor results were more common in those with Lenke 3 curve pattern (pain), less preoperative coronal imbalance, trunk shift and rib prominence (function), preoperative bracing (self-image), and anterior procedures (mental). Poor results also had slightly less average curve correction (50% vs. 60%) and larger curve residuals (31° vs. 23°). Complications, postoperative curve magnitude, and instrumentation type did not significantly contribute to postoperative scores, and no identifiable factors contributed to satisfaction. Curve correction improves patient's self-image whereas pain and poor function before surgery carry over after surgery. Patients with less spinal appearance issues (higher body mass index, Lenke 3 curves) are less happy with their results. Except in surgical patient selection, many of these factors are beyond physician control.

Histological grading of ovarian clear cell adenocarcinoma: proposal for a simple and reproducible grouping system based on tumor growth architecture.

PubMed

Yamamoto, Sohei; Tsuda, Hitoshi; Shimazaki, Hideyuki; Takano, Masashi; Yoshikawa, Tomoyuki; Kuzuya, Kazuo; Tsuda, Hiroshi; Kurachi, Hirohisa; Kigawa, Junzo; Kikuchi, Yoshihiro; Sugiyama, Toru; Matsubara, Osamu

2012-03-01

In this study, we aimed to develop a histological grading system for ovarian clear cell adenocarcinoma (CCA), based on the tumor growth architectures. Cases were defined as Group A if ≥90% of a tumor examined was composed of well-differentiated tubulocystic and/or papillary architectures; Group C if at least 10% of the tumor was composed of very poorly differentiated histology (i.e. solid masses or individual infiltrating tumor cells with no or little glandular/papillary differentiation); and tumors not corresponding to the first 2 descriptions were defined as Group B. The interobserver reproducibility and prognostic value of the assigned groups were analyzed for 159 CCAs from 5 institutions. The level of agreement in assigning the groups between 2 pathologists was 88.7% (=0.82). After consensus was reached, 46 (29%), 79 (50%), and 34 (21%) tumors were classified in Groups A, B, and C, respectively. In early-stage cases [International Federation of Gynecology and Obstetrics (FIGO) stage I-II], Group A tumors had significantly better outcomes (100% 5-yr survival) than Group B tumors (82% 5-yr survival, P=0.024 by log-rank test) or Group C tumors (56% 5-yr survival, P=0.00054 by log-rank test). Moreover, early-stage Group B tumors had significantly better outcomes than Group C tumors (P<0.001 by a generalized Wilcoxon test). In advanced cases (FIGO stage III-IV), Group A tumors had significantly better outcomes than Group C tumors (52% vs. 16% 5-yr survival, respectively, P=0.043). Group A and C tumors defined with our system were identified to have favorable and unfavorable prognostic factors, respectively, independent of the clinical stage of the disease and presence of residual tumors after the initial surgery. The proposed grouping system could divide patients with CCA into 3 subgroups with distinct prognostic indications, providing a 3-tier histological grading system for ovarian CCA.

The prognostic impact of dynamic ventricular dyssynchrony in patients with idiopathic dilated cardiomyopathy and narrow QRS.

PubMed

D'Andrea, Antonello; Mele, Donato; Nistri, Stefano; Riegler, Lucia; Galderisi, Maurizio; Agricola, Eustachio; Losi, Maria Angela; Ballo, Piercarlo; Mondillo, Sergio; Badano, Luigi P

2013-02-01

Asynchronous myocardial contraction adversely influences left ventricular (LV) function and is therefore associated with a poor prognosis in heart failure. Exercise-induced change in ventricular dyssynchrony may be an important determinant of dynamic changes in cardiac output and mitral regurgitation. A prospective, longitudinal study was designed with pre-defined dyssynchrony index and outcome variables to test the hypothesis that dynamic dyssynchrony is associated with worse long-term event-free survival in patients with dilated cardiomyopathy (DCM) and 'narrow' QRS complex. One-hundred eighty patients (62 ± 8 years; 110 males) with NYHA class II-III, idiopathic DCM, ejection fraction ≤35%, and QRS duration <120 ms were selected. All the patients underwent standard Doppler echo, colour tissue velocity imaging (DTI), and supine bicycle exercise stress echocardiography. Cardiac synchronicity was defined, at rest and at peak exercise, as DTI velocity opposing-wall delay (significant if ≥65 ms). Outcome was defined as freedom from death, heart transplantation, or LV-assist device implantation, over a median follow-up of 48 months, and a Cox proportional hazards model was used for survival analysis. At baseline examination, DCM patients showed a reduced LV ejection fraction (31 + 4%). A significant electromechanical delay in 58 patients (32%). At the peak of physical exercise, a significant electromechanical delay was detected in 103 patients (57%). There were 41 events during the follow-up (23%): 28 cardiac deaths, 8 heart transplantations, and 5 LV-assist device implantations over 4 years. When adjusted for confounding baseline variables, LV end-diastolic volume, restrictive mitral flow pattern, severity of mitral regurgitation, and the presence of exercise-induced intraventricular dyssynchrony were the only independent determinants of an adverse outcome. In patients with idiopathic DCM and narrow QRS, the increase in echocardiographic dyssynchrony during exercise was the strongest predictor of less favourable event-free survival.

Impaired Patient-Reported Outcomes Predict Poor School Functioning and Daytime Sleepiness: The PROMIS Pediatric Asthma Study.

PubMed

Jones, Conor M; DeWalt, Darren A; Huang, I-Chan

Poor asthma control in children is related to impaired patient-reported outcomes (PROs; eg, fatigue, depressive symptoms, anxiety), but less well studied is the effect of PROs on children's school performance and sleep outcomes. In this study we investigated whether the consistency status of PROs over time affected school functioning and daytime sleepiness in children with asthma. Of the 238 children with asthma enrolled in the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Asthma Study, 169 children who provided survey data for all 4 time points were used in the analysis. The child's PROs, school functioning, and daytime sleepiness were measured 4 times within a 15-month period. PRO domains included asthma impact, pain interference, fatigue, depressive symptoms, anxiety, and mobility. Each child was classified as having poor/fair versus good PROs per meaningful cut points. The consistency status of each domain was classified as consistently poor/fair if poor/fair status was present for at least 3 time points; otherwise, the status was classified as consistently good. Seemingly unrelated regression was performed to test if consistently poor/fair PROs predicted impaired school functioning and daytime sleepiness at the fourth time point. Consistently poor/fair in all PRO domains was significantly associated with impaired school functioning and excessive daytime sleepiness (Ps < .01) after controlling for the influence of the child's age, sex, and race/ethnicity. Children with asthma with consistently poor/fair PROs are at risk of poor school functioning and daytime sleepiness. Developing child-friendly PRO assessment systems to track PROs can inform potential problems in the school setting. Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Tumor-infiltrating T lymphocytes improve clinical outcome of therapy-resistant neuroblastoma.

PubMed

Mina, Marco; Boldrini, Renata; Citti, Arianna; Romania, Paolo; D'Alicandro, Valerio; De Ioris, Maretta; Castellano, Aurora; Furlanello, Cesare; Locatelli, Franco; Fruci, Doriana

2015-09-01

Neuroblastoma grows within an intricate network of different cell types including epithelial, stromal and immune cells. The presence of tumor-infiltrating T cells is considered an important prognostic indicator in many cancers, but the role of these cells in neuroblastoma remains to be elucidated. Herein, we examined the relationship between the type, density and organization of infiltrating T cells and clinical outcome within a large collection of neuroblastoma samples by quantitative analysis of immunohistochemical staining. We found that infiltrating T cells have a prognostic value greater than, and independent of, the criteria currently used to stage neuroblastoma. A variable in situ structural organization and different concurrent infiltration of T-cell subsets were detected in tumors with various outcomes. Low-risk neuroblastomas were characterized by a higher number of proliferating T cells and a more structured T-cell organization, which was gradually lost in tumors with poor prognosis. We defined an immunoscore based on the presence of CD3 + , CD4 + and CD8 + infiltrating T cells that associates with favorable clinical outcome in MYCN-amplified tumors, improving patient survival when combined with the v-myc avian myelocytomatosis viral oncogene neuroblastoma derived homolog (MYCN) status. These findings support the hypothesis that infiltrating T cells influence the behavior of neuroblastoma and might be of clinical importance for the treatment of patients.

Market-Based Health Care in Specialty Surgery: Finding Patient-Centered Shared Value.

PubMed

Smith, Timothy R; Rambachan, Aksharananda; Cote, David; Cybulski, George; Laws, Edward R

2015-10-01

: The US health care system is struggling with rising costs, poor outcomes, waste, and inefficiency. The Patient Protection and Affordable Care Act represents a substantial effort to improve access and emphasizes value-based care. Value in health care has been defined as health outcomes for the patient per dollar spent. However, given the opacity of health outcomes and cost, the identification and quantification of patient-centered value is problematic. These problems are magnified by highly technical, specialized care (eg, neurosurgery). This is further complicated by potentially competing interests of the 5 major stakeholders in health care: patients, doctors, payers, hospitals, and manufacturers. These stakeholders are watching with great interest as health care in the United States moves toward a value-based system. Market principles can be harnessed to drive costs down, improve outcomes, and improve overall value to patients. However, there are many caveats to a market-based, value-driven system that must be identified and addressed. Many excellent neurosurgical efforts are already underway to nudge health care toward increased efficiency, decreased costs, and improved quality. Patient-centered shared value can provide a philosophical mooring for the development of health care policies that utilize market principles without losing sight of the ultimate goals of health care, to care for patients.

Anhedonia Is Associated with Poorer Outcomes in Contingency Management for Cocaine Use Disorder

PubMed Central

Wardle, Margaret C.; Vincent, Jessica N.; Suchting, Robert; Green, Charles E.; Lane, Scott D.; Schmitz, Joy M.

2016-01-01

This study explored anhedonia (lack of interest or pleasure in non-drug rewards) as a potentially modifiable individual difference associated with the effectiveness of Contingency Management (CM). It also tested the hypothesis that a dopaminergic drug, levodopa (L-DOPA), would improve the effectiveness of CM, particularly in individuals high in anhedonia. The study was a single-site, randomized, double-blind, parallel group, 12-week trial comparing L-DOPA with placebo, with both medication groups receiving voucher-based CM targeting cocaine-negative urines. Participants were N = 85 treatment-seeking adults with CUD. Anhedonia was measured at baseline using a validated self-report measure and a progressive ratio behavioral measure. Treatment Effectiveness Score (TES) was defined as the total number of cocaine-negative urines submitted. Analyses based on Frequentist general linear models were not significant, but Bayesian analyses indicated a high probability (92.6%) that self-reported anhedonia was associated with poor treatment outcomes (lower TES). L-DOPA did not significantly improve outcomes, nor was the effect of L-DOPA moderated by anhedonia. While the study failed to replicate positive findings from previous studies of L-DOPA in combination with CM, it does provide preliminary evidence that anhedonia may be a modifiable individual difference associated with poorer CM outcomes. PMID:27646197

Differences in clinical presentation and pregnancy outcomes in antepartum preeclampsia and new-onset postpartum preeclampsia: Are these the same disorder?

PubMed

Vilchez, Gustavo; Hoyos, Luis R; Leon-Peters, Jocelyn; Lagos, Moraima; Argoti, Pedro

2016-11-01

New-onset postpartum preeclampsia is a poorly defined condition that accounts for a significant percentage of eclampsia cases. It is unclear whether new-onset postpartum preeclampsia is a different disorder from or belongs to the same spectrum of classic antepartum preeclampsia. The objective of this study was to compare the clinical presentation and pregnancy outcomes of antepartum preeclampsia and new-onset postpartum preeclampsia. A retrospective study including 92 patients with antepartum preeclampsia and 92 patients with new-onset postpartum preeclampsia was performed. Clinical presentation and pregnancy outcomes were compared. Chi-square test was used to analyze categorical variables, and independent t -test and Mann-Whitney U -test for numerical variables. P -values of <0.05 were used to indicate statistical signifi cance. Patients with antepartum preeclampsia and new-onset postpartum preeclampsia differ significantly in profile, symptoms at presentation, laboratory markers and pregnancy outcomes. New-onset postpartum preeclampsia has a distinct patient profile and clinical presentation than antepartum preeclampsia, suggesting they may represent different disorders. Characterization of a patient profile with increased risk of developing this condition will help clinicians to identify patients at risk and provide early and targeted interventions to decrease the morbidity associated with this condition.

Tranexamic acid for acute intracerebral hemorrhage growth predicted by spot sign trial: Rationale and design.

PubMed

Liu, Liping; Wang, Yilong; Meng, Xia; Li, Na; Tan, Ying; Nie, Ximing; Liu, Dacheng; Zhao, Xingquan

2017-04-01

Rationale Acute intracerebral hemorrhage inflicts a high-economic and -health burden. Computed tomography angiography spot sign is a predictor of hematoma expansion, is associated with poor clinical outcome and is an important stratifying variable for patients treated with haemostatic therapy. Aims We aim to compare the effect of treatment with tranexamic acid to placebo for the prevention of hemorrhage growth in patients with high-risk acute intracerebral hemorrhage with a positive spot sign. Design The tranexamic acid for acute intracerebral hemorrhage growth predicted by spot sign (TRAIGE) is a prospective, multicenter, placebo-controlled, double-blind, investigator-led, randomized clinical trial that will include an estimated 240 participants. Patients with intracerebral hemorrhage demonstrating symptom onset within 8 h and with the spot sign as a biomarker for ongoing hemorrhage, and no contraindications for antifibrinolytic therapy, will be enrolled to receive either tranexamic acid or placebo. The primary outcome measure is the presence of hemorrhage growth defined as an increase in intracerebral hemorrhage volume >33% or >6 ml from baseline to 24 ± 2 h. The secondary outcomes include safety and clinical outcomes. Conclusion The TRAIGE trial evaluates the efficacy of haemostatic therapy with tranexamic acid in the prevention of hemorrhage growth among high-risk patients with acute intracerebral hemorrhage.

Can we direct organ allocation based on predicted outcome? Hepatocellular carcinoma outside of UCSF criteria or retransplant?

PubMed

Rochon, Caroline; Sheiner, Patricia; Mahadevappa, Basant; Gunasekaran, Ganesh; Sharma, Joyti; Wolf, David C; Facciuto, Marcelo

2012-06-01

In this study, we ask between patients with graft failure listed for retransplant and patients with hepatocellular carcinoma (HCC) outside of UCSF criteria, who has the greater survival benefit with transplantation? This is a retrospective analysis, of liver transplant (LT) patients, done between February 2002 and December 2009 at our center. Patients were included in the "extended HCC" group if their tumor was pathologically beyond UCSF criteria at LT and in the "redo" group if they underwent LT for graft failure occurring more than 3 months after the initial LT. Extended criteria donors (ECDs) were defined as donors above 70 years old, DCD, serology positive for HCV, and split grafts. There were 25 redos and 37 extended HCC patients. Use of ECDs or high donor risk index organs was associated with poor outcome in both groups (P = 0.005). Overall, the extended HCC population had a much better survival than redos, both at 1 and 3 years. These two very different but high risk patient populations have very different survival rates. At a time where regulatory agencies demand more and more with regards to transplant outcomes, we think the transplant community has to reflect on whether allocation justice and fair access to transplant are respected if we start allocating organs based on outcomes.

Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.

PubMed

Davison, Sara N; Levin, Adeera; Moss, Alvin H; Jha, Vivekanand; Brown, Edwina A; Brennan, Frank; Murtagh, Fliss E M; Naicker, Saraladevi; Germain, Michael J; O'Donoghue, Donal J; Morton, Rachael L; Obrador, Gregorio T

2015-09-01

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.

Molecular Profiling Reveals Biologically Discrete Subsets and Pathways of Progression in Diffuse Glioma.

PubMed

Ceccarelli, Michele; Barthel, Floris P; Malta, Tathiane M; Sabedot, Thais S; Salama, Sofie R; Murray, Bradley A; Morozova, Olena; Newton, Yulia; Radenbaugh, Amie; Pagnotta, Stefano M; Anjum, Samreen; Wang, Jiguang; Manyam, Ganiraju; Zoppoli, Pietro; Ling, Shiyun; Rao, Arjun A; Grifford, Mia; Cherniack, Andrew D; Zhang, Hailei; Poisson, Laila; Carlotti, Carlos Gilberto; Tirapelli, Daniela Pretti da Cunha; Rao, Arvind; Mikkelsen, Tom; Lau, Ching C; Yung, W K Alfred; Rabadan, Raul; Huse, Jason; Brat, Daniel J; Lehman, Norman L; Barnholtz-Sloan, Jill S; Zheng, Siyuan; Hess, Kenneth; Rao, Ganesh; Meyerson, Matthew; Beroukhim, Rameen; Cooper, Lee; Akbani, Rehan; Wrensch, Margaret; Haussler, David; Aldape, Kenneth D; Laird, Peter W; Gutmann, David H; Noushmehr, Houtan; Iavarone, Antonio; Verhaak, Roel G W

2016-01-28

Therapy development for adult diffuse glioma is hindered by incomplete knowledge of somatic glioma driving alterations and suboptimal disease classification. We defined the complete set of genes associated with 1,122 diffuse grade II-III-IV gliomas from The Cancer Genome Atlas and used molecular profiles to improve disease classification, identify molecular correlations, and provide insights into the progression from low- to high-grade disease. Whole-genome sequencing data analysis determined that ATRX but not TERT promoter mutations are associated with increased telomere length. Recent advances in glioma classification based on IDH mutation and 1p/19q co-deletion status were recapitulated through analysis of DNA methylation profiles, which identified clinically relevant molecular subsets. A subtype of IDH mutant glioma was associated with DNA demethylation and poor outcome; a group of IDH-wild-type diffuse glioma showed molecular similarity to pilocytic astrocytoma and relatively favorable survival. Understanding of cohesive disease groups may aid improved clinical outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Notch3 overexpression enhances progression and chemoresistance of urothelial carcinoma.

PubMed

Zhang, Heng; Liu, Limei; Liu, Chungang; Pan, Jinhong; Lu, Gensheng; Zhou, Zhansong; Chen, Zhiwen; Qian, Cheng

2017-05-23

Abnormal activation of Notch signaling is involved in the etiology of various diseases, including cancer, but the association between Notch3 expression in urothelial cancer and clinical outcome remains unclear, and the molecular mechanisms underlying Notch3 signaling activation are not well defined. In this study we examined 59 urothelial cancer patients and found that Notch3 was more highly expressed in human urothelial cancer tissues than in non-tumorous bladder tissue samples, with Notch3 overexpression being associated with poor clinical outcome. Notch3 knockdown resulted in decreased proliferation of urothelial cancer cells in vitro and decreased xenograft tumor growth in vivo. In addition, Notch3 knockdown rendered urothelial cancer cells more sensitive to cisplatin. Furthermore, suberoylanilide hydroxamic acid (SAHA, a histone deacetylase [HDAC] inhibitor) induced acetylation of NOTCH3, downregulated Notch 3, prevented urothelial cancer cell proliferation, and induced cell cycle arrest. Taken together, these data suggested that Notch 3 overexpression promotes growth and chemoresistance in urothelial cancer.

Notch3 overexpression enhances progression and chemoresistance of urothelial carcinoma

PubMed Central

Zhang, Heng; Liu, Limei; Liu, Chungang; Pan, Jinhong; Lu, Gensheng; Zhou, Zhansong; Chen, Zhiwen; Qian, Cheng

2017-01-01

Abnormal activation of Notch signaling is involved in the etiology of various diseases, including cancer, but the association between Notch3 expression in urothelial cancer and clinical outcome remains unclear, and the molecular mechanisms underlying Notch3 signaling activation are not well defined. In this study we examined 59 urothelial cancer patients and found that Notch3 was more highly expressed in human urothelial cancer tissues than in non-tumorous bladder tissue samples, with Notch3 overexpression being associated with poor clinical outcome. Notch3 knockdown resulted in decreased proliferation of urothelial cancer cells in vitro and decreased xenograft tumor growth in vivo. In addition, Notch3 knockdown rendered urothelial cancer cells more sensitive to cisplatin. Furthermore, suberoylanilide hydroxamic acid (SAHA, a histone deacetylase [HDAC] inhibitor) induced acetylation of NOTCH3, downregulated Notch 3, prevented urothelial cancer cell proliferation, and induced cell cycle arrest. Taken together, these data suggested that Notch 3 overexpression promotes growth and chemoresistance in urothelial cancer. PMID:28416766

Heart Failure Clinical Trials in East and Southeast Asia: Understanding the Importance and Defining the Next Steps

PubMed Central

Mentz, Robert J.; Roessig, Lothar; Greenberg, Barry H.; Sato, Naoki; Shinagawa, Kaori; Yeo, Daniel; Kwok, Bernard W.K.; Reyes, Eugenio B.; Krum, Henry; Pieske, Burkert; Greene, Stephen J.; Ambrosy, Andrew P.; Kelly, Jacob P.; Zannad, Faiez; Pitt, Bertram; Lam, Carolyn S.P.

2016-01-01

Heart failure (HF) is a major and increasing global public health problem. In Asia, aging populations and recent increases in cardiovascular risk factors have contributed to a particularly high burden of HF with similarly poor outcomes compared to the rest of the world. Representation of Asians in landmark HF trials has been variable. In addition, HF patients from Asia demonstrate clinical differences from other geographic regions. Thus, the generalizability of some clinical trials results to the Asian population remains uncertain. In this manuscript, we review differences in the HF phenotype, management and outcomes in patients from East and Southeast Asia. We describe lessons learned in Asia from recent HF registries and clinical trial databases and outline strategies to improve the potential for success in future trials. This review is based on discussions between scientists, clinical trialists, industry representatives and regulatory representatives at the CardioVascular Clinical Trialist Asia Forum on July 4, 2014. PMID:27256745

Evolving paradigms for desensitization in managing broadly HLA sensitized transplant candidates.

PubMed

Reinsmoen, Nancy L; Lai, Chi-Hung; Vo, Ashley; Jordan, Stanley C

2012-04-01

The broadly human leukocyte antigen (HLA) sensitized patient awaiting organ transplantation remains a persistent and significant problem for transplant medicine. Sensitization occurs as a consequence of exposure to HLA antigens through pregnancy, blood and platelet transfusions, and previous transplants. Early experience with desensitization protocols coupled with improved diagnostics for donor-specific antibodies (DSAs) and renal pathology have greatly improved transplant rates and outcomes for patients once considered un-transplantable or at high risk for poor outcomes. More recent advances have occurred through implementation of a national allocation system requiring the entering of unacceptable antigens that reduces the rate of crossmatch positivity. Current desensitization therapies include high-dose intravenous immunoglobulin (IVIG), plasma exchange (PLEX) with low-dose IVIG, and IVIG combined with rituximab. Developing therapies include proteasome inhibitors aimed at plasma cells and modifiers of complement-mediated injury. Here we discuss the important advancements in desensitization including defining the risk for antibody-mediated rejection prior to transplantation and the evolution of therapies aimed at reducing the impact of antibody injury on allografts.

Economic inequality increases risk taking

PubMed Central

Payne, B. Keith; Brown-Iannuzzi, Jazmin L.; Hannay, Jason W.

2017-01-01

Rising income inequality is a global trend. Increased income inequality has been associated with higher rates of crime, greater consumer debt, and poorer health outcomes. The mechanisms linking inequality to poor outcomes among individuals are poorly understood. This research tested a behavioral account linking inequality to individual decision making. In three experiments (n = 811), we found that higher inequality in the outcomes of an economic game led participants to take greater risks to try to achieve higher outcomes. This effect of unequal distributions on risk taking was driven by upward social comparisons. Next, we estimated economic risk taking in daily life using large-scale data from internet searches. Risk taking was higher in states with greater income inequality, an effect driven by inequality at the upper end of the income distribution. Results suggest that inequality may promote poor outcomes, in part, by increasing risky behavior. PMID:28416655

3 Tesla MRI-negative focal epilepsies: Presurgical evaluation, postoperative outcome and predictive factors.

PubMed

Kogias, Evangelos; Klingler, Jan-Helge; Urbach, Horst; Scheiwe, Christian; Schmeiser, Barbara; Doostkam, Soroush; Zentner, Josef; Altenmüller, Dirk-Matthias

2017-12-01

To investigate presurgical diagnostic modalities, clinical and seizure outcome as well as predictive factors after resective epilepsy surgery in 3 Tesla MRI-negative focal epilepsies. This retrospective study comprises 26 patients (11 males/15 females, mean age 34±12years, range 13-50 years) with 3 Tesla MRI-negative focal epilepsies who underwent resective epilepsy surgery. Non-invasive and invasive presurgical diagnostic modalities, type and localization of resection, clinical and epileptological outcome with a minimum follow-up of 1year (range 1-11 years, mean 2.5±2.3years) after surgery as well as outcome predictors were evaluated. All patients underwent invasive video-EEG monitoring after implantation of intracerebral depth and/or subdural electrodes. Ten patients received temporal and 16 extratemporal or multilobar (n=4) resections. There was no perioperative death or permanent morbidity. Overall, 12 of 26 patients (46%) were completely seizure-free (Engel IA) and 65% had a favorable outcome (Engel I-II). In particular, seizure-free ratio was 40% in the temporal and 50% in the extratemporal group. In the temporal group, long duration of epilepsy correlated with poor seizure outcome, whereas congruent unilateral FDG-PET hypometabolism correlated with a favorable outcome. In almost two thirds of temporal and extratemporal epilepsies defined as "non-lesional" by 3 Tesla MRI criteria, a favorable postoperative seizure outcome (Engel I-II) can be achieved with accurate multimodal presurgical evaluation including intracranial EEG recordings. In the temporal group, most favorable results were obtained when FDG-PET displayed congruent unilateral hypometabolism. Copyright © 2017 Elsevier B.V. All rights reserved.

The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding.

PubMed

Kwak, Min Seob; Cha, Jae Myung; Han, Yong Jae; Yoon, Jin Young; Jeon, Jung Won; Shin, Hyun Phil; Joo, Kwang Ro; Lee, Joung Il

2016-10-01

The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.

From Childhood Conduct Problems to Poor Functioning at Age 18 Years: Examining Explanations in a Longitudinal Cohort Study.

PubMed

Wertz, Jasmin; Agnew-Blais, Jessica; Caspi, Avshalom; Danese, Andrea; Fisher, Helen L; Goldman-Mellor, Sidra; Moffitt, Terrie E; Arseneault, Louise

2018-01-01

Childhood conduct problems are associated with poor functioning in early adulthood. We tested a series of hypotheses to understand the mechanisms underlying this association. We used data from the Environmental Risk (E-Risk) Longitudinal Twin Study, a birth cohort of 2,232 twins born in England and Wales in 1994 and 1995, followed up to age 18 years with 93% retention. Severe conduct problems in childhood were assessed at ages 5, 7, and 10 years using parent and teacher reports. Poor functioning at age 18 years, including cautions and convictions, daily cigarette smoking, heavy drinking, and psychosocial difficulties, was measured through interviews with participants and official crime record searches. Participants 18 years old with versus without a childhood history of severe conduct problems had greater rates of each poor functional outcome, and they were more likely to experience multiple poor outcomes. This association was partly accounted for by concurrent psychopathology in early adulthood, as well as by early familial risk factors, both genetic and environmental. Childhood conduct problems, however, continued to predict poor outcomes at age 18 years after accounting for these explanations. Children with severe conduct problems display poor functioning at age 18 years because of concurrent problems in early adulthood and familial risk factors originating in childhood. However, conduct problems also exert a lasting effect on young people's lives independent of these factors, pointing to early conduct problems as a target for early interventions aimed at preventing poor functional outcomes. Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.

Long-term neurodevelopmental outcomes in children born with gastroschisis: the tiebreaker.

PubMed

Gorra, Adam S; Needelman, Howard; Azarow, Kenneth S; Roberts, Holly J; Jackson, Barbara J; Cusick, Robert A

2012-01-01

We evaluated 2-year neurodevelopmental outcomes in children with gastroschisis. We reviewed the records of children with gastroschisis treated between August 2001 and July 2008. Children discharged from the neonatal intensive care unit were referred to the state-sponsored Developmental Tracking Infant Progress Statewide (TIPS) program. We reviewed TIPS assessments performed before age 2 years. School districts evaluated children referred by TIPS and determined their eligibility for early intervention services. Poor outcomes were defined as scores of "failure" or "moderate/high risk" on the screening assessment or enrollment in early intervention services by 2 years. Children with gastroschisis were compared with case-matched nonsurgical, nonsyndromic children of similar gestational age and birth weight. One hundred five children were born with gastroschisis, and 46 were followed up with TIPS. There was no statistically significant difference in performance on screening assessments or in the rate of enrollment in early intervention services between the gastroschisis children and controls. Children born with gastroschisis have similar 2-year neurodevelopmental outcomes as nonsurgical, nonsyndromic neonatal intensive care unit children of similar gestational age and birth weight. Both groups of children have a higher rate of enrollment in early intervention than their healthy peers. These data suggest that neurodevelopmental outcomes in gastroschisis children are delayed secondary to prematurity rather than the presence of the surgical disease. Copyright © 2012 Elsevier Inc. All rights reserved.

Poor outcome and death among youth, young adults, and midlife adults with eating disorders: an investigation of risk factors by age at assessment.

PubMed

Ackard, Diann M; Richter, Sara; Egan, Amber; Cronemeyer, Catherine

2014-11-01

Eating disorders (EDs) present across a broad age range, yet little is known about the characteristics and outcome of midlife patients compared to younger patients. Among patients seeking ED treatment who were stratified by age at initial assessment (IA), this study aimed to (1) discern sociodemographic and clinical differences, (2) determine outcome rates, and (3) identify predictors of poor outcome including death. Participants [219 females (12 years or older, 94.1% Caucasian) who completed outcome assessment and 31 known decedents] were stratified by age at IA (<18 as youth, 18-39 as young adult, and ≥40 years as midlife adult). Analyses of variance and chi-square tests identified group differences; ordered logistic regression with stepwise selection identified factors predicting outcome. Midlife adults were more significantly compromised at follow-up compared to youths and young adults, including psychological and physical quality of life, ineffectiveness, interpersonal concerns, and general psychological maladjustment. Midlife adults had the highest rates of poor outcome or death; good outcome was achieved by only 5.9% of midlife adult compared to 14.0% of young adult and 27.5% of youth patients. Older age at IA, alcohol and/or drug misuse, endocrine concerns, and absence of family ED history predicted poor outcome or death. Midlife adults seeking ED treatment have more complex medical and psychological concerns and poorer outcomes than youths and young adults; further exploration is needed to improve treatment outcome. Specialized treatment focusing on quality of life, comorbid medical concerns, interpersonal connection, and emotion regulation is encouraged. © 2014 Wiley Periodicals, Inc.

Perceived discrimination and health-related quality-of-life: gender differences among older African Americans.

PubMed

Coley, Sheryl L; Mendes de Leon, Carlos F; Ward, Earlise C; Barnes, Lisa L; Skarupski, Kimberly A; Jacobs, Elizabeth A

2017-12-01

Emerging data suggest that African-American women may fare worse than African-American men in health-related quality-of-life (HRQOL). Perceived discrimination is an important contributor to poor health overall among African Americans, but few studies examined the intersecting effects of perceived discrimination and gender in explaining HRQOL disparities. We investigated gender differences in HRQOL and tested whether perceived discrimination accounted for these differences. We examined data from the Chicago Health and Aging Project in which 5652 African-American adults aged 65 and older completed structured questionnaires about demographic and socioeconomic characteristics, HRQOL, perceived discrimination, and health-related variables. Logistic regression models were used to identify associations between perceived discrimination and gender differences in poor HRQOL outcomes (defined as 14+ unhealthy days in overall, physical, or mental health over the past 30 days) when controlling for the other variables. More women reported poor overall HRQOL than men (24 vs. 16% respectively). Higher perceived discrimination was significantly associated with worse overall HRQOL (OR 1.11; 95% CI 1.08, 1.15), with stronger effects for women in overall and mental HRQOL. These gender disparities remained significant until controlling for potentially confounding variables. Perceived discrimination did not account for gender differences in poor physical HRQOL. Perceived discrimination is associated with poor HRQOL in older African Americans, with this association appearing stronger in women than men for mental HRQOL. These findings warrant further investigation of effects of perceived discrimination in gender disparities in overall health, and such research can inform and guide efforts for reducing these disparities.

Association between depression and glycemic control among type 2 diabetes patients in Lima, Peru.

PubMed

Crispín-Trebejo, Brenda; Robles-Cuadros, María Cristina; Bernabé-Ortiz, Antonio

2015-12-01

There is limited and controversial information regarding the potential impact of depression on glycemic control. This study aims to evaluate the association between depression and poor glycemic control. In addition, the prevalence of depression and rates of poor glycemic control were determined. Cross-sectional study performed in the endocrinology unit of two hospitals of ESSALUD in Peru. The outcome of interest was poor glycemic control, evaluated by glycated hemoglobin (HbA1c: <7% versus ≥7%), whereas the exposure of interest was depression defined as 15 or more points in the Patient Health Questionnaire-9 tool. The association of interest was evaluated using Poisson regression models with robust standard errors reporting prevalence ratios (PR) and 95% confidence intervals (95% CI) adjusting for potential confounders. A total of 277 participants, 184 (66.4%) males, mean age 59.0 (SD: 4.8), and 7.1 (SD: 6.8) years of disease were analyzed. Only 31 participants (11.2%; 95% CI: 7.5%-14.9%) had moderately severe or severe depression, whereas 70 (25.3%; 95% CI 20.3%-30.8%) had good glycemic control. Depression increased the probability of having poor glycemic control (PR=1.32; 95% CI 1.15-1.51) after adjusting for several potential confounders. There is an association between depression and poor glycemic control among type 2 diabetes patients. Our results suggest that early detection of depression might be important to facilitate appropriate glycemic control and avoid further metabolic complications. © 2015 Wiley Publishing Asia Pty Ltd.

Association between depression and glycemic control among type 2 diabetes patients in Lima, Peru

PubMed Central

Crispín‐Trebejo, Brenda; Bernabé‐Ortiz, Antonio

2015-01-01

Abstract Introduction There is limited and controversial information regarding the potential impact of depression on glycemic control. This study aims to evaluate the association between depression and poor glycemic control. In addition, the prevalence of depression and rates of poor glycemic control were determined. Methods Cross‐sectional study performed in the endocrinology unit of two hospitals of ESSALUD in Peru. The outcome of interest was poor glycemic control, evaluated by glycated hemoglobin (HbA1c: < 7% versus ≥ 7%), whereas the exposure of interest was depression defined as 15 or more points in the Patient Health Questionnaire‐9 tool. The association of interest was evaluated using Poisson regression models with robust standard errors reporting prevalence ratios (PR) and 95% confidence intervals (95% CI) adjusting for potential confounders. Results A total of 277 participants, 184 (66.4%) males, mean age 59.0 (SD: 4.8), and 7.1 (SD: 6.8) years of disease were analyzed. Only 31 participants (11.2%; 95% CI: 7.5%–14.9%) had moderately severe or severe depression, whereas 70 (25.3%; 95% CI 20.3%–30.8%) had good glycemic control. Depression increased the probability of having poor glycemic control (PR = 1.32; 95% CI 1.15–1.51) after adjusting for several potential confounders. Conclusions There is an association between depression and poor glycemic control among type 2 diabetes patients. Our results suggest that early detection of depression might be important to facilitate appropriate glycemic control and avoid further metabolic complications. PMID:26037488

Identifying socio-demographic and socioeconomic determinants of health inequalities in a diverse London community: the South East London Community Health (SELCoH) study.

PubMed

Hatch, Stephani L; Frissa, Souci; Verdecchia, Maria; Stewart, Robert; Fear, Nicola T; Reichenberg, Abraham; Morgan, Craig; Kankulu, Bwalya; Clark, Jennifer; Gazard, Billy; Medcalf, Robert; Hotopf, Matthew

2011-11-11

Responses to public health need require information on the distribution of mental and physical ill health by demographic and socioeconomic factors at the local community level. The South East London Community Health (SELCoH) study is a community psychiatric and physical morbidity survey. Trained interviewers conducted face-to-face computer assisted interviews with 1698 adults aged 16 years and over, from 1076 randomly selected private households in two south London boroughs. We compared the prevalence of common mental disorders, hazardous alcohol use, long standing illness and general physical health by demographic and socioeconomic indicators. Unadjusted and models adjusted for demographic and socioeconomic indicators are presented for all logistic regression models. Of those in the sample, 24.2% reported common mental disorder and 44.9% reported having a long standing illness, with 15.7% reporting hazardous alcohol consumption and 19.2% rating their health as fair or poor. The pattern of indicators identifying health inequalities for common mental disorder, poor general health and having a long term illness is similar; individuals who are socioeconomically disadvantaged have poorer health and physical health worsens as age increases for all groups. The prevalence of poor health outcomes by ethnic group suggests that there are important differences between groups, particularly for common mental disorder and poor general health. Higher socioeconomic status was protective for common mental disorder, fair or poor health and long standing illness, but those with higher socioeconomic status reported higher levels of hazardous alcohol use. The proportion of participants who met the criteria for common mental disorder with co-occurring functional limitations was similar or greater to those with poor physical health. Health service providers and policy makers should prioritise high risk, socially defined groups in combating inequalities in individual and co-occurring poor mental and physical problems. In population terms, poor mental health has a similar or greater burden on functional impairment than long term conditions and perceived health.

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital

PubMed Central

Kurumi, Hiroki; Takeda, Yohei; Yashima, Kazuo; Isomoto, Hajime

2017-01-01

Background Peptic ulcer bleeding (PUB) is the main cause of non-variceal upper gastrointestinal bleeding (UGIB). Endoscopic treatment and acid suppression with proton-pump inhibitors (PPIs) are most important in the management of PUB and these treatments have reduced mortality. However, elderly patients sometimes have a poor prognostic outcome due to severe comorbidities. Methods A retrospective study was performed on 504 cases with acute non-variceal UGIB who were examined in our hospital, in order to reveal the risk factor of a poor outcome in elderly patients. Results Two hundred and thirty-four cases needed hemostasis; 11 cases had unsuccessful endoscopic treatments; 31 cases had re-bleeding after endoscopic hemostasis. Forty-three cases died within 30 days after the initial urgent endoscopy, but only seven cases died from bleeding. Elderly patients aged over 65 years had more severe comorbidities, and were prescribed non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and/or anticoagulation agents, more frequently, compared with non-elderly patients. The significant risk factor of needing hemostatic therapy was the taking of two or more NSAIDs, antiplatelet agents and/or anticoagulation agents. The most important risk of a poor outcome in elderly patients was various kinds of severe comorbidities. And so, it is important to predict such an outcome in these cases. AIMS65 is a simple and relatively useful scoring system that predicts the risk of a poor outcome in UGIB. High-score patients via AIMS65 were associated with a high mortality rate because of death from comorbidities. Conclusions The elderly patients in whom were prescribed two or more NSAIDs, antiplatelet agents and/or anticoagulation agents, should have UGIB prevented using a PPI. The most significant risk of a poor outcome in elderly patients was severe comorbidities. We recommend that elderly patients with UGIB should be estimated as having a poor outcome as soon as possible via the risk scoring system AIMS65. PMID:28616396

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital.

PubMed

Kawaguchi, Koichiro; Kurumi, Hiroki; Takeda, Yohei; Yashima, Kazuo; Isomoto, Hajime

2017-04-01

Peptic ulcer bleeding (PUB) is the main cause of non-variceal upper gastrointestinal bleeding (UGIB). Endoscopic treatment and acid suppression with proton-pump inhibitors (PPIs) are most important in the management of PUB and these treatments have reduced mortality. However, elderly patients sometimes have a poor prognostic outcome due to severe comorbidities. A retrospective study was performed on 504 cases with acute non-variceal UGIB who were examined in our hospital, in order to reveal the risk factor of a poor outcome in elderly patients. Two hundred and thirty-four cases needed hemostasis; 11 cases had unsuccessful endoscopic treatments; 31 cases had re-bleeding after endoscopic hemostasis. Forty-three cases died within 30 days after the initial urgent endoscopy, but only seven cases died from bleeding. Elderly patients aged over 65 years had more severe comorbidities, and were prescribed non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and/or anticoagulation agents, more frequently, compared with non-elderly patients. The significant risk factor of needing hemostatic therapy was the taking of two or more NSAIDs, antiplatelet agents and/or anticoagulation agents. The most important risk of a poor outcome in elderly patients was various kinds of severe comorbidities. And so, it is important to predict such an outcome in these cases. AIMS65 is a simple and relatively useful scoring system that predicts the risk of a poor outcome in UGIB. High-score patients via AIMS65 were associated with a high mortality rate because of death from comorbidities. The elderly patients in whom were prescribed two or more NSAIDs, antiplatelet agents and/or anticoagulation agents, should have UGIB prevented using a PPI. The most significant risk of a poor outcome in elderly patients was severe comorbidities. We recommend that elderly patients with UGIB should be estimated as having a poor outcome as soon as possible via the risk scoring system AIMS65.

Correlates of adverse childhood events among adults with schizophrenia spectrum disorders.

PubMed

Rosenberg, Stanley D; Lu, Weili; Mueser, Kim T; Jankowski, Mary Kay; Cournos, Francine

2007-02-01

Multiple studies have found that childhood adversity is related to a range of poor mental health, substance abuse, poor physical health, and poor social functioning outcomes in the general population of adults. However, despite the high rates of childhood adversity in schizophrenia, the clinical correlates of these events have not been systematically evaluated. This study evaluated the relationship between adverse experiences in childhood and functional, clinical, and health outcomes among adults with schizophrenia. The authors surveyed 569 adults with schizophrenia regarding adverse childhood events (including physical abuse, sexual abuse, parental mental illnesses, loss of a parent, parental separation or divorce, witnessing domestic violence, and foster or kinship care). The relationships between cumulative exposure to these events and psychiatric, physical, and functional outcomes were evaluated. Increased exposure to adverse childhood events was strongly related to psychiatric problems (suicidal thinking, hospitalizations, distress, and posttraumatic stress disorder), substance abuse, physical health problems (HIV infection), medical service utilization (physician visits), and poor social functioning (homelessness or criminal justice involvement). The findings extend the results of research in the general population by suggesting that childhood adversity contributes to worse mental health, substance abuse, worse physical health, and poor functional outcomes in schizophrenia.

Timing of operation for poor-grade aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

PubMed Central

2013-01-01

Background Subarachnoid hemorrhage is a common and dangerous disease with an unfavorable prognosis. Patients with poor-grade subarachnoid hemorrhage (Hunt & Hess Grades 4–5) are unconscious on admission. Because of the high mortality and disability rate associated with poor-grade subarachnoid hemorrhage, it is often treated conservatively. Timing of surgery for poor-grade aneurysmal subarachnoid hemorrhage is still controversial, therefore this study aims to identify the optimal time to operate on patients admitted in poor clinical condition. Methods/design Ninety-nine patients meeting the inclusion criteria were randomly assigned into three treatment groups. The early surgery group received operation within 3 days after onset of subarachnoid hemorrhage (day of SAH = day 1); the intermediate surgery group received operation from days 4 to 7, and surgery was performed on the late surgery group after day 7. Follow-up was performed 1, 3, and 6 months after aneurysm clipping. Primary indicators of outcome included the Extended Glasgow Outcome Scale and the Modified Rankin Scale, while secondary indicators of outcome were assessed using the Barthel Index and mortality. Discussion This is the first prospective, single-center, observer-blinded, randomized controlled trial to elucidate optimal timing for surgery in poor-grade subarachnoid hemorrhage patients. The results of this study will be used to direct decisions of surgical intervention in poor-grade subarachnoid hemorrhage, thus improving clinical outcomes for patients. Trial registration Chinese Clinical Trial Registry: ChiCTR-TRC-12002917 PMID:23957458

The upside down world of diabetes care medical economics and what we might do to improve it.

PubMed

Harlan, David M; Hirsch, Irl B

2017-04-01

Increasingly over the past generation, the American healthcare delivery system has received consistently poor marks with regard to public health outcomes and costs. This review by two seasoned diabetes care providers is intended to shed light on the fundamental flaws we believe to underlie that poor performance, and suggest options for better outcomes and cost efficiencies. Despite major advances in diabetes management medications and tools, overall public health with regard to diabetes outcomes remains poor. Efforts focused on controlling costs appear to be exacerbating the problem. For chronic diseases like diabetes, fee-for-service care models are fundamentally flawed and predictably fail. We suggest that a major overhaul of the medical economics underlying diabetes care can improve patient outcomes and decrease costs.

Periodontal disease and pregnancy outcomes.

PubMed

Babalola, Dolapo A; Omole, Folashade

2010-01-01

An increasing number of studies are confirming an association between periodontal disease (PD) and adverse outcomes in pregnancy. PD places pregnant women at greater risk for preterm birth than alcohol consumption or smoking. This underscores the importance of offering dental screening to women who are pregnant or contemplating pregnancy and the need for physicians who provide obstetric care to be aware of the possible connection between poor dental health and poor pregnancy outcomes.

Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

PubMed Central

Grille, Pedro; Tommasino, Nicolas

2015-01-01

Objective To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy. Methods Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed. Results A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome. Conclusion This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population. PMID:26340150

Ten-year follow-up of SpA-related oligoarthritis involving the knee: the presence of psoriasis but not HLA-B27 or baseline MRI bone oedema predicts outcome.

PubMed

Bennett, Alexander N; Marzo-Ortega, Helena; Tan, Ai Lyn; Hensor, Elizabeth M A; Green, Mike; Emery, Paul; McGonagle, Dennis

2012-06-01

Bone marrow oedema (BMO) and HLA-B27 are poor prognostic factors in axial SpA, and psoriasis is a poor prognostic factor in small-joint polyarthropathy. The aim of this study was to investigate the influence of HLA-B27, MRI BMO and psoriasis on long-term outcomes in early SpA-related knee joint oligoarthritis. Patients with SpA-related oligoarthritis with knee involvement were recruited. Baseline assessment included ESSG criteria, RF, HLA-B27 and MRI. The degree of MRI BMO was determined on fat-suppression sequences and scored using the whole-organ magnetic resonance imaging score (WORMS) (range 0-45). Patients were treated at the discretion of their rheumatologist and followed up for 10 years. Outcome assessments included joint counts, functional and symptomatic questionnaire, CRP and radiographic assessment for OA. Forty-four patients were recruited [mean age 32 years (range 15-59 years), 70% male] with a mean disease duration at baseline of 9.75 months (1-48 months). Twenty-six (59%) patients (mean age 43 years, 65% male) returned for follow-up after a mean of 10 years (range 8.4-12.6 years). Ten (38%) patients had persistent clinical synovitis and 31% of knees had secondary radiographic OA. Global outcome was poor/very poor in 69% of cases. The only factor predicting outcome at 10 years was psoriasis, but neither HLA-B27 nor BMO. PsA patients had significantly worse global outcome compared with ReA (P = 0.036), and significantly worse symptomatic (P = 0.001) and functional (P = 0.001) outcome compared with other subtypes. SpA-related knee joint oligoarthritis has significant long-term clinical and radiological morbidity despite standard treatments. HLA-B27 and MRI BMO were not predictors of poor outcome as they are in axial SpA; however, the presence of psoriasis predicted significantly worse outcome.

Maxillary post-traumatic outcome correction literature review and our experience. Part I: maxillary bone non-unions-"poor bone positioning".

PubMed

D'Agostino, A; Toffanetti, G; Scala, R; Trevisiol, L; Ferrari, F

2004-04-01

Still today, there is no classification of non-unions in maxillofacial traumatology. There is a broad spectrum of definitions that simultaneously describe the pathological conditions and functional implications determined by the anatomical location of the fractures and the time factor. In this article the authors describe a literature review about bone non-union classification. Weber, in 1973, introduced the term "pseudo-arthrosis" to describe an altered process of bone healing characterised by the presence of fibrous tissue interposed between the fracture segments, that was lined with cartilaginous tissue and joined by a capsule; Spiessl, in 1988, used the term "non-union" to define any alteration of the bone healing process after a time period of more than 6 months from the initial traumatic event; Rosen, in 1990, proposed a new classification of the modes of altered bone healing in fractures, distinguishing 5 categories: delayed consolidation, non-union, non-union vascular, non union avascular, pseudoarthrosis. The authors also talk about "poor bone positioning". This factor describes the incorrect anatomical position of the bone fragments despite perfectly normal healing according to Gruss. In this article they also discuss about the treatment of non-unions and the treatment of occlusal alterations caused by poor post-traumatic bone positioning.

An empirical review of antimalarial quality field surveys: the importance of characterising outcomes.

PubMed

Grech, James; Robertson, James; Thomas, Jackson; Cooper, Gabrielle; Naunton, Mark; Kelly, Tamsin

2018-01-05

For decades, thousands of people have been dying from malaria infections because of poor-quality medicines (PQMs). While numerous efforts have been initiated to reduce their presence, PQMs are still risking the lives of those seeking treatment. This review addresses the importance of characterising results of antimalarial medicine field surveys based upon the agreement of clearly defined definitions. Medicines found to be of poor quality can be falsified or counterfeit, substandard or degraded. The distinction between these categories is important as each category requires a different countermeasure. To observe the current trends in the reporting of field surveys, a systematic literature search of six academic databases resulted in the quantitative analysis of 61 full-text journal articles. Information including sample size, sampling method, geographical regions, analytical techniques, and characterisation conclusions was observed for each. The lack of an accepted uniform reporting system has resulted in varying, incomplete reports, which may not include important information that helps form effective countermeasures. The programmes influencing medicine quality such as prequalification, procurement services, awareness and education can be supported with the information derived from characterised results. The implementation of checklists such as the Medicine Quality Assessment Reporting Guidelines will further strengthen the battle against poor-quality antimalarials. Copyright © 2017 Elsevier B.V. All rights reserved.

The paradox of transient worsening renal function in patients with acute heart failure: the role of B-type natriuretic peptide and diuretic response.

PubMed

Ruocco, Gaetano; Nuti, Ranuccio; Giambelluca, Amalia; Evangelista, Isabella; De Vivo, Oreste; Daniello, Cosimo; Palazzuoli, Alberto

2017-11-01

Worsening renal function (WRF) occurs in one-third of patients hospitalized for acute decompensated heart failure. Recently, WRF was categorized in two subtypes: persistent and transient WRF. Thus, we sought to investigate the different prognostic impact of persistent vs. transient WRF; we also evaluate the relation of two WRF phenotypes with congestion, B-type natriuretic peptide (BNP) changes, and diuretic response at discharge. The prospective was a single centre study including patients screened for interventional Diur-heart failure Trial (NCT01441245). Patients were eligible if they were admitted with a primary diagnosis of acute heart failure with evidence of volume overload. Persistent WRF was defined as a sustained creatinine increase by at least 0.3 mg/dl throughout the hospitalisation; transient WRF was defined as creatinine increase by at least 0.3 mg/dl within 72 h and a return to baseline levels at discharge. Patients were followed for 6 months after discharge. Our population included 192 acute decompensated heart failure patients. In total, 61 patients developed persistent WRF and 29 developed transient WRF. Patients with persistent WRF showed a lower mean urine output with respect to the transient WRF group and patients with preserved renal function (1618 ± 374 vs. 2132 ± 392 vs. 2075 ± 442 ml; P < 0.001). Similarly, patients with transient WRF demonstrated a higher rate of BNP decrease more than 30% than seen in patients with stable creatinine levels and in the persistent WRF group (95 vs. 76 vs. 54%; P = 0.001). Univariate Cox regression analysis demonstrated that BNP decrease less than 30% [HR 2.15 (1.40-3.40); P < 0.001] and persistent WRF [HR 1.70 (1.11-2.61); P = 0.01] were related to poor outcome; conversely, transient WRF should be considered as a protective factor [HR 0.42 (0.19-0.93); P = 0.03]. In the multivariable model, only persistent WRF appeared to be related to poor prognosis [HR 1.61 (1.02-2.57); P = 0.04]. WRF occurring during hospitalization has a different significance: transient deterioration appears to be associated with a favourable clinical course; conversely, persistent WRF is related to poor outcome.

Lidar monitoring of regions of intense backscatter with poorly defined boundaries

Treesearch

Vladimir A. Kovalev; Alexander Petkov; Cyle Wold; WeiMin Hao

2011-01-01

The upper height of a region of intense backscatter with a poorly defined boundary between this region and a region of clear air above it is found as the maximal height where aerosol heterogeneity is detectable, that is, where it can be discriminated from noise. The theoretical basis behind the retrieval technique and the corresponding lidar-data-processing procedures...

Money, kisses, and electric shocks: on the affective psychology of risk.

PubMed

Rottenstreich, Y; Hsee, C K

2001-05-01

Prospect theory's S-shaped weighting function is often said to reflect the psychophysics of chance. We propose an affective rather than psychophysical deconstruction of the weighting function resting on two assumptions. First, preferences depend on the affective reactions associated with potential outcomes of a risky choice. Second, even with monetary values controlled, some outcomes are relatively affect-rich and others relatively affect-poor. Although the psychophysical and affective approaches are complementary, the affective approach has one novel implication: Weighting functions will be more S-shaped for lotteries involving affect-rich than affect-poor outcomes. That is, people will be more sensitive to departures from impossibility and certainty but less sensitive to intermediate probability variations for affect-rich outcomes. We corroborated this prediction by observing probability-outcome interactions: An affect-poor prize was preferred over an affect-rich prize under certainty, but the direction of preference reversed under low probability. We suggest that the assumption of probability-outcome independence, adopted by both expected-utility and prospect theory, may hold across outcomes of different monetary values, but not different affective values.

Effects of decompressive craniectomy on functional outcomes and death in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

PubMed

Alotaibi, Naif M; Elkarim, Ghassan Awad; Samuel, Nardin; Ayling, Oliver G S; Guha, Daipayan; Fallah, Aria; Aldakkan, Abdulrahman; Jaja, Blessing N R; de Oliveira Manoel, Airton Leonardo; Ibrahim, George M; Macdonald, R Loch

2017-12-01

OBJECTIVE Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) (World Federation of Neurosurgical Societies Grade IV or V) are often considered for decompressive craniectomy (DC) as a rescue therapy for refractory intracranial hypertension. The authors performed a systematic review and meta-analysis to assess the impact of DC on functional outcome and death in patients after poor-grade aSAH. METHODS A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were identified through the Ovid Medline, Embase, Web of Science, and Cochrane Library databases from inception to October 2015. Only studies dedicated to patients with poor-grade aSAH were included. Primary outcomes were death and functional outcome assessed at any time period. Patients were grouped as having a favorable outcome (modified Rankin Scale [mRS] Scores 1-3, Glasgow Outcome Scale [GOS] Scores 4 and 5, extended Glasgow Outcome Scale [GOSE] Scores 5-8) or unfavorable outcome (mRS Scores 4-6, GOS Scores 1-3, GOSE Scores 1-4). Pooled estimates of event rates and odds ratios with 95% confidence intervals were calculated using the random-effects model. RESULTS Fifteen studies encompassing 407 patients were included in the meta-analysis (all observational cohorts). The pooled event rate for poor outcome across all studies was 61.2% (95% CI 52%-69%) and for death was 27.8% (95% CI 21%-35%) at a median of 12 months after aSAH. Primary (or early) DC resulted in a lower overall event rate for unfavorable outcome than secondary (or delayed) DC (47.5% [95% CI 31%-64%] vs 74.4% [95% CI 43%-91%], respectively). Among studies with comparison groups, there was a trend toward a reduced mortality rate 1-3 months after discharge among patients who did not undergo DC (OR 0.58 [95% CI 0.27-1.25]; p = 0.168). However, this trend was not sustained at the 1-year follow-up (OR 1.09 [95% CI 0.55-2.13]; p = 0.79). CONCLUSIONS Results of this study summarize the best evidence available in the literature for DC in patients with poor-grade aSAH. DC is associated with high rates of unfavorable outcome and death. Because of the lack of robust control groups in a majority of the studies, the effect of DC on functional outcomes versus that of other interventions for refractory intracranial hypertension is still unknown. A randomized trial is needed.

Severe traumatic head injury: prognostic value of brain stem injuries detected at MRI.

PubMed

Hilario, A; Ramos, A; Millan, J M; Salvador, E; Gomez, P A; Cicuendez, M; Diez-Lobato, R; Lagares, A

2012-11-01

Traumatic brain injuries represent an important cause of death for young people. The main objectives of this work are to correlate brain stem injuries detected at MR imaging with outcome at 6 months in patients with severe TBI, and to determine which MR imaging findings could be related to a worse prognosis. One hundred and eight patients with severe TBI were studied by MR imaging in the first 30 days after trauma. Brain stem injury was categorized as anterior or posterior, hemorrhagic or nonhemorrhagic, and unilateral or bilateral. Outcome measures were GOSE and Barthel Index 6 months postinjury. The relationship between MR imaging findings of brain stem injuries, outcome, and disability was explored by univariate analysis. Prognostic capability of MR imaging findings was also explored by calculation of sensitivity, specificity, and area under the ROC curve for poor and good outcome. Brain stem lesions were detected in 51 patients, of whom 66% showed a poor outcome, as expressed by the GOSE scale. Bilateral involvement was strongly associated with poor outcome (P < .05). Posterior location showed the best discriminatory capability in terms of outcome (OR 6.8, P < .05) and disability (OR 4.8, P < .01). The addition of nonhemorrhagic and anterior lesions or unilateral injuries showed the highest odds and best discriminatory capacity for good outcome. The prognosis worsens in direct relationship to the extent of traumatic injury. Posterior and bilateral brain stem injuries detected at MR imaging are poor prognostic signs. Nonhemorrhagic injuries showed the highest positive predictive value for good outcome.

Analysis of the association of fluid balance and short-term outcome in traumatic brain injury.

PubMed

Zhao, Zilong; Wang, Dong; Jia, Ying; Tian, Ye; Wang, Yi; Wei, Yingsheng; Zhang, Jianning; Jiang, Rongcai

2016-05-15

A balance of fluid intake and output (fluid balance) influences outcomes of critical illness, but the level of such influence remains poorly understood for traumatic brain injury (TBI) and was quantitatively examined in this study. We conducted a retrospective cohort study of 351 moderate and severe TBI patients to associate the degree of fluid balance with clinical outcomes of TBI. Fluid balance and intracranial pressure (ICP) were continuously recorded for 7days on patients admitted to neurocritical care unit (NCCU). The short-term outcome was dichotomized into improvement and deterioration groups based on changes in Glasgow Coma Scale (GCS) measured between admission and 30days after admission. Fluid balance was calculated as: Fluid intake (mL) - fluid outputs (mL)/day×5 and used to group patients in tertiles to study its effect on TBI outcome. Patients at the low (<637mL) and upper (>3673mL) tertiles of fluid balance were associated with poor outcomes. Those in the upper tertile also had a higher incidence of acute kidney injury (AKI) and refractory intracranial hypertension (RIH). There was a negative correlation between the cumulative fluid balance and the short-term outcome for patients in the low tertile and a positive correlation between the cumulative fluid balance and the short-term outcome in the upper fluid balance group. Levels of fluid balance were also associated with serum creatinine (Cr, r=0.451, P<0.0001) and days in NCCU (r=0.188, P=0.001). More patients in the upper tertile had ICP higher than 20mmHg (P=0.009). A fluid balance in the upper tertile is an independent predictor of poor 30-day clinical outcomes after the adjustment for confounding variables in a multivariable logistic regression model. We found that fluid balance in low and upper tertiles were associated with poor short-term outcomes and ICP variations. Fluid balance in the upper tertile may be an independent predictor for poor 30-day outcome, primarily due to high AKI and RIH. Copyright © 2016. Published by Elsevier B.V.

Pharmacist-led discharge medication counselling: A scoping review.

PubMed

Bonetti, Aline F; Reis, Wálleri C; Lombardi, Natália Fracaro; Mendes, Antonio M; Netto, Harli Pasquini; Rotta, Inajara; Fernandez-Llimos, Fernando; Pontarolo, Roberto

2018-06-01

Discharge medication counselling has produced improved quality of care and health outcomes, especially by reducing medication errors and readmission rates, and improving medication adherence. However, no studies have assembled an evidence-based discharge counselling process for clinical pharmacists. Thus, the present study aims to map the components of the pharmacist-led discharge medication counselling process. We performed a scoping review by searching electronic databases (Pubmed, Scopus, and DOAJ) and conducting a manual search to identify studies published up to July 2017. Studies that addressed pharmacist-led discharge medication counselling, regardless of the population, clinical conditions, and outcomes evaluated, were included. A total of 1563 studies were retrieved, with 75 matching the inclusion criteria. Thirty-two different components were identified, and the most prevalent were the indication of the medications and adverse drug reactions, which were reported in more than 50% of the studies. The components were reported similarly by studies from the USA and the rest of the world, and over the years. However, 2 differences were identified: the use of a dosage schedule, which was more frequent in studies published in 2011 or before and in studies outside the USA; and the teach-back technique, which was used more frequently in the USA. Poor quality reporting was also observed, especially regarding the duration of the counselling, the number of patients, and the medical condition. Mapping the components of the pharmacist-led discharge counselling studies through a scoping review allowed us to reveal how this service is performed around the world. Wide variability in this process and poor reporting were identified. Future studies are needed to define the core outcome set of this clinical pharmacy service to allow the generation of robust evidence and reproducibility in clinical practice. © 2018 John Wiley & Sons, Ltd.

The natural history of Perthes' disease

PubMed Central

2010-01-01

Background The prognosis in Perthes' disease varies considerably according to certain risk factors, but there is no concensus regarding the relative importance of these factors. We assessed the natural history of the disease and defined prognostic factors of value in deciding the proper treatment. Patients and methods During the 5-year period 1996–2000, a nationwide study on Perthes' disease was performed in Norway. 425 patients were registered. The present study involved the 212 children (mean age 5.1 years, 77% boys) who were affected unilaterally and who had been treated with physiotherapy only (which is considered not to change the natural history). They were followed by taking radiographs at the time of diagnosis and after 1, 3, and 5 years. At the 5-year follow-up, the outcome was evaluated according to a modification of the Stulberg classification: good (spherical femoral head), fair (ovoid femoral head), and poor (flat femoral head). Results The 5-year radiographic results were strongly dependent on 4 risk factors: age 6 years or more at diagnosis, total femoral head necrosis, height of the lateral pillar of the epiphysis less than 50% of normal height, and femoral head cover less than 80%. As the number of risk factors increased from 0 to 4, the proportion of patients with good radiographic 5-year outcome decreased from 79% to 0% and the proportion with poor outcome increased from 3% to 91%. Interpretation Most children under 6 years of age do not need any special treatment. In older children, no special treatment is indicated if the whole femoral head is not necrotic and the femoral head cover is > 80%. In the most severe forms of the disease (i.e. more than 2 risk factors), surgical containment treatment seems advisable. PMID:21067434

The natural history of Perthes' disease.

PubMed

Terjesen, Terje; Wiig, Ola; Svenningsen, Svein

2010-12-01

The prognosis in Perthes' disease varies considerably according to certain risk factors, but there is no concensus regarding the relative importance of these factors. We assessed the natural history of the disease and defined prognostic factors of value in deciding the proper treatment. During the 5-year period 1996-2000, a nationwide study on Perthes' disease was performed in Norway. 425 patients were registered. The present study involved the 212 children (mean age 5.1 years, 77% boys) who were affected unilaterally and who had been treated with physiotherapy only (which is considered not to change the natural history). They were followed by taking radiographs at the time of diagnosis and after 1, 3, and 5 years. At the 5-year follow-up, the outcome was evaluated according to a modification of the Stulberg classification: good (spherical femoral head), fair (ovoid femoral head), and poor (flat femoral head). The 5-year radiographic results were strongly dependent on 4 risk factors: age 6 years or more at diagnosis, total femoral head necrosis, height of the lateral pillar of the epiphysis less than 50% of normal height, and femoral head cover less than 80%. As the number of risk factors increased from 0 to 4, the proportion of patients with good radiographic 5-year outcome decreased from 79% to 0% and the proportion with poor outcome increased from 3% to 91%. Most children under 6 years of age do not need any special treatment. In older children, no special treatment is indicated if the whole femoral head is not necrotic and the femoral head cover is > 80%. In the most severe forms of the disease (i.e. more than 2 risk factors), surgical containment treatment seems advisable.

Surgical patient selection and counseling.

PubMed

Ziegelmann, Matt; Köhler, Tobias S; Bailey, George C; Miest, Tanner; Alom, Manaf; Trost, Landon

2017-08-01

The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of credibility, or even significant patient or personal harm.

Daily Laboratory Monitoring is of Poor Health Care Value in Adolescents Acutely Hospitalized for Eating Disorders.

PubMed

Ridout, Kathryn K; Kole, Jonathan; Fitzgerald, Kelly L; Ridout, Samuel J; Donaldson, Abigail A; Alverson, Brian

2016-07-01

This study investigates how the clinical practice guideline-recommended laboratory monitoring for refeeding syndrome impacts management and outcomes of adolescents with eating disorders hospitalized for acute medical stabilization and examines the value of laboratory monitoring (defined as the patient health outcomes achieved per dollar spent). A retrospective chart review of medical admissions in a children's hospital between October 2010 and February 2014 was performed. Encounters were identified using International Classification of Diseases, Ninth Revision codes of eating disorders as primary or secondary diagnoses. Exclusion criteria included systemic diseases associated with significant electrolyte abnormalities. Chart abstraction was performed using a predetermined form. Costs were estimated by converting hospital-fixed Medicaid charges using a statewide cost-to-charge ratio. Of the 196 patient encounters, there were no cases of refeeding syndrome. A total of 3,960 key recommended laboratories were obtained; 1.9% were below normal range and .05% were critical values. Of these, .28% resulted in supplementation; none were associated with a change in inpatient management. Total laboratory costs were $269,250.85; the calculated health care value of this monitoring is 1.04 × 10(-8) differential outcomes per dollar spent. This study provides evidence to suggest that daily laboratory monitoring for refeeding syndrome is a poor health care value in the management of adolescents hospitalized for acute medical stabilization with eating disorders. This initial analysis suggests that starting at a relatively low caloric level and advancing nutrition slowly may negate the need for daily laboratory assessment, which may have important implications for current guidelines. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Systematic Review and Meta-Analysis of Objective and Subjective Quality of Life among Pediatric, Adolescent, and Young Adult Bone Tumor Survivors

PubMed Central

Stokke, Jamie; Sung, Lillian; Gupta, Abha; Lindberg, Antoinette; Rosenberg, Abby R.

2015-01-01

Background Pediatric, adolescent and young adult (AYA) survivors of bone sarcomas are at risk for poor quality of life (QOL). We conducted a systematic review and meta-analysis to summarize the literature describing QOL in this population and differences in QOL based on local control procedures. Procedure Included studies described ≥5 patients <25 years-old who had completed local control treatment for bone sarcoma, defined QOL as a main outcome, and measured it with a validated instrument. Data extraction and quality assessments were conducted with standardized tools. Meta-analyses compared QOL based on surgical procedure (limb-sparing versus amputation) and were stratified by assessment type (objective physical function, clinician-assessed disability, patient-reported disability and patient-reported QOL). Effect sizes were reported as the Standard Mean Difference when multiple instruments were used within a comparison and Weighted Mean Difference otherwise. All were weighted by inverse variance and modeled with random effects. Results Twenty-two of 452 unique manuscripts were included in qualitative syntheses, 8 of which were included in meta-analyses. Manuscripts were heterogeneous with respect to included patient populations (age, tumor type, time since treatment) and QOL instruments. Prospective studies suggested that QOL improves over time, and that female sex and older age at diagnosis are associated with poor QOL. Meta-analyses showed no differences in outcomes between patients who underwent limb-sparing versus amputation for local control. Conclusion QOL studies among children and AYAs with bone sarcoma are remarkably diverse, making it difficult to detect trends in patient outcomes. Future research should focus on standardized QOL instruments and interpretations. PMID:25820683

Neuropsychological profiles and outcomes in children with new onset frontal lobe epilepsy.

PubMed

Matricardi, Sara; Deleo, Francesco; Ragona, Francesca; Rinaldi, Victoria Elisa; Pelliccia, Sarah; Coppola, Giangennaro; Verrotti, Alberto

2016-02-01

Frontal lobe epilepsy (FLE) is the second most frequent type of localization-related epilepsy, and it may impact neurocognitive functioning with high variability. The prevalence of neurocognitive impairment in affected children remains poorly defined. This report outlines the neuropsychological profiles and outcomes in children with new onset FLE, and the impact of epilepsy-related factors, such as seizure frequency and antiepileptic drug (AED) load, on the neurocognitive development. Twenty-three consecutive children (15 males and 8 females) with newly diagnosed cryptogenic FLE were enrolled; median age at epilepsy onset was 7 years (6-9.6 years). They underwent clinical and laboratory evaluation and neuropsychological assessment before starting AED treatment (time 0) and after one year of treatment (time 1). Twenty age-matched patients affected by idiopathic generalized epilepsy (10 male and 10 females) and eighteen age-matched healthy subjects (9 males and 9 females) were enrolled as controls and underwent the same assessment. All patients with FLE showed a significant difference in almost all assessed cognitive domains compared with controls, mainly in frontal functions and memory. At time 1, patients were divided into two groups according to epilepsy-related factors: group 1 (9 patients) with persisting seizures despite AED polytherapy, and group 2 (14 patients) with good seizure control in monotherapy. A significant difference was highlighted in almost all subtests in group 1 compared with group 2, both at time 0 and at time 1. In children with FLE showing a broad range of neurocognitive impairments, the epilepsy-related factors mostly related to a worse neurocognitive outcome are poor seizure control and the use of AED polytherapy, suggesting that epileptic discharges may have a negative impact on the functioning of the involved cerebral regions. Copyright © 2015 Elsevier Inc. All rights reserved.

Surgical patient selection and counseling

PubMed Central

Ziegelmann, Matt; Köhler, Tobias S.; Bailey, George C.; Miest, Tanner; Alom, Manaf

2017-01-01

The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of credibility, or even significant patient or personal harm. PMID:28904893

Long-term outcome and prognostic factors after C2 ganglion decompression in 68 consecutive patients with intractable occipital neuralgia.

PubMed

Choi, Kyu-Sun; Ko, Yong; Kim, Young-Soo; Yi, Hyeong-Joong

2015-01-01

Occipital neuralgia is a rare cause of severe headache characterized by paroxysmal shooting or stabbing pain in the distribution of the greater occipital or lesser occipital nerve. In cases of intractable occipital neuralgia, a definite cause has not been uncovered, so various types of treatment have been applied. The aim of this study is to evaluate the prognostic factors, safety, and long-term clinical efficacy of second cervical (C2) ganglion decompression for intractable occipital neuralgia. Retrospective analysis was performed in 68 patients with medically refractory occipital neuralgia who underwent C2 ganglion decompression. Factors based on patients' demography, pre- and postoperative headache severity/characteristics, medication use, and postoperative complications were investigated. Therapeutic success was defined as pain relief by at least 50 % without ongoing medication. The visual analog scale (VAS) score was significantly reduced between the preoperative and most recent follow-up period. One year later, excellent or good results were achieved in 57 patients (83.9 %), but poor in 11 patients (16.1 %). The long-term outcome after 5 years was only slightly less than the 1-year outcome; 47 of the 68 patients (69.1 %) obtained therapeutic success. Longer duration of headache (over 13 years; p = 0.029) and presence of retro-orbital/frontal radiation (p = 0.040) were significantly associated with poor prognosis. In the current study, C2 ganglion decompression provided durable, adequate pain relief with minimal complications in patients suffering from intractable occipital neuralgia. Due to the minimally invasive and nondestructive nature of this surgical procedure, C2 ganglion decompression is recommended as an initial surgical treatment option for intractable occipital neuralgia before attempting occipital nerve stimulation. However, further study is required to manage the pain recurrence associated with longstanding nerve injury.

Are food insecurity's health impacts underestimated in the U.S. population? Marginal food security also predicts adverse health outcomes in young U.S. children and mothers.

PubMed

Cook, John T; Black, Maureen; Chilton, Mariana; Cutts, Diana; Ettinger de Cuba, Stephanie; Heeren, Timothy C; Rose-Jacobs, Ruth; Sandel, Megan; Casey, Patrick H; Coleman, Sharon; Weiss, Ingrid; Frank, Deborah A

2013-01-01

This review addresses epidemiological, public health, and social policy implications of categorizing young children and their adult female caregivers in the United States as food secure when they live in households with "marginal food security," as indicated by the U.S. Household Food Security Survey Module. Existing literature shows that households in the US with marginal food security are more like food-insecure households than food-secure households. Similarities include socio-demographic characteristics, psychosocial profiles, and patterns of disease and health risk. Building on existing knowledge, we present new research on associations of marginal food security with health and developmental risks in young children (<48 mo) and health in their female caregivers. Marginal food security is positively associated with adverse health outcomes compared with food security, but the strength of the associations is weaker than that for food insecurity as usually defined in the US. Nonoverlapping CIs, when comparing odds of marginally food-secure children's fair/poor health and developmental risk and caregivers' depressive symptoms and fair/poor health with those in food-secure and -insecure families, indicate associations of marginal food security significantly and distinctly intermediate between those of food security and food insecurity. Evidence from reviewed research and the new research presented indicates that households with marginal food security should not be classified as food secure, as is the current practice, but should be reported in a separate discrete category. These findings highlight the potential underestimation of the prevalence of adverse health outcomes associated with exposure to lack of enough food for an active, healthy life in the US and indicate an even greater need for preventive action and policies to limit and reduce exposure among children and mothers.

Poverty and health sector inequalities.

PubMed Central

Wagstaff, Adam

2002-01-01

Poverty and ill-health are intertwined. Poor countries tend to have worse health outcomes than better-off countries. Within countries, poor people have worse health outcomes than better-off people. This association reflects causality running in both directions: poverty breeds ill-health, and ill-health keeps poor people poor. The evidence on inequalities in health between the poor and non-poor and on the consequences for impoverishment and income inequality associated with health care expenses is discussed in this article. An outline is given of what is known about the causes of inequalities and about the effectiveness of policies intended to combat them. It is argued that too little is known about the impacts of such policies, notwithstanding a wealth of measurement techniques and considerable evidence on the extent and causes of inequalities. PMID:11953787

Blend sign predicts poor outcome in patients with intracerebral hemorrhage.

PubMed

Li, Qi; Yang, Wen-Song; Wang, Xing-Chen; Cao, Du; Zhu, Dan; Lv, Fa-Jin; Liu, Yang; Yuan, Liang; Zhang, Gang; Xiong, Xin; Li, Rui; Hu, Yun-Xin; Qin, Xin-Yue; Xie, Peng

2017-01-01

Blend sign has been recently described as a novel imaging marker that predicts hematoma expansion. The purpose of our study was to investigate the prognostic value of CT blend sign in patients with ICH. Patients with intracerebral hemorrhage who underwent baseline CT scan within 6 hours were included. The presence of blend sign on admission nonenhanced CT was independently assessed by two readers. The functional outcome was assessed by using the modified Rankin Scale (mRS) at 90 days. Blend sign was identified in 40 of 238 (16.8%) patients on admission CT scan. The proportion of patients with a poor functional outcome was significantly higher in patients with blend sign than those without blend sign (75.0% versus 47.5%, P = 0.001). The multivariate logistic regression analysis demonstrated that age, intraventricular hemorrhage, admission GCS score, baseline hematoma volume and presence of blend sign on baseline CT independently predict poor functional outcome at 90 days. The CT blend sign independently predicts poor outcome in patients with ICH (odds ratio 3.61, 95% confidence interval [1.47-8.89];p = 0.005). Early identification of blend sign is useful in prognostic stratification and may serve as a potential therapeutic target for prospective interventional studies.

The Burden of Surgical Diseases on Critical Care Services at a Tertiary Referral Hospital in Sub-Saharan Africa

PubMed Central

Tomlinson, Jared; Haac, Bryce; Kadyaudzu, Clement; Samuel, Jonathan C; Campbell, Emilia LP; Lee, Clara; Charles, Anthony G

2013-01-01

In many developing countries including those of sub-Saharan Africa care of the critically ill is poorly developed. We therefore sought to elucidate the characteristics and outcomes of critically ill patients to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographic, patient characteristics, clinical specialty and outcome data was collected. There were 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynecologic patients. Use of the ventilator and transfusions were not associated with increased mortality. Head injured patients had the highest mortality rate among all diagnoses. Rationing of critical care resources using admitting diagnosis or scoring tools can maximize access to critical care services in resource-limited settings. Furthermore, improvements on critical care services will be central to future efforts at reducing surgical morbidity and mortality and improving outcomes in all critically ill patients. PMID:23492923

Selective activation of cannabinoid receptor-2 reduces neuroinflammation after traumatic brain injury via alternative macrophage polarization.

PubMed

Braun, Molly; Khan, Zenab T; Khan, Mohammad B; Kumar, Manish; Ward, Ayobami; Achyut, Bhagelu R; Arbab, Ali S; Hess, David C; Hoda, Md Nasrul; Baban, Babak; Dhandapani, Krishnan M; Vaibhav, Kumar

2018-02-01

Inflammation is an important mediator of secondary neurological injury after traumatic brain injury (TBI). Endocannabinoids, endogenously produced arachidonate based lipids, have recently emerged as powerful anti-inflammatory compounds, yet the molecular and cellular mechanisms underlying these effects are poorly defined. Endocannabinoids are physiological ligands for two known cannabinoid receptors, CB1R and CB2R. In the present study, we hypothesized that selective activation of CB2R attenuates neuroinflammation and reduces neurovascular injury after TBI. Using a murine controlled cortical impact (CCI) model of TBI, we observed a dramatic upregulation of CB2R within infiltrating myeloid cells beginning at 72 h. Administration of the selective CB2R agonist, GP1a (1-5 mg/kg), attenuated pro-inflammatory M1 macrophage polarization, increased anti-inflammatory M2 polarization, reduced edema development, enhanced cerebral blood flow, and improved neurobehavioral outcomes after TBI. In contrast, the CB2R antagonist, AM630, worsened outcomes. Taken together, our findings support the development of selective CB2R agonists as a therapeutic strategy to improve TBI outcomes while avoiding the psychoactive effects of CB1R activation. Published by Elsevier Inc.

Does Histologic Subtype Influence the Post-Operative Outcome in Spinal Meningioma?

PubMed

Zham, Hanieh; Moradi, Afshin; Rakhshan, Azadeh; Zali, Alireza; Rahbari, Ali; Raee, Mohammadreza; Ashrafi, Farzad; Ahadi, Mahsa; Larijani, Leila; Baikpour, Masoud; Khayamzadeh, Maryam

2016-04-01

Postoperative outcome of spinal meningiomas is an important issue in surgery decision-making. There are limited and conflicting data in the literature about the prognostic factors influencing recovery, especially about the histopathologic subtypes. This study was carried out to evaluate the effect of some of these factors on postoperative outcome. This study was performed on 39 patients operated for spinal meningioma between October 1998 and January 2012; their histopathologic subtype was determined according to WHO criteria. The follow up period ranged between 8 - 120 months. The influence of histopathologic subtype, grade, age, sex, surgical approach, local adhesion and anatomical location was assessed according to Frankel classification of neurologic deficit. From a total number of 39 spinal meningiomas, 34 cases were WHO grade I, from which 15 cases were psammomatous, 7 cases were meningothelial, 9 cases were transitional and 3 cases were fibroblastic. Five cases were grade II, 3 of which had clear cell appearance and the remaining 2 had chordoid appearance. The mean age was 51.6 (22 to 76) years; 25 cases were female and 14 cases were male. This study revealed that grade II meningioma cases had poor prognosis in all 5 cases and psammomatous subtype had poor postoperative outcome in 40% of cases while the other subtypes had good outcome in all cases (P = 0.026). Cervical location of the tumor was also related with poor outcome in 37.5% of the cases, while 22.5% had poor outcome in other locations (P = 0.029). Age below and above 45 years and sex had no significant influence on the outcome. Spinal meningiomas of psammomatous type and grade II spinal meningiomas are associated with less favorable postoperative neurologic outcome. Cervical location has also a negative correlation with a good outcome.

Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial.

PubMed

Rebbeck, Trudy; Leaver, Andrew; Bandong, Aila Nica; Kenardy, Justin; Refshauge, Kathryn; Connelly, Luke; Cameron, Ian; Mitchell, Geoffrey; Willcock, Simon; Ritchie, Carrie; Jagnoor, Jagnoor; Sterling, Michele

2016-04-01

Whiplash-associated disorders (WAD) are a huge worldwide health and economic burden. The propensity towards developing into chronic, disabling conditions drives the rise in health and economic costs associated with treatment, productivity loss and compulsory third party insurance claims. Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes. A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective. (1) Does a guideline-based clinical pathway of care improve health outcomes after whiplash injury compared to usual care? (2) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care? (3) Is the clinical pathway of care intervention cost-effective? (4) What are the variations in professional practice between usual care and the clinical pathway of care? Multi-centre, randomised, controlled trial conducted over two Australian states: Queensland and New South Wales. 236 people with WAD (grade I-III, within 6 weeks of injury) and their primary healthcare providers. A clinical pathway of care, with care matched to the predicted risk of poor recovery. Participants at low risk of ongoing pain and disability (hence, predicted to fully recover) will receive up to three sessions of guideline-based advice and exercise with their primary healthcare provider. Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist (defined as a practitioner with expertise in whiplash) who will conduct a more in-depth physical and psychological assessment. As a result, the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care. Usual care provided by the primary healthcare provider that is based on clinical judgment. Primary (global rating of change and neck-related disability) and secondary (self-efficacy, pain intensity, general health and disability and psychological health) outcomes will be collected using validated scales. Direct (eg, professional care, transportation costs, time spent for care, co-payments) and indirect (eg, lost economic productivity) costs will be obtained through an electronic cost diary. Health and cost outcomes will be assessed at baseline, 3, 6 and 12 months after randomisation. Professional practice outcomes will be evaluated through questionnaires completed by healthcare providers and their patients at 3 months. Potential participants (patients) will be identified through emergency departments, primary health clinics and advertisements. Eligible participants will complete baseline assessments and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule. After this assessment, participants will be randomly allocated to either a control group (n=118) or intervention group (n=118), stratified by risk subgroup and treatment site. The participants' nominated primary healthcare providers will be informed of their involvement in the trial. Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice. Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category. Analysis will be conducted on an intention-to-treat basis. Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods, with an appropriate link function, to test for an intervention effect, adjusted for the baseline values. The risk category will be tested for its association with treatment effect by adding risk group to the regression equation. Cost-effectiveness will be calculated using utility weights and the resulting measure will be cost per quality-adjusted life year (QALY) saved. Professional practice outcomes will be analysed using descriptive statistics. This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence-based interventions to projected risk of poor recovery. The results of this trial have the potential to change clinical practice for WAD, thereby maximising treatment effects, improving patient outcomes, reducing costs and maintaining the compulsory third party system. Copyright © 2016. Published by Elsevier B.V.

Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan.

PubMed

Älgå, Andreas; Wong, Sidney; Shoaib, Muhammad; Lundgren, Kalle; Giske, Christian G; von Schreeb, Johan; Malmstedt, Jonas

2018-05-22

Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014-2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42-4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. ClinicalTrials.gov ( NCT02744144 ). Registered April 13, 2016. Retrospectively registered.

Defining success in diabetes disease management: digging deeper in the data.

PubMed

Bray, Karen; Turpin, Robin S; Jungkind, Kim; Heuser, George

2008-04-01

We evaluated the effectiveness of a diabetes life coach program designed to address the concerns of limited coordination and collaboration of care for chronically ill patients in the physician office. The program emphasized lipid, blood pressure, and glycemic control, using personal coaching, group classes, reminders, and customized feedback. The target population was all health plan members over age 18 with type 1 or 2 diabetes mellitus in 6 primary care practice sites in the Hampton Roads area of Virginia. Primary outcomes were 1 Health Plan Employer Data and Information Set measure (A1c poor control of >9% or no test), 3 American Diabetes Association (ADA) measures (A1c <7%, blood pressure of <130/80 mmHg, low-density lipoprotein cholesterol [LDL-C] of <100 mg/dL), 1 pharmacy measure (percentage of patients filling at least 1 insulin prescription), and 2 self-reported behavioral measures (percentage adherent to a meal plan and percentage adherent to an activity plan). We assessed overall program outcomes and differences between individual physician practices and evaluated outcomes separately for engaged compared with non-engaged program participants. Outcomes for 1117 participants were evaluated. Statistically significant improvement at P < 0.05 was noted in all 7 targeted measures compared with baseline. Participants who were engaged in the life coach program were 40% less likely to experience poor control of their A1c, 50% more likely to meet the ADA A1c goal of < 7%, 11% more likely to meet their blood pressure goal of <130/80 mmHg, and 7% more likely to meet their LDL-C goal of <100 mg/dL compared with those not engaged. Patients who became engaged in the program performed significantly better in the key diabetes indicators that ultimately lead to reductions in the complications of the disease over time. Our study contributes to the evidence that clinical multidisciplinary, collaborative models of care can influence and improve the management of diabetes.

Traumatic brain injury (TBI) outcomes in an LMIC tertiary care centre and performance of trauma scores.

PubMed

Samanamalee, Samitha; Sigera, Ponsuge Chathurani; De Silva, Ambepitiyawaduge Pubudu; Thilakasiri, Kaushila; Rashan, Aasiyah; Wadanambi, Saman; Jayasinghe, Kosala Saroj Amarasiri; Dondorp, Arjen M; Haniffa, Rashan

2018-01-08

This study evaluates post-ICU outcomes of patients admitted with moderate and severe Traumatic Brain Injury (TBI) in a tertiary neurocritical care unit in an low middle income country and the performance of trauma scores: A Severity Characterization of Trauma, Trauma and Injury Severity Score, Injury Severity Score and Revised Trauma Score in this setting. Adult patients directly admitted to the neurosurgical intensive care units of the National Hospital of Sri Lanka between 21st July 2014 and 1st October 2014 with moderate or severe TBI were recruited. A telephone administered questionnaire based on the Glasgow Outcome Scale Extended (GOSE) was used to assess functional outcome of patients at 3 and 6 months after injury. The economic impact of the injury was assessed before injury, and at 3 and 6 months after injury. One hundred and one patients were included in the study. Survival at ICU discharge, 3 and 6 months after injury was 68.3%, 49.5% and 45.5% respectively. Of the survivors at 3 months after injury, 43 (86%) were living at home. Only 19 (38%) patients had a good recovery (as defined by GOSE 7 and 8). Three months and six months after injury, respectively 25 (50%) and 14 (30.4%) patients had become "economically dependent". Selected trauma scores had poor discriminatory ability in predicting mortality. This observational study of patients sustaining moderate or severe TBI in Sri Lanka (a LMIC) reveals only 46% of patients were alive at 6 months after ICU discharge and only 20% overall attained a good (GOSE 7 or 8) recovery. The social and economic consequences of TBI were long lasting in this setting. Injury Severity Score, Revised Trauma Score, A Severity Characterization of Trauma and Trauma and Injury Severity Score, all performed poorly in predicting mortality in this setting and illustrate the need for setting adapted tools.

Mycotoxins are conventional and novel risk biomarkers for hepatocellular carcinoma

PubMed Central

Matsuda, Yasunobu; Wakai, Toshifumi; Kubota, Masayuki; Osawa, Mami; Sanpei, Ayumi; Fujimaki, Shun

2013-01-01

Hepatocellular carcinoma (HCC) is a common malignant disease with poor prognosis. To improve the clinical outcome, early diagnosis of HCC arising from nonviral agents and hepatitis virus is important. Among several etiological factors, mycotoxins defined as carcinogens by the International Agency for Research in Cancer might be one of the critical risk factors for nonviral HCC. Aflatoxin B1 is the most well-known carcinogenic mycotoxin for HCC, but the role of the other types of mycotoxin remains unclear. Several studies have reported that a chromatographic separation technique based on high-performance liquid chromatography can successfully detect the concentration of mycotoxins in plasma. In this article, we review recent studies of mycotoxin, and discuss its possible significance as a biomarker of HCC. PMID:23674865

Cancer stem cells in the development of liver cancer

PubMed Central

Yamashita, Taro; Wang, Xin Wei

2013-01-01

Liver cancer is an aggressive disease with a poor outcome. Several hepatic stem/progenitor markers are useful for isolating a subset of liver cells with stem cell features, known as cancer stem cells (CSCs). These cells are responsible for tumor relapse, metastasis, and chemoresistance. Liver CSCs dictate a hierarchical organization that is shared in both organogenesis and tumorigenesis. An increased understanding of the molecular signaling events that regulate cellular hierarchy and stemness, and success in defining key CSC-specific genes, have opened up new avenues to accelerate the development of novel diagnostic and treatment strategies. This Review highlights recent advances in understanding the pathogenesis of liver CSCs and discusses unanswered questions about the concept of liver CSCs. PMID:23635789

Early play may predict later dominance relationships in yellow-bellied marmots (Marmota flaviventris).

PubMed

Blumstein, Daniel T; Chung, Lawrance K; Smith, Jennifer E

2013-05-22

Play has been defined as apparently functionless behaviour, yet since play is costly, models of adaptive evolution predict that it should have some beneficial function (or functions) that outweigh its costs. We provide strong evidence for a long-standing, but poorly supported hypothesis: that early social play is practice for later dominance relationships. We calculated the relative dominance rank by observing the directional outcome of playful interactions in juvenile and yearling yellow-bellied marmots (Marmota flaviventris) and found that these rank relationships were correlated with later dominance ranks calculated from agonistic interactions, however, the strength of this relationship attenuated over time. While play may have multiple functions, one of them may be to establish later dominance relationships in a minimally costly way.

[Characteristics and outcome of acute ischemic stroke patients with atrial fibrillation].

PubMed

Li, Shenjun; Wang, Shucai; Gu, Mingming; Cao, Bingzhen

2015-11-17

To evaluate clinical characteristics and outcome of acute ischemic stroke patients with atrial fibrillation. Consecutive acute ischemic stroke patients who were hospitalized in the neurology department of General Hospital of Jinan Military Region were prospectively recruited from August 2010 to November 2013.The baseline datum including age, sex, National Institute of Health Stroke Scale (NIHSS), type of Oxfordshire Community Stroke Project (OCSP: total anterior circulation infarct, partial anterior circulation infarction, posterior circulation infarction and lacunar infarction), serum creatinine, serum albumin levels etc.were recorded.Atrial fibrillation (AF) was defined as a history of persistent atrial fibrillation or paroxysmal atrial fibrillation, supported by past electrocardiogram or diagnosed by the attending physicians based on physical examination, electrocardiogram and/or 24-hour electrocardiogram monitoring during hospitalization. Outcome was assessed by modified Rankin Scale (mRS) which was obtained 180 days after stroke by telephone interview (mRS ≤ 2 reflected good prognosis, and mRS>2 reflected unfavorable prognosis), and death defined as all-cause mortality. Multivariate regression model was used to analyze predictors of mortality and disability. Of the 965 patients included in this study, 113 (11.71%) had AF; valvular AF was observed in 11 patients (9.7%) among them.Only 4 patients with valvular AF and none of the patients with non-valvular AF took warfarin before the stroke event. 14.2% (16/113) acute ischemic stroke patients with AF took aspirin. Compared to patients without AF, patients with AF had a higher NIHSS score on admission (median 11 vs 5, P=0.000); were more often with diabetes (26.55% vs 9.74%, P=0.028), congestive heart failure (12.37% vs 11.03%, P=0.000), prior stroke (31.86% vs 21.83%, P=0.023), total anterior circulation infarct subtype (51.33% vs 19.37%, P=0.000); they were less often smokers (20.35% vs 37.32%, P=0.000), alcohol consumers (13.27% vs 27.58%, P=0.001), partial anterior circulation infarction subtype (24.78% vs 36.74%, P=0.012), lacunar infarct subtype (0 vs 17.61%, P=0.000); they had less often experienced myocardial infarction (11.50% vs 11.74%, P=0.041). AF was a significant independent prognostic factor for long-term poor outcomes (OR=2.227, 95%CI: 1.262-3.933, P=0.006). Oral anticoagulants are underused in AF patients.Brain infarction patients with AF is more severe than patients without AF; have higher frequency of total anterior circulation infarct subtype, prior stroke and lower frequency of lacunar infarct subtype. AF is a significant independent prognostic factor for long-term poor outcome in patients with acute brain infarction.

A tool to determine financial impact of adverse events in health care: healthcare quality calculator.

PubMed

Yarbrough, Wendell G; Sewell, Andrew; Tickle, Erin; Rhinehardt, Eric; Harkleroad, Rod; Bennett, Marc; Johnson, Deborah; Wen, Li; Pfeiffer, Matthew; Benegas, Manny; Morath, Julie

2014-12-01

Hospital leaders lack tools to determine the financial impact of poor patient outcomes and adverse events. To provide health-care leaders with decision support for investments to improve care, we created a tool, the Healthcare Quality Calculator (HQCal), which uses institution-specific financial data to calculate impact of poor patient outcomes or quality improvement on present and future margin. Excel and Web-based versions of the HQCal were based on a cohort study framework and created with modular components including major drivers of cost and reimbursement. The Healthcare Quality Calculator (HQCal) compares payment, cost, and profit/loss for patients with and without poor outcomes or quality issues. Cost and payment information for groups with and without quality issues are used by the HQCal to calculate profit or loss. Importantly, institution-specific payment and cost data are used to calculate financial impact and attributable cost associated with poor patient outcomes, adverse events, or quality issues. Because future cost and reimbursement changes can be forecast, the HQCal incorporates a forward-looking component. The flexibility of the HQCal was demonstrated using surgical site infections after abdominal surgery and postoperative surgical airway complications. The Healthcare Quality Calculator determines financial impact of poor patient outcomes and the benefit of initiatives to improve quality. The calculator can identify quality issues that would provide the largest financial benefit if improved; however, it cannot identify specific interventions. The calculator provides a tool to improve transparency regarding both short- and long-term financial consequences of funding, or failing to fund, initiatives to close gaps in quality or improve patient outcomes.

Identifying Children With Poor Cochlear Implantation Outcomes Using Massively Parallel Sequencing

PubMed Central

Wu, Chen-Chi; Lin, Yin-Hung; Liu, Tien-Chen; Lin, Kai-Nan; Yang, Wei-Shiung; Hsu, Chuan-Jen; Chen, Pei-Lung; Wu, Che-Ming

2015-01-01

Abstract Cochlear implantation is currently the treatment of choice for children with severe to profound hearing impairment. However, the outcomes with cochlear implants (CIs) vary significantly among recipients. The purpose of the present study is to identify the genetic determinants of poor CI outcomes. Twelve children with poor CI outcomes (the “cases”) and 30 “matched controls” with good CI outcomes were subjected to comprehensive genetic analyses using massively parallel sequencing, which targeted 129 known deafness genes. Audiological features, imaging findings, and auditory/speech performance with CIs were then correlated to the genetic diagnoses. We identified genetic variants which are associated with poor CI outcomes in 7 (58%) of the 12 cases; 4 cases had bi-allelic PCDH15 pathogenic mutations and 3 cases were homozygous for the DFNB59 p.G292R variant. Mutations in the WFS1, GJB3, ESRRB, LRTOMT, MYO3A, and POU3F4 genes were detected in 7 (23%) of the 30 matched controls. The allele frequencies of PCDH15 and DFNB59 variants were significantly higher in the cases than in the matched controls (both P < 0.001). In the 7 CI recipients with PCDH15 or DFNB59 variants, otoacoustic emissions were absent in both ears, and imaging findings were normal in all 7 implanted ears. PCDH15 or DFNB59 variants are associated with poor CI performance, yet children with PCDH15 or DFNB59 variants might show clinical features indistinguishable from those of other typical pediatric CI recipients. Accordingly, genetic examination is indicated in all CI candidates before operation. PMID:26166082

Divorce and Health: Current Trends and Future Directions

PubMed Central

Sbarra, David A.

2015-01-01

OBJECTIVE Social relationships play a vital role in health and wellbeing, and it follows that loss experiences can be highly stressful for some people. This paper reviews what is known about the association between marital separation, divorce and health outcomes. METHODS Key findings in the area of divorce and health are discussed, and the review outlines a series of specific questions for future research. In particular, the paper integrates research in social epidemiology with research in social psychophysiology. The former approach provides a broad-based estimate of the association between marital status and health outcomes, whereas the latter approach studies mechanisms of action and individual differences associated with increased risk for poor outcomes. RESULTS The experience of separation or divorce confers risk for poor health outcomes, including a 23% higher mortality rate. However, most people cope well and are resilient after their marriage or long-term relationship ends. Despite the fact that resilience is the most common response, a small percentage of people (approximately 10–15%) struggle quite substantially, and it appears that the overall elevated adverse health risks are driven by the poor functioning of this group. Several candidate mechanisms and novel (ambulatory) assessment techniques are discussed that may elucidate the poor outcomes among people who adapt poorly to separation. CONCLUSIONS To increase knowledge on the association between divorce and health, three primary areas require more research: (a) genetic and third variable explanations for divorce-related health outcomes; (b) better studies of objective social behavior following separation; and, (c) increased attention to interventions targeting high risk adults. PMID:25829240

Periodontal Disease and Pregnancy Outcomes

PubMed Central

Babalola, Dolapo A.; Omole, Folashade

2010-01-01

An increasing number of studies are confirming an association between periodontal disease (PD) and adverse outcomes in pregnancy. PD places pregnant women at greater risk for preterm birth than alcohol consumption or smoking. This underscores the importance of offering dental screening to women who are pregnant or contemplating pregnancy and the need for physicians who provide obstetric care to be aware of the possible connection between poor dental health and poor pregnancy outcomes. PMID:21490739

Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients.

PubMed

Kofler, Mario; Schiefecker, Alois J; Beer, Ronny; Gaasch, Maxime; Rhomberg, Paul; Stover, John; Pfausler, Bettina; Thomé, Claudius; Schmutzhard, Erich; Helbok, Raimund

2018-03-01

Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.

Variations and inter-relationship in outcome from emergency admissions in England: a retrospective analysis of Hospital Episode Statistics from 2005-2010.

PubMed

Holt, Peter James Edward; Sinha, Sidhartha; Ozdemir, Baris Ata; Karthikesalingam, Alan; Poloniecki, Jan Dominik; Thompson, Matt Merfyn

2014-06-19

The quality of care delivered and clinical outcomes of care are of paramount importance. Wide variations in the outcome of emergency care have been suggested, but the scale of variation, and the way in which outcomes are inter-related are poorly defined and are critical to understand how best to improve services. This study quantifies the scale of variation in three outcomes for a contemporary cohort of patients undergoing emergency medical and surgical admissions. The way in which the outcomes of different diagnoses relate to each other is investigated. A retrospective study using the English Hospital Episode Statistics 2005-2010 with one-year follow-up for all patients with one of 20 of the commonest and highest-risk emergency medical or surgical conditions. The primary outcome was in-hospital all-cause risk-standardised mortality rate (in-RSMR). Secondary outcomes were 1-year all-cause risk-standardised mortality rate (1 yr-RSMR) and 28-day all-cause emergency readmission rate (RSRR). 2,406,709 adult patients underwent emergency medical or surgical admissions in the groups of interest. Clinically and statistically significant variations in outcome were observed between providers for all three outcomes (p < 0.001). For some diagnoses including heart failure, acute myocardial infarction, stroke and fractured neck of femur, more than 20% of hospitals lay above the upper 95% control limit and were statistical outliers. The risk-standardised outcomes within a given hospital for an individual diagnostic group were significantly associated with the aggregated outcome of the other clinical groups. Hospital-level risk-standardised outcomes for emergency admissions across a range of specialties vary considerably and cross traditional speciality boundaries. This suggests that global institutional infra-structure and processes of care influence outcomes. The implications are far reaching, both in terms of investigating performance at individual hospitals and in understanding how hospitals can learn from the best performers to improve outcomes.

Incidence, Determinants, and Outcomes of Coronary Perforation During Percutaneous Coronary Intervention in the United Kingdom Between 2006 and 2013: An Analysis of 527 121 Cases From the British Cardiovascular Intervention Society Database.

PubMed

Kinnaird, Tim; Kwok, Chun Shing; Kontopantelis, Evangelos; Ossei-Gerning, Nicholas; Ludman, Peter; deBelder, Mark; Anderson, Richard; Mamas, Mamas A

2016-08-01

As coronary perforation (CP) is a rare but serious complication of percutaneous coronary intervention (PCI) the current evidence base is limited to small series. Using a national PCI database, the incidence, predictors, and outcomes of CP as a complication of PCI were defined. Data were prospectively collected and retrospectively analyzed from the British Cardiovascular Intervention Society data set on all PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. In total, 1762 CPs were recorded from 527 121 PCI procedures (incidence of 0.33%). Patients with CP were more often women or older, with a greater burden of comorbidity and underwent more complex PCI procedures. Factors predictive of CP included age per year (odds ratio [OR], 1.03; 95% confidence intervals, 1.02-1.03; P<0.001), previous coronary artery bypass graft (OR, 1.44; 95% confidence intervals, 1.17-1.77; P<0.001), left main (OR, 1.54; 95% confidence intervals, 1.21-1.96; P<0.001), use of rotational atherectomy (OR, 2.37; 95% confidence intervals, 1.80-3.11; P<0.001), and chronic total occlusions intervention (OR, 3.96; 95% confidence intervals, 3.28-4.78; P<0.001). Adjusted odds of adverse outcomes were higher in patients with CP for all major adverse coronary events, including stroke, bleeding, and mortality. Emergency surgery was required in 3% of cases. Predictors of mortality in patients with CP included age, diabetes mellitus, previous myocardial infarction, renal disease, ventilatory support, use of circulatory support, glycoprotein inhibitor use, and stent type. Using a national PCI database for the first time, the incidence, predictors, and outcomes of CP were defined. Although CP as a complication of PCI occurred rarely, it was strongly associated with poor outcomes. © 2016 American Heart Association, Inc.

Single and Cumulative Relations of Social Risk Factors with Children's Dental Health and Care-Utilization Within Regions of the United States.

PubMed

Yang, Alyssa J; Gromoske, Andrea N; Olson, Melissa A; Chaffin, Jeffrey G

2016-03-01

The purpose is to examine the relation of social risk factors, and the cumulative burden of social risk factors, on parent-reported dental health and dental care-seeking behavior. National Survey of Children's Health data (2011-2012) were analyzed for US children by Title V Block Grant regions. Multivariate logistic regressions were estimated for ten social risk factors, as well as a cumulative risk index, to find any associations with poor condition of teeth, presence of dental caries, and no dental care visits. Almost all of the risk factors were significantly associated with poor condition of teeth and presence of dental caries for the US. Models associating no dental care visits suggested that low family income (OR 1.58), poor maternal mental health (OR 1.54), high school education or less (OR 1.34), and multi-racial/other race (OR 1.18) were significant factors for the US. Regional variation existed for those risk factors and their association with the outcomes, but income, education, and poor maternal mental health consistently played a significant role in adverse outcomes. The cumulative risk index was strongly related to poor oral health outcomes, with a weaker relationship to dental care utilization. US children experiencing certain social risk factors, such as low family income, high school education or less, and poor maternal mental health, are likely to be at greater risk for poor dental health and low levels of dental-care seeking behavior. Children experiencing multiple social risks are at greater risk for poor oral outcomes than children who experience fewer social risks. An approach that involves the social determinants of health is needed to address these issues.

Experienced HIV-Related Stigma in Health Care and Community Settings: Mediated Associations With Psychosocial and Health Outcomes.

PubMed

Kay, Emma S; Rice, Whitney S; Crockett, Kaylee B; Atkins, Ghislaine C; Batey, David Scott; Turan, Bulent

2018-03-01

There are multiple dimensions of HIV-related stigma that can compromise the mental and physical health of people living with HIV. We focused on the dimension of experienced stigma, defined as exposure to acts of discrimination, devaluation, and prejudice, and investigated its relationship with HIV health and psychosocial outcomes. We examined associations between experienced stigma in the community and health care settings and psychosocial and health outcomes for people living with HIV (N = 203) receiving care at an urban HIV clinic in the Southeastern United States. We also investigated whether those effects are unique to experienced stigma or are mediated by other dimensions of HIV-related stigma. Experienced stigma was associated with suboptimal clinical outcomes such as viral nonsuppression, as well as poor affective, cognitive, and mental health outcomes (self-esteem, depressive symptoms, avoidance coping, and blame coping) and interpersonal outcomes such as social support and physician trust. Furthermore, serial mediation models suggested significant indirect effects of experienced stigma through internalized stigma and anticipated stigma from various theoretically expected sources of stigma (eg, community members, friends and family, and health care workers), with varying effects depending on the source. These findings suggest nuanced mechanisms for the effects of experienced HIV-related stigma, especially in health care settings, and may be used to inform stigma-reduction interventions. Interventions designed to address experienced stigma in health care settings might be more tailored to specific outcomes, such as depression and physician trust, than interventions designed to address experienced stigma in the community.

Association of brain metabolites with blood lactate and glucose levels with respect to neurological outcomes after out-of-hospital cardiac arrest: A preliminary microdialysis study.

PubMed

Hifumi, Toru; Kawakita, Kenya; Yoda, Takeshi; Okazaki, Tomoya; Kuroda, Yasuhiro

2017-01-01

Out-of-hospital cardiac arrest (OHCA) is associated with poor prognosis. Cerebral microdialysis (CMD) is an efficient sampling technique to detect neurochemical changes in brain interstitial tissue. In this retrospective study, we hypothesised that there are different CMD levels between patients with favourable and unfavourable neurological outcomes. Data of patients with OHCA admitted to Kagawa University Hospital and administered therapeutic hypothermia (TH) were collected. Using a CMD probe, extracellular glucose, lactate and pyruvate levels were measured hourly along with intracranial perfusion pressure (ICP) and cerebral perfusion pressure (CPP) for the initial 72h during TH. The lactate/pyruvate (LP) ratio was calculated. Patients were divided into favourable [Glasgow-Pittsburgh cerebral performance category 1-2 at 30days after cardiac arrest] or unfavourable neurological outcome groups. CMD biochemical markers and blood lactate and glucose levels were compared between two groups. Ten patients were included. ICP was significantly higher in the unfavourable than in the favourable neurological outcome group; there were no significant differences with respect to CPP. The CMD LP ratio in the unfavourable outcome group progressively increased; significant differences were observed on days 2, 3 and 4 (p<0.01). Significant differences in blood lactate levels were observed between the groups only on day 3.5. CMD and blood glucose levels were higher in the unfavourable than in the favourable outcome group during TH. The association of CMD levels with long-term outcomes would be better defined in a large randomised prospective study. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Child Health, Maternal Marital and Socioeconomic Factors, and Maternal Health

PubMed Central

Witt, Whitney P.

2012-01-01

While maternal socioeconomic status and health predict in part children’s future health and socioeconomic prospects, it is possible that the intergenerational association flows in the other direction such that child health affects maternal outcomes. Previous research demonstrates that poor child health increases the risk of adverse maternal physical and mental health outcomes. We hypothesize that poor child health may also increase the risk of poor maternal health outcomes through an interaction between child health and factors associated with health outcomes, such as marital status, marital quality, and socioeconomic status. Using data on women in the National Longitudinal Study of Youth 1979 cohort (N = 2,279), we find evidence that the effects of certain maternal marital quality and socioeconomic factors on maternal physical and mental health depend on child health status and vice versa. PMID:23788824

An Integrated Systems Biology Approach Identifies TRIM25 as a Key Determinant of Breast Cancer Metastasis.

PubMed

Walsh, Logan A; Alvarez, Mariano J; Sabio, Erich Y; Reyngold, Marsha; Makarov, Vladimir; Mukherjee, Suranjit; Lee, Ken-Wing; Desrichard, Alexis; Turcan, Şevin; Dalin, Martin G; Rajasekhar, Vinagolu K; Chen, Shuibing; Vahdat, Linda T; Califano, Andrea; Chan, Timothy A

2017-08-15

At the root of most fatal malignancies are aberrantly activated transcriptional networks that drive metastatic dissemination. Although individual metastasis-associated genes have been described, the complex regulatory networks presiding over the initiation and maintenance of metastatic tumors are still poorly understood. There is untapped value in identifying therapeutic targets that broadly govern coordinated transcriptional modules dictating metastatic progression. Here, we reverse engineered and interrogated a breast cancer-specific transcriptional interaction network (interactome) to define transcriptional control structures causally responsible for regulating genetic programs underlying breast cancer metastasis in individual patients. Our analyses confirmed established pro-metastatic transcription factors, and they uncovered TRIM25 as a key regulator of metastasis-related transcriptional programs. Further, in vivo analyses established TRIM25 as a potent regulator of metastatic disease and poor survival outcome. Our findings suggest that identifying and targeting keystone proteins, like TRIM25, can effectively collapse transcriptional hierarchies necessary for metastasis formation, thus representing an innovative cancer intervention strategy. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Diagnosis and management of primary central nervous system lymphoma.

PubMed

Han, Catherine H; Batchelor, Tracy T

2017-11-15

Primary central nervous system lymphoma (PCNSL) is a rare and aggressive extranodal non-Hodgkin lymphoma (NHL) that is confined to the brain, eyes, spinal cord, or leptomeninges without systemic involvement. The overall prognosis, diagnosis, and management of PCNSL differ from those for other types of NHL. Prompt diagnosis and initiation of treatment are vital for improving clinical outcomes. PCNSL is responsive to radiation therapy; however, whole-brain radiotherapy (WBRT) inadequately controls the disease when it is used alone, and its delayed neurotoxicity causes neurocognitive impairment, especially in elderly patients. High-dose methotrexate (HD-MTX)-based induction chemotherapy with or without autologous stem cell transplantation (ASCT) or reduced-dose WBRT leads to durable disease control and less neurotoxicity. The optimal treatment has yet to be defined; however, HD-MTX-based induction chemotherapy is considered standard for newly diagnosed PCNSL. Ongoing randomized trials are addressing the roles of rituximab and consolidative treatment with ASCT or reduced-dose WBRT. Despite high tumor response rates with the initial treatment, many patients relapse with a very poor prognosis. The optimal treatment for refractory or relapsed PCNSL is poorly defined. The choice of salvage treatment depends on a patient's age, previous treatment and response, performance status, and comorbidities at the time of relapse. This review provides an overview of the clinical features, diagnosis, pathology, and management of PCNSL in immunocompetent patients, and it focuses on recent advances in treatment. Cancer 2017;123:4314-24. © 2017 American Cancer Society. © 2017 American Cancer Society.

Interictal Scalp Electroencephalography and Intraoperative Electrocorticography in Magnetic Resonance Imaging–Negative Temporal Lobe Epilepsy Surgery

PubMed Central

Burkholder, David B.; Sulc, Vlastimil; Hoffman, E. Matthew; Cascino, Gregory D.; Britton, Jeffrey W.; So, Elson L.; Marsh, W. Richard; Meyer, Fredric B.; Van Gompel, Jamie J.; Giannini, Caterina; Wass, C. Thomas; Watson, Robert E.; Worrell, Gregory A.

2014-01-01

IMPORTANCE Scalp electroencephalography (EEG) and intraoperative electrocorticography (ECoG) are routinely used in the evaluation of magnetic resonance imaging–negative temporal lobe epilepsy (TLE) undergoing standard anterior temporal lobectomy with amygdalohippocampectomy (ATL), but the utility of interictal epileptiform discharge (IED) identification and its role in outcome are poorly defined. OBJECTIVES To determine whether the following are associated with surgical outcomes in patients with magnetic resonance imaging–negative TLE who underwent standard ATL: (1) unilateral-only IEDs on preoperative scalp EEG; (2) complete resection of tissue generating IEDs on ECoG; (3) complete resection of opioid-induced IEDs recorded on ECoG; and (4) location of IEDs recorded on ECoG. DESIGN, SETTING, AND PARTICIPANTS Data were gathered through retrospective medical record review at a tertiary referral center. Adult and pediatric patients with TLE who underwent standard ATL between January 1, 1990, and October 15, 2010, were considered for inclusion. Inclusion criteria were magnetic resonance imaging–negative TLE, standard ECoG performed at the time of surgery, and a minimum follow-up of 12 months. Univariate analysis was performed using log-rank time-to-event analysis. Variables reaching significance with log-rank testing were further analyzed using Cox proportional hazards. MAIN OUTCOMES AND MEASURES Excellent or nonexcellent outcome at time of last follow-up. An excellent outcome was defined as Engel class I and a nonexcellent outcome as Engel classes II through IV. RESULTS Eighty-seven patients met inclusion criteria, with 48 (55%) achieving an excellent outcome following ATL. Unilateral IEDs on scalp EEG (P = .001) and complete resection of brain regions generating IEDs on baseline intraoperative ECoG (P = .02) were associated with excellent outcomes in univariate analysis. Both were associated with excellent outcomes when analyzed with Cox proportional hazards (unilateral-only IEDs, relative risk = 0.31 [95% CI, 0.16-0.64]; complete resection of IEDs on baseline ECoG, relative risk = 0.39 [95% CI, 0.20-0.76]). Overall, 25 of 35 patients (71%) with both unilateral-only IEDs and complete resection of baseline ECoG IEDs had an excellent outcome. CONCLUSIONS AND RELEVANCE Unilateral-only IEDs on preoperative scalp EEG and complete resection of IEDs on baseline ECoG are associated with better outcomes following standard ATL in magnetic resonance imaging–negative TLE. Prospective evaluation is needed to clarify the use of ECoG in tailoring temporal lobectomy. PMID:24781216

Non-operative management of medial meniscus posterior horn root tears is associated with worsening arthritis and poor clinical outcome at 5-year follow-up.

PubMed

Krych, Aaron J; Reardon, Patrick J; Johnson, Nick R; Mohan, Rohith; Peter, Logan; Levy, Bruce A; Stuart, Michael J

2017-02-01

Medial meniscus posterior root tears (MMPRTs) are a significant source of pain and dysfunction, but little is known about the natural history and outcome and for non-operative management of these lesions. The purpose of this study was to evaluate (1) the mid-term clinical and radiographic outcomes of non-operative treatment of MMPRTs and (2) risk factors for worse outcomes. A retrospective review was performed for patients with symptomatic, unrepaired MMPRTs and a minimum 2-year follow-up for IKDC and Tegner outcome scores. Baseline and final radiographs were reviewed and graded according to Kellgren-Lawrence scores. Baseline MRIs were reviewed for the presence of meniscal extrusion, subchondral oedema, and insufficiency fractures. Failure was defined as conversion to arthroplasty or severely abnormal patient subjective IKDC score. Fifty-two patients (21M:31F) with a mean age of 58 ± 10 years were diagnosed with symptomatic MMPRTs clinically and confirmed by MRI and followed for a mean of 62 ± 30 months. Sixteen patients (31 %) underwent total knee arthroplasty at a mean of 30 ± 32 months after diagnosis with higher Kellgren-Lawrence grades associated with increased rates of arthroplasty (p = 0.01). Mean IKDC scores for the remaining patients were 61.2 ± 21 with significantly lower scores in females compared to males (75 ± 12 vs. 49 ± 20; p = 0.03). Mean Kellgren-Lawrence grades and rates of arthritis progressed over time on radiographs (1.5 ± 0.7 vs. 2.4 ± 1.0; p < 0.001 and 78 % vs. 51 %; p = 0.01). Overall, 87 % of patients failed non-operative treatment. Non-operative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Female gender was associated with lower subjective scores and higher rate of arthroplasty. The current study provides a natural history benchmark for clinical outcomes that can be expected in patients with medial meniscus posterior horn root tears undergoing non-operative treatment and helps in counselling patients with these types of injuries. IV.

Characteristics and treatment outcomes of patients with multi-drug resistant tuberculosis at a tertiary care hospital in Peshawar, Pakistan

PubMed Central

Khan, Mazhar A.; Mehreen, Sumaira; Basit, Anila; Khan, Raza A.; Jan, Faheem; Ullah, Irfan; Ihtesham, Muhammad; Khan, Afsar; Ullah, Ubaid; Javaid, Arshad

2015-01-01

Objectives: To determine characteristics and treatment outcomes of multidrugs resistant tuberculosis (MDR-TB) patients and risk factors for poor outcomes in MDR-TB patients in a tertiary care hospital in Peshawar, Pakistan. Methods: This retrospective study was conducted at the Programmatic Management of Drug Resistant TB Unit, Lady Reading Hospital Peshawar, Pakistan and included all MDR-TB patients registered between January 2012 and December 2012. A special proforma was used for data collection. Analysis was performed using SPSS version 16, after exporting data from the proforma. Differences in proportions were assessed using Pearson’s Chi square test whereas for predictors of poor outcomes, multivariate logistic regression analysis with Wald Statistical criteria using backward elimination method was performed. Results: The treatment success rate was 74.3%. In univariate analysis, poor outcomes were associated in patients with age ≥44 years (odds ratio [OR]=0.250; 95% confidence interval [CI]: 0.114-0.519, p=0.001), rural residence (OR=0.417; 95% CI: 0.18-0.937, p=0.03), lung cavitation (OR=0.22; 95% CI, 0.007-0.067, p=0.001), resistance to second line drugs (SLD) (OR=3.441; 95% CI: 1.579-7.497, p=0.001), and resistance to ofloxacin (OR=2.944; 95% CI: 1.361-6.365, p=0.005); whereas multivariate logistic regression analysis, poor outcomes were associated in patients with age ≥44 years (OR=0.249, 95% CI: 0.075-0.828, p=0.023), rural residence (OR=0.143, 95% CI: 0.052-0.774, p=0.032), and cavitatory lungs (OR=0.022, 95% CI: 0.007-0.072, p=0.000). Conclusion: The MDR-TB patient needs special attention for better treatment outcomes. The presence of older age, rural area residence, resistance to ofloxacin, SLD resistance, and cavitary disease are independent prognostic factors for poor outcome in patients with MDR-TB. PMID:26620989

Decline of Cosmetic Outcomes Following Accelerated Partial Breast Irradiation Using Intensity Modulated Radiation Therapy: Results of a Single-Institution Prospective Clinical Trial

DOE Office of Scientific and Technical Information (OSTI.GOV)

Liss, Adam L.; Ben-David, Merav A.; Jagsi, Reshma

2014-05-01

Purpose: To report the final cosmetic results from a single-arm prospective clinical trial evaluating accelerated partial breast irradiation (APBI) using intensity modulated radiation therapy (IMRT) with active-breathing control (ABC). Methods and Materials: Women older than 40 with breast cancer stages 0-I who received breast-conserving surgery were enrolled in an institutional review board-approved prospective study evaluating APBI using IMRT administered with deep inspiration breath-hold. Patients received 38.5 Gy in 3.85-Gy fractions given twice daily over 5 consecutive days. The planning target volume was defined as the lumpectomy cavity with a 1.5-cm margin. Cosmesis was scored on a 4-category scale by themore » treating physician. Toxicity was scored according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 3.0). We report the cosmetic and toxicity results at a median follow-up of 5 years. Results: A total of 34 patients were enrolled. Two patients were excluded because of fair baseline cosmesis. The trial was terminated early because fair/poor cosmesis developed in 7 of 32 women at a median follow-up of 2.5 years. At a median follow-up of 5 years, further decline in the cosmetic outcome was observed in 5 women. Cosmesis at the time of last assessment was 43.3% excellent, 30% good, 20% fair, and 6.7% poor. Fibrosis according to CTCAE at last assessment was 3.3% grade 2 toxicity and 0% grade 3 toxicity. There was no correlation of CTCAE grade 2 or greater fibrosis with cosmesis. The 5-year rate of local control was 97% for all 34 patients initially enrolled. Conclusions: In this prospective trial with 5-year median follow-up, we observed an excellent rate of tumor control using IMRT-planned APBI. Cosmetic outcomes, however, continued to decline, with 26.7% of women having a fair to poor cosmetic result. These results underscore the need for continued cosmetic assessment for patients treated with APBI by technique.« less

Comparison of mild and microdose GnRH agonist flare protocols on IVF outcome in poor responders.

PubMed

Karimzadeh, Mohammad Ali; Mashayekhy, Mehri; Mohammadian, Farnaz; Moghaddam, Fatemeh Mansoori

2011-05-01

To compare the IVF outcome of clomiphene citrate/gonadotropin/antagonist (mild protocol) and microdose GnRH agonist flare protocols for poor responders undergoing in vitro fertilization. 159 poor responder patients were randomized and ovarian stimulation was performed with clomiphene citrate, gonadotropin and antagonist (group I) or microdose GnRH agonist flare (group II) protocols. Main outcome was clinical pregnancy rate and secondary outcomes were doses of gonadotropin administration and duration of stimulation. There were no significant differences in age, causes of infertility, basal FSH, BMI, duration of infertility, E(2) level on the day of hCG injection in both groups. Although the cancellation, fertilization, and clinical pregnancy rates were similar in both groups, the endometrial thickness, number of retrieved oocytes, mature oocytes and implantation rate were significantly higher in mild protocol. The doses of gonadotropin administration and duration of stimulation were significantly lower in mild protocol. We recommend mild protocol in assisted reproductive technology cycles for poor responders based on our results regarding less doses of used gonadotropin and a shorter duration of stimulation.

Predictors of poor treatment outcomes in multidrug-resistant tuberculosis patients: a retrospective cohort study.

PubMed

Javaid, A; Ullah, I; Masud, H; Basit, A; Ahmad, W; Butt, Z A; Qasim, M

2018-06-01

We aimed to determine the characteristics, treatment outcomes and risk factors for poor treatment outcomes among multidrug-resistant (MDR) tuberculosis (TB) patients in Khyber Pakhtunkhwa province, Pakistan. A retrospective cohort study including all patients with MDR-TB who sought care at the MDR-TB unit in Peshawar was conducted between January 2012 and April 2014. Patients were followed until an outcome of TB treatment was recorded as successful (cured or completed) or unsuccessful. Binary logistic regression was used to identify predictors of poor outcome, i.e. unsuccessful treatment outcomes. Overall, 535 patients were included. The proportion of female subjects was relatively higher (n = 300, 56.1%) than male subjects. The mean (standard deviation) age of patients was 30.37 (14.09) years. Of 535 patients for whom treatment outcomes were available, 402 (75.1%) were cured, 4 (0.7%) completed therapy, 34 (6.4%) had disease that failed to respond to therapy, 93 (17.4%) died and two (0.4%) defaulted; in total, 129 (24.1%) had an unsuccessful outcome. We found three significant predictors of unsuccessful treatment during multivariate logistic regression: being married (odds ratio (OR) = 2.17, 95% confidence interval (CI) 1.01, 4.66), resistance to second-line drugs (OR = 2.61, 95% CI 1.61, 4.21) and presence of extensively drug-resistant TB (OR = 7.82, 95% CI 2.90, 21.07). Approximately 75% of the treatment success rate set by the Global Plan to Stop TB was achieved. Resistance to second-line drugs and presence of extensively drug-resistant TB are the main risk factors for poor treatment outcomes. Copyright © 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

A STUDY OF LONGITUDINAL PATTERNS OF FAILURE AMONG HIGH SCHOOL DROP-OUTS AND POORLY PERFORMING GRADUATES.

ERIC Educational Resources Information Center

STOLLER, DAVID S.

THE RELATIONSHIP BETWEEN PATTERNS OF POOR PERFORMANCE AND SIGNIFICANT DISTINGUISHING FACTORS WHICH MIGHT IDENTIFY DROPOUTS IS EXPLORED. DATA WERE OBTAINED ON 270 STUDENTS (FROM A PARENT POPULATION OF 2,500) WHO WERE POOR PERFORMERS (POOR PERFORMANCE BEING DEFINED AS THREE "D'S" OR "F'S" IN HIGH SCHOOL). THE VAST MAJORITY OF…

National survey of adherence, efficacy, and side effects of methylphenidate in children with attention-deficit/hyperactivity disorder in Taiwan.

PubMed

Gau, Susan Shur-Fen; Chen, Shin-Jaw; Chou, Wen-Jiun; Cheng, Helen; Tang, Ching-Shu; Chang, Hsueh-Ling; Tzang, Ruu-Fen; Wu, Yu-Yu; Huang, Ya-Fen; Chou, Miao-Chun; Liang, Hsin-Yi; Hsu, Ya-Chen; Lu, Hui-Hua; Huang, Yu-Shu

2008-01-01

To identify the determinants of adherence to immediate-release (IR) methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder (ADHD); to examine the impact of adherence on ADHD-related symptoms; and to compare the efficacy, adherence, and side effects of IR methylphenidate and osmotic release oral system (OROS) methylphenidate. This national survey, involving 12 hospitals, consisted of 2 phases of assessment. Treatment adherence in 240 (39.5%) of the 607 children aged 5 to 16 years with a clinical diagnosis of DSM-IV ADHD enrolled in the study was poor (defined as missing >or= 1 dose of ADHD medication a day and on 2 days or more during school days). Children with poor adherence at phase 1 were able to switch to OROS methylphenidate, while adherents remained on the IR variant. We reassessed 124 poor adherents who switched to OROS methylphenidate. The global ADHD severity, parent-child interaction, classroom behavior, academic performance, and side effects of the child subjects were evaluated by investigators. Parents completed the rating scales about the ADHD-related symptoms. The study began in April 2005 and was completed in February 2006. Determinants for poor adherence included older age, later onset of ADHD, family history of ADHD, higher paternal education level, and multi-dose administration. Mental retardation and treatment at medical centers were inversely related to poor adherence. Overall, poor adherence was associated with more severe ADHD-related symptoms by comparison to good adherence. Similar side effect profile, superior adherence, and improved efficacy were demonstrated in intra-individual comparison of the OROS and IR methylphenidate forms. Given that poor adherence to medication may be an important reason for suboptimal outcome in ADHD treatment, physicians should ensure adherence with therapy before adjusting dosage or switching medication. clinicaltrials.gov Identifier NCT00460720.

Intracerebral hemorrhage location and outcome among INTERACT2 participants.

PubMed

Delcourt, Candice; Sato, Shoichiro; Zhang, Shihong; Sandset, Else Charlotte; Zheng, Danni; Chen, Xiaoying; Hackett, Maree L; Arima, Hisatomi; Hata, Jun; Heeley, Emma; Al-Shahi Salman, Rustam; Robinson, Thompson; Davies, Leo; Lavados, Pablo M; Lindley, Richard I; Stapf, Christian; Chalmers, John; Anderson, Craig S

2017-04-11

To clarify associations between intracerebral hemorrhage (ICH) location and clinical outcomes among participants of the main phase Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Associations between ICH sites and poor outcomes (death [6] or major disability [3-5] of modified Rankin Scale) and European Quality of Life Scale (EQ-5D) utility scores at 90 days were assessed in logistic regression models. Of 2,066 patients included in the analyses, associations were identified between ICH sites and poor outcomes: involvement of posterior limb of internal capsule increased risks of death or major disability (odds ratio [OR] 2.10) and disability (OR 1.81); thalamic involvement increased risks of death or major disability (OR 2.24) and death (OR 1.97). Involvement of the posterior limb of the internal capsule, thalamus, and infratentorial sites were each associated with poor EQ-5D utility score (≤0.7 [median]; OR 1.87, 2.14, and 2.81, respectively). Posterior limb of internal capsule involvement was strongly associated with low scores across all health-related quality of life domains. ICH encompassing the thalamus and posterior limb of internal capsule were associated with death or major disability, major disability, and poor EQ-5D utility score (OR 1.72, 2.26, and 1.71, respectively). Poor clinical outcomes are related to ICH affecting the posterior limb of internal capsule, thalamus, and infratentorial sites. The highest association with death or major disability and poor EQ-5D utility score was seen in ICH encompassing the thalamus and posterior limb of internal capsule. NCT00716079. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

The association between teenage motherhood and poor offspring outcomes: A national cohort study across 30 years

PubMed Central

Coyne, Claire A; Långström, Niklas; Rickert, Martin E; Lichtenstein, Paul; D’Onofrio, Brian M

2013-01-01

Teenage motherhood is associated with poor offspring outcomes but these associations may be influenced by offspring birth year because of substantial social changes in recent decades. Existing research also has not examined whether these associations are due to the specific effect of mother’s age at childbirth or factors shared by siblings in a family. We used a population-based cohort study in Sweden comprising all children born from 1960–1989 (N=3,162,239), and a subsample of siblings differentially exposed to maternal teenage childbearing (N=485,259) to address these limitations. We examined the effect of teenage childbearing on offspring violent and nonviolent criminal convictions, poor academic performance, and substance-related problems. Population-wide, teenage childbearing was associated with offspring criminal convictions, poor academic performance, and substance-related problems. The magnitude of these associations increased over time. Comparisons of differentially exposed siblings indicated no within-family association between teenage childbearing and offspring violent and nonviolent criminal convictions or poor academic performance, although offspring born to teenage mothers were more likely to experience substance-related problems than their later-born siblings. Being born to a teenage mother in Sweden has become increasingly associated with negative outcomes across time, but the nature of this association may differ by outcome. Teenage childbearing may be associated with offspring violent and nonviolent criminal convictions and poor academic performance because of shared familial risk factors but may be causally associated with offspring substance-related problems. The findings suggest that interventions to improve offspring outcomes should delay teenage childbearing and target risk factors influencing all offspring of teenage mothers. PMID:23632141

Cataract Surgery Visual Outcomes and Associated Risk Factors in Secondary Level Eye Care Centers of L V Prasad Eye Institute, India.

PubMed

Matta, Sumathi; Park, Jiwon; Palamaner Subash Shantha, Ghanshyam; Khanna, Rohit C; Rao, Gullapalli N

2016-01-01

To evaluate cataract surgery visual outcomes and associated risk factors in rural secondary level eye care centers of L V Prasad Eye Institute (LVPEI), India. The Eye Health pyramid of LVPEI has a network of rural secondary care centres (SCs) and attached vision centres (VCs) that provide high quality comprehensive eye care with permanent infrastructure to the most disadvantaged sections of society. The most common procedure performed at SCs is cataract surgery. We audited the outcome of a random sample of 2,049 cataract surgeries done from October 2009-March 2010 at eight rural SCs. All patients received a comprehensive ophthalmic examination, both before and after surgery. The World Health Organization recommended cataract surgical record was used for data entry. Visual outcomes were measured at discharge, 1-3 weeks and 4-11 weeks follow up visits. Poor outcome was defined as best corrected visual acuity <6/18. Mean age was 61.8 years (SD: 8.9 years) and 1,133 (55.3%) surgeries were performed on female patients. Pre-existing ocular co-morbidity was present in 165 patients (8.1%). The most common procedure was small incision cataract surgery (SICS) with intraocular lens (IOL) implantation (91.8%). Intraoperative complications were seen in 29 eyes (1.4%). At the 4-11 weeks follow-up visit, based on presenting visual acuity (PVA), 61.8% had a good outcome and based on best-corrected visual acuity (BCVA), 91.7% had a good outcome. Based on PVA and BCVA, those with less than 6/60 were only 2.9% and 1.6% respectively. Using multivariable analysis, poor visual outcomes were significantly higher in patients aged ≥70 (OR 4.63; 95% CI 1.61, 13.30), in females (OR 1.58; 95% CI 1.04, 2.41), those with preoperative comorbidities (odds ratio 4.68; 95% CI 2.90, 7.57), with intraoperative complications (OR 8.01; 95% CI 2.91, 22.04), eyes that underwent no IOL or anterior chamber-IOL (OR 12.63; 95% CI 2.65, 60.25) and those undergoing extracapsular cataract extraction (OR 9.39; 95% CI 1.18, 74.78). This study demonstrates that quality cataract surgeries can be achieved at rural SCs. The concept of the LVPEI SCs can be applied to other developing countries, allowing rural patients to attain better vision through cataract surgery. Despite improvements in quality of cataract surgery, gender discrimination in terms of outcome continues to be an issue and needs further investigation.

Interaction of sleep quality and sleep duration on glycemic control in patients with type 2 diabetes mellitus.

PubMed

Tang, Yunzhao; Meng, Lingling; Li, Daiqing; Yang, Min; Zhu, Yanjuan; Li, Chenguang; Jiang, Zhenhuan; Yu, Ping; Li, Zhu; Song, Hongna; Ni, Changlin

2014-01-01

Copious evidence from epidemiological and laboratory studies has revealed that sleep status is associated with glucose intolerance, insulin resistance, thus increasing the risk of developing type 2 diabetes. The aim of this study was to reveal the interaction of sleep quality and sleep quantity on glycemic control in patients with type 2 diabetes mellitus. From May 2013 to May 2014, a total of 551 type 2 diabetes patients in Tianjin Metabolic Diseases Hospital were enrolled. Blood samples were taken to measure glycosylated hemoglobin (HbA1c), and all the patients completed the Chinese version of the Pittsburgh Sleep Quality Index (PSQI) questionnaire to evaluate their sleep status. "Good sleep quality" was defined as PQSI <5, "average sleep quality" was defined as PQSI 6-8, and "poor sleep quality" was defined as PQSI >8. Poor glycemic control was defined as HbA1c ≥7%. Sleep quantity was categorized as <6, 6-8, and >8 hours/night. Short sleep time was defined as sleep duration <6 hours/night. In the poor glycemic control group, the rate of patients who had insufficient sleep was much higher than that in the other group (χ(2) = 11.16, P = 0.037). The rate of poor sleep quality in poor glycemic control group was much greater than that in the average control group (χ(2) = 9.79, P = 0.007). After adjusted by gender, age, body mass index, and disease duration, the adjusted PSQI score's OR was 1.048 (95% CI 1.007-1.092, P = 0.023) for HbA1c level. The sleep duration's OR was 0.464 (95% CI 0.236-0.912, P = 0.026) for HbA1c level. One-way analysis of variance showed that the poor sleep quality group had the highest homeostasis model assessment-insulin resistance (P < 0.01). Inadequate sleep, in both quality and quantity, should be regarded as a plausible risk factor for glycemic control in type 2 diabetes. Poor sleep might bring much more serious insulin resistance and could be the reason for bad glycemic control. A good night's sleep should be seen as a critical health component tool in the prevention and treatment of type 2 diabetes. It is important for clinicians to target the root causes of short sleep duration and/or poor sleep quality.

Poor versus rich children with epilepsy have the same clinical course and remission rates but a less favorable social outcome: A population-based study with 25 years of follow-up.

PubMed

Camfield, Carol; Camfield, Peter; Smith, Bruce

2016-11-01

To explore the influence of several estimates of family socioeconomic status on the long-term clinical course and social outcomes of children with epilepsy. The Nova Scotia childhood epilepsy cohort is population based and includes all children in this Canadian province who developed epilepsy between 1977 and 1985. Eligible patients had ≥10 years of follow-up. Children with childhood absence epilepsy were excluded. Total family income at seizure onset was assessed at seizure onset and classified as "poor" (first quintile), "adequate" (second to third quintiles), and "well-off" (fourth to fifth quintiles). We also assessed parental education and home ownership. Social outcome was assessed in those with normal intelligence who were ≥18 years of age at the end of follow-up using a semistructured interview that explored eight adverse effects. Of 584 patients, 421 (72%) were included. Average follow-up was 26 ± 5.6 years. Overall 137 families (33%) had "poor" income, 159 (38%) had "adequate income," and 125 (30%) were "well-off." Terminal remission of epilepsy occurred in 65% of the poor, 61% of the adequate, and 61% of the well-off (p = ns). Intractable epilepsy, status epilepticus, number of antiepileptic drugs (AEDs) used, and the number of generalized tonic-clonic or focal with secondary generalization seizures through the clinical course was the same in all groups. Home ownership did not predict remission. Neither paternal nor maternal education was associated with remission. Poor children had significantly more adverse social outcomes including failure to graduate from high school, unemployment, personal poverty, inadvertent pregnancy, and psychiatric diagnoses. In Nova Scotia with universal health care, coming from a poor or more affluent family does not seem to affect the clinical course or long-term seizure outcome of childhood epilepsy. Unfortunately children from poor families are less likely to have a good social outcome. Wiley Periodicals, Inc. © 2016 International League Against Epilepsy.

Coding of obesity in administrative hospital discharge abstract data: accuracy and impact for future research studies.

PubMed

Martin, Billie-Jean; Chen, Guanmin; Graham, Michelle; Quan, Hude

2014-02-13

Obesity is a pervasive problem and a popular subject of academic assessment. The ability to take advantage of existing data, such as administrative databases, to study obesity is appealing. The objective of our study was to assess the validity of obesity coding in an administrative database and compare the association between obesity and outcomes in an administrative database versus registry. This study was conducted using a coronary catheterization registry and an administrative database (Discharge Abstract Database (DAD)). A Body Mass Index (BMI) ≥30 kg/m2 within the registry defined obesity. In the DAD obesity was defined by diagnosis codes E65-E68 (ICD-10). The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an obesity diagnosis in the DAD was determined using obesity diagnosis in the registry as the referent. The association between obesity and outcomes was assessed. The study population of 17380 subjects was largely male (68.8%) with a mean BMI of 27.0 kg/m2. Obesity prevalence was lower in the DAD than registry (2.4% vs. 20.3%). A diagnosis of obesity in the DAD had a sensitivity 7.75%, specificity 98.98%, NPV 80.84% and PPV 65.94%. Obesity was associated with decreased risk of death or re-hospitalization, though non-significantly within the DAD. Obesity was significantly associated with an increased risk of cardiac procedure in both databases. Overall, obesity was poorly coded in the DAD. However, when coded, it was coded accurately. Administrative databases are not an optimal datasource for obesity prevalence and incidence surveillance but could be used to define obese cohorts for follow-up.

Use of Transcranial Doppler in Patients with Severe Traumatic Brain Injuries.

PubMed

Ziegler, Daniel; Cravens, George; Poche, Gerard; Gandhi, Raj; Tellez, Mark

2017-01-01

Severe traumatic brain injuries (TBI) are associated with a high rate of mortality and disability. Transcranial Doppler (TCD) sonography permits a noninvasive measurement of cerebral blood flow. The purpose of this study is to determine the usefulness of TCD in patients with severe TBI. TCD was performed, from April 2008 to April 2013, on 255 patients with severe TBI, defined as a Glasgow Coma Scale score of ≤8 on admission. TCD was performed on hospital days 1, 2, 3, and 7. Hypoperfusion was defined by having two out of three of the following: 1) mean velocity (Vm) of the middle cerebral artery <35 cm/sec, 2) diastolic velocity (Vd) of the middle cerebral artery <20 cm/sec, or 3) pulsatility index (PI) of >1.4. Vasospasm was defined by the following: Vm of the middle cerebral artery >120 cm/sec and/or a Lindegaard index (LI) >3. One hundred fourteen (45%) had normal measurements. Of these, 92 (80.7%) had a good outcome, 6 (5.3%) had moderate disability, and 16 (14%) died, 4 from brain death. Seventy-two patients (28%) had hypoperfusion and 71 (98.6%) died, 65 from brain death, and 1 patient survived with moderate disability. Sixty-nine patients (27%) had vasospasm, 31 (44.9%) had a good outcome, 16 (23.2%) had severe disability, and 22 (31.9%) died, 13 from brain death. The vasospasm was detected on hospital day 1 in 8 patients, on day 2 in 23 patients, on day 3 in 22 patients, and on day 7 in 16 patients. Patients with normal measurements can be expected to survive. Patients with hypoperfusion have a poor prognosis. Patients with vasospasm have a high incidence of mortality and severe disability. TCD is useful in determining early prognosis.

Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study).

PubMed

Walsh, Timothy S; Kydonaki, Kalliopi; Antonelli, Jean; Stephen, Jacqueline; Lee, Robert J; Everingham, Kirsty; Hanley, Janet; Uutelo, Kimmo; Peltola, Petra; Weir, Christopher J

2016-03-04

To describe the rationale, design and methodology for a trial of three novel interventions developed to improve sedation-analgesia quality in adult intensive care units (ICUs). 8 clusters, each a Scottish ICU. All mechanically ventilated sedated patients were potentially eligible for inclusion in data analysis. Cluster randomised design in 8 ICUs, with ICUs randomised after 45 weeks baseline data collection to implement one of four intervention combinations: a web-based educational programme (2 ICUs); education plus regular sedation quality feedback using process control charts (2 ICUs); education plus a novel sedation monitoring technology (2 ICUs); or all three interventions. ICUs measured sedation-analgesia quality, relevant drug use and clinical outcomes, during a 45-week preintervention and 45-week postintervention period separated by an 8-week implementation period. The intended sample size was >100 patients per site per study period. The primary outcome was the proportion of 12 h care periods with optimum sedation-analgesia, defined as the absence of agitation, unnecessary deep sedation, poor relaxation and poor ventilator synchronisation. Secondary outcomes were proportions of care periods with each of these four components of optimum sedation and rates of sedation-related adverse events. Sedative and analgesic drug use, and ICU and hospital outcomes were also measured. Multilevel generalised linear regression mixed models will explore the effects of each intervention taking clustering into account, and adjusting for age, gender and APACHE II score. Sedation-analgesia quality outcomes will be explored at ICU level and individual patient level. A process evaluation using mixed methods including quantitative description of intervention implementation, focus groups and direct observation will provide explanatory information regarding any effects observed. The DESIST study uses a novel design to provide system-level evaluation of three contrasting complex interventions on sedation-analgesia quality. Recruitment is complete and analysis ongoing. NCT01634451. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Hyperglycaemia, Insulin Therapy and Critical Penumbral Regions for Prognosis in Acute Stroke: Further Insights from the INSULINFARCT Trial

PubMed Central

Rosso, Charlotte; Pires, Christine; Corvol, Jean-Christophe; Baronnet, Flore; Crozier, Sophie; Leger, Anne; Deltour, Sandrine; Valabregue, Romain; Amor-Sahli, Mélika; Lehéricy, Stéphane; Dormont, Didier; Samson, Yves

2015-01-01

Background Recently, the concept of ‘clinically relevant penumbra’ was defined as an area saved by arterial recanalization and correlated with stroke outcome. This clinically relevant penumbra was located in the subcortical structures, especially the periventricular white matter. Our aims were to confirm this hypothesis, to investigate the impact of admission hyperglycemia and of insulin treatment on the severity of ischemic damages in this area and to study the respective contributions of infarct volume and ischemic damage severity of the clinically relevant penumbra on 3-month outcome. Methods We included 99 patients from the INSULINFARCT trial. Voxel-Based Analysis was carried on the Apparent Diffusion Coefficient (ADC) maps obtained at day one to localize the regions, which were more damaged in patients i) with poor clinical outcomes at three months and ii) without arterial recanalization. We determined the intersection of the detected areas, which represents the clinically relevant penumbra and investigated whether hyperglycemic status and insulin regimen affected the severity of ischemic damages in this area. We performed logistic regression to examine the contribution of infarct volume or early ADC decrease in this strategic area on 3-month outcome. Findings Lower ADC values were found in the corona radiata in patients with poor prognosis (p< 0.0001) and in those without arterial recanalization (p< 0.0001). The tracking analysis showed that lesions in this area interrupted many important pathways. ADC values in this area were lower in hyperglycemic than in normoglycemic patients (average decrease of 41.6 ± 20.8 x10−6mm2/s) and unaffected by the insulin regimen (p: 0.10). ADC values in the clinically relevant penumbra, but not infarct volumes, were significant predictors of 3-month outcome. Conclusion These results confirm that the deep hemispheric white matter is part of the clinically relevant penumbra and show that hyperglycaemia exacerbates the apparition of irreversible ischemic damage within 24 hours in this area. However, early intensive insulin therapy fails to protect this area from infarction. Trial Registration ClinicalTrials.gov NCT00472381 PMID:25793765

Microbial host interactions and impaired wound healing in mice and humans: defining a role for BD14 and NOD2.

PubMed

Williams, Helen; Campbell, Laura; Crompton, Rachel A; Singh, Gurdeep; McHugh, Brian J; Davidson, Donald J; McBain, Andrew J; Cruickshank, Sheena M; Hardman, Matthew J

2018-04-30

Chronic wounds cause significant patient morbidity and mortality. A key factor in their etiology is microbial infection, yet skin host-microbiota interactions during wound repair remain poorly understood. Microbiome profiles of non-infected human chronic wounds are associated with subsequent healing outcome. Furthermore, poor clinical healing outcome was associated with increased local expression of the pattern recognition receptor NOD2. To investigate NOD2 function in the context of cutaneous healing, we treated mice with the NOD2 ligand muramyl dipeptide (MDP) and analyzed wound repair parameters and expression of anti-microbial peptides. MDP treatment of littermate controls significantly delayed wound repair associated with reduced re-epithelialization, heightened inflammation and upregulation of murine β-Defensins (mBD) 1, 3 and particularly 14. We postulated that although BD14 might impact on local skin microbial communities it may further impact other healing parameters. Indeed, exogenously administered mBD14 directly delayed mouse primary keratinocyte scratch wound closure in vitro. To further explore the role of mBD14 in wound repair, we employed Defb14 -/- mice, and showed they had a global delay in healing in vivo, associated with alterations in wound microbiota. Taken together these studies suggest a key role for NOD2-mediated regulation of local skin microbiota which in turn impacts on chronic wound etiology. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Traumatic Brain Injury among Older Adults at Level I and II Trauma Centers

PubMed Central

Cuthbert, Jeffrey P.; Whyte, John; Corrigan, John D.; Faul, Mark; Harrison-Felix, Cynthia

2013-01-01

Abstract Individuals 65 years of age and over have the highest rates of traumatic brain injury (TBI)-related hospitalizations and deaths, and older adults (defined variably across studies) have particularly poor outcomes after TBI. The factors predicting these outcomes remain poorly understood, and age-specific care guidelines for TBI do not exist. This study provides an overview of TBI in older adults using data from the National Trauma Data Bank (NTDB) gathered between 2007 and 2010, evaluates age group-specific trends in rates of TBI over time using U.S. Census data, and examines whether routinely collected information is able to predict hospital discharge status among older adults with TBI in the NTDB. Results showed a 20–25% increase in trauma center admissions for TBI among the oldest age groups (those >=75 years), relative to the general population, between 2007 and 2010. Older adults (>=65 years) with TBI tended to be white females who have incurred an injury from a fall resulting in a “severe” Abbreviated Injury Scale (AIS) score of the head. Older adults had more in-hospital procedures, such as neuroimaging and neurosurgery, tended to experience longer hospital stays, and were more likely to require continued medical care than younger adults. Older age, injury severity, and hypotension increased the odds of in-hospital death. The public health burden of TBI among older adults will likely increase as the Baby Boom generation ages. Improved primary and secondary prevention of TBI in this cohort is needed. PMID:23962046

Predictors of outcome in patients with advanced nonseminomatous germ cell testicular tumors.

PubMed

Yetisyigit, Tarkan; Babacan, Nalan; Urun, Yuksel; Seber, Erdogan Selcuk; Cihan, Sener; Arpaci, Erkan; Yildirim, Nuriye; Aksoy, Sercan; Budakoglu, Burcin; Zengin, Nurullah; Oksuzoglu, Berna; Yalcin, Banu Cicek; Alkis, Necati

2014-01-01

Predictor factors determining complete response to treatment are still not clearly defined. We aimed to evaluate clinicopathological features, risk factors, treatment responses, and survival analysis of patient with advanced nonseminomatous GCTs (NSGCTs). Between November 1999 and September 2011, 140 patients with stage II and III NSGCTs were referred to our institutions and 125 patients with complete clinical data were included in this retrospective study. Four cycles of BEP regimen were applied as a first-line treatment. Salvage chemotherapy and/or high-dose chemotherapy (HDCT) with autologous stem cell transplantation were given in patients who progressed after BEP chemotherapy. Post-chemotherapy surgery was performed in selected patients with incomplete radiographic response and normal tumor markers. The median age was 28 years. For the good, intermediate and poor risk groups, compete response rates (CRR) were, 84.6%, 67.9% and 59.4%, respectively. Extragonadal tumors, stage 3 disease, intermediate and poor risk factors, rete testis invasion were associated with worse outcomes. There were 32 patients (25.6%) with non-CR who were treated with salvage treatment. Thirty-one patients died from GCTs and 94% of them had stage III disease. Even though response rates are high, some patients with GCTs still need salvage treatment and cure cannot be achieved. Non-complete response to platinium-based first-line treatment is a negative prognostic factor. Our study confirmed the need for a prognostic and predictive model and more effective salvage approaches.

Treatments for compulsive buying: A systematic review of the quality, effectiveness and progression of the outcome evidence.

PubMed

Hague, Ben; Hall, Jo; Kellett, Stephen

2016-09-01

Background and aims This review appraises the progression and status of the evidence base for the treatment of compulsive buying disorder (CBD), in order to highlight what currently works and to prompt useful future research. Methods Online databases ISI Web of Knowledge, PsycINFO, and PubMed via Ovid were searched at two time points. Two quality checklists and an established model of therapy evaluation (hourglass model) evaluated the quality and progression of both psychotherapy and pharmacotherapy treatments for CBD. Uncontrolled effect sizes were calculated and meta-regression analyses were performed regarding treatment duration. Results A total of 29 articles met the inclusion criteria, which were divided into psychotherapy (n = 17) and pharmacotherapy treatments (n = 12). Of the 29 studies, only 5 studies have been tested under conditions of high methodological quality. Both forms of treatment had been evaluated in a haphazard manner across the stages of the hourglass model. Although large effects were demonstrated for group psychotherapy and pharmacotherapy, such evidence of effectiveness was undermined by poor study quality and risk of publication bias. Long-term CBD treatment was associated with improved outcome with pharmacotherapy, but not when delivering psychotherapy. Discussion Group psychotherapy currently appears the most promising treatment option for CBD. Poor methodological control and sporadic evaluation of specific treatments have slowed the generation of a convincing evidence base for CBD treatment. Defining the active ingredients of effective CBD treatment is a key research goal.

Treatments for compulsive buying: A systematic review of the quality, effectiveness and progression of the outcome evidence

PubMed Central

Hague, Ben; Hall, Jo; Kellett, Stephen

2016-01-01

Background and aims This review appraises the progression and status of the evidence base for the treatment of compulsive buying disorder (CBD), in order to highlight what currently works and to prompt useful future research. Methods Online databases ISI Web of Knowledge, PsycINFO, and PubMed via Ovid were searched at two time points. Two quality checklists and an established model of therapy evaluation (hourglass model) evaluated the quality and progression of both psychotherapy and pharmacotherapy treatments for CBD. Uncontrolled effect sizes were calculated and meta-regression analyses were performed regarding treatment duration. Results A total of 29 articles met the inclusion criteria, which were divided into psychotherapy (n = 17) and pharmacotherapy treatments (n = 12). Of the 29 studies, only 5 studies have been tested under conditions of high methodological quality. Both forms of treatment had been evaluated in a haphazard manner across the stages of the hourglass model. Although large effects were demonstrated for group psychotherapy and pharmacotherapy, such evidence of effectiveness was undermined by poor study quality and risk of publication bias. Long-term CBD treatment was associated with improved outcome with pharmacotherapy, but not when delivering psychotherapy. Discussion Group psychotherapy currently appears the most promising treatment option for CBD. Poor methodological control and sporadic evaluation of specific treatments have slowed the generation of a convincing evidence base for CBD treatment. Defining the active ingredients of effective CBD treatment is a key research goal. PMID:27640529

Global notes: counting the world's poor--how do we define poverty?

PubMed

Vidyasagar, D

2006-06-01

Health professionals are in constant interaction with parents and infants who are victims of poverty and poor socioeconomic status. But an important question remains: do we know how to define poverty? Defining poverty accurately is important as the definition is the basis of policy development. The definition of poverty has changed during the last quarter century. In addition to economic considerations, it is broadened to include other dimensions of life such as literacy, health and longevity. This article attempts to provide national and international definitions of poverty, the magnitude and effects of poverty.

Association of stroke clinical outcomes with coexistence of hyperglycemia and biomarkers of inflammation.

PubMed

Zhou, Jingwen; Wu, Jiahui; Zhang, Jintao; Xu, Tan; Zhang, Huan; Zhang, Yonghong; Zhang, Shaoyan

2015-06-01

To investigate the association of short-term clinical outcomes with coexistence of hyperglycemia and elevated biomarkers of inflammation among acute ischemic stroke (AIS) patients. We performed a retrospective study of 2675 patients diagnosed with AIS from January 2006 to December 2008. The study outcomes were defined as neurologic deficiency (National Institutes of Health Stroke Scale score ≥5) at discharge or death during hospitalization. Compared with normoglycemia and without any elevated biomarkers, patients with hyperglycemia, elevated white blood cell (WBC) count, elevated neutrophils ratio (NEUR), and elevated erythrocyte sedimentation rate (ESR) had higher rates of study outcomes (all P < .05). Furthermore, patients with coexistence of hyperglycemia with any of elevated WBC count, NEUR, or ESR were more likely to have study outcomes (all P < .05). Compared with subjects with normoglycaemia and without any elevated biomarker, multivariate adjusted odds ratios (95% confidence interval) of study outcomes associated with hyperglycemia, elevated WBC count, elevated NEUR, elevated ESR, coexistences of hyperglycemia with elevated WBC count, elevated NEUR, and elevated ESR were 1.492 (1.139-1.955), 1.404 (1.048-1.881), 1.897 (1.411-2.551), 2.184 (1.339-3.564), 1.963 (1.337-2.883), 2.544(1.715- 3.775), and 2.687 (1.347-5.363), respectively. This study indicated that hyperglycemia and elevated biomarkers of inflammation were associated with short-term clinical outcomes, and individuals with coexistence of hyperglycemia and elevated biomarkers of inflammation had higher risk of poor clinical outcomes among AIS patients. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Association of high waist-to-height ratio with functional outcomes in patients with acute ischemic stroke

PubMed Central

Yu, Ping; Pan, Yuesong; Zheng, Huaguang; Wang, Xianwei; Yan, Hongyi; Tong, Xu; Jing, Jing; Zhang, Xiao; Guo, Li; Wang, Yilong

2017-01-01

Abstract The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study. A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance. The higher WHR was associated with worse functional outcome, but not predictive of the patients’ mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08–1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86–1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83–1.33, P = 0.71). Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery. PMID:28353610

Association of high waist-to-height ratio with functional outcomes in patients with acute ischemic stroke: A report from the ACROSS-China study.

PubMed

Yu, Ping; Pan, Yuesong; Zheng, Huaguang; Wang, Xianwei; Yan, Hongyi; Tong, Xu; Jing, Jing; Zhang, Xiao; Guo, Li; Wang, Yilong

2017-03-01

The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study.A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance.The higher WHR was associated with worse functional outcome, but not predictive of the patients' mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08-1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86-1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83-1.33, P = 0.71).Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery.

Neurologic outcome in comatose patients resuscitated from out-of-hospital cardiac arrest with prolonged downtime and treated with therapeutic hypothermia.

PubMed

Kim, Won Young; Giberson, Tyler A; Uber, Amy; Berg, Katherine; Cocchi, Michael N; Donnino, Michael W

2014-08-01

Previous reports have shown that prolonged duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) is associated with poor neurologic outcome. This concept has recently been questioned with advancements in post-cardiac arrest care including the use of therapeutic hypothermia (TH). The aim of this study was to determine the rate of good neurologic outcome based on the duration of resuscitation efforts in OHCA patients treated with TH. This prospective, observational, study was conducted between January 2008 and September 2012. Inclusion criteria consisted of adult non-traumatic OHCA patients who were comatose after return of spontaneous circulation (ROSC) and received TH. The primary endpoint was good neurologic outcome defined as a cerebral performance category score of 1 or 2. Downtime was calculated as the length of time between the patient being recognized as pulseless and ROSC. 105 patients were treated with TH and 19 were excluded due to unknown downtime, leaving 86 patients for analysis. The median downtime was 18.5 (10.0-32.3)min and 33 patients (38.0%) had a good neurologic outcome. When downtime was divided into four groups (≤10min, 11-20min, 21-30min, >30min), good neurologic outcomes were 62.5%, 37%, 25%, and 21.7%, respectively (p=0.02). However, even with downtime >20min, 22.9% had a good neurologic outcome, and this percentage increased to 37.5% in patients with an initial shockable rhythm. Although longer downtime is associated with worse outcome in OHCA patients, we found that comatose patients who have been successfully resuscitated and treated with TH have neurologically intact survival rates of 23% even with downtime >20min. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Neurologic outcome in comatose patients resuscitated from out-of-hospital cardiac arrest with prolonged downtime and treated with therapeutic hypothermia

PubMed Central

Kim, Won Young; Giberson, Tyler A.; Uber, Amy; Berg, Katherine; Cocchi, Michael N.; Donnino, Michael W.

2014-01-01

Background Previous reports have shown that prolonged duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) is associated with poor neurologic outcome. This concept has recently been questioned with advancements in post-cardiac arrest care including the use of therapeutic hypothermia (TH). The aim of this study was to determine the rate of good neurologic outcome based on the duration of resuscitation efforts in OHCA patients treated with TH. Methods This prospective, observational, study was conducted between January 2008 and September 2012. Inclusion criteria consisted of adult non-traumatic OHCA patients who were comatose after return of spontaneous circulation (ROSC) and received TH. The primary endpoint was good neurologic outcome defined as a cerebral performance category score of 1 or 2. Downtime was calculated as the length of time between the patient being recognized as pulseless and ROSC. Results 105 patients were treated with TH and 19 were excluded due to unknown downtime, leaving 86 patients for analysis. The median downtime was 18.5 (10.0–32.3) minutes and 33 patients (38.0%) had a good neurologic outcome. When downtime was divided into four groups (≤10 min, 11-20 min, 21-30 min, > 30 min), good neurologic outcomes were 62.5%, 37%, 25%, and 21.7%, respectively (p=0.02). However, even with downtime >20 minutes, 22.9% had a good neurologic outcome, and this percentage increased to 37.5% in patients with an initial shockable rhythm. Conclusions Although longer downtime is associated with worse outcome in OHCA patients, we found that comatose patients who have been successfully resuscitated and treated with TH have neurologically intact survival rates of 23% even with downtime > 20 minutes. PMID:24746783

Blend sign predicts poor outcome in patients with intracerebral hemorrhage

PubMed Central

Cao, Du; Zhu, Dan; Lv, Fa-Jin; Liu, Yang; Yuan, Liang; Zhang, Gang; Xiong, Xin; Li, Rui; Hu, Yun-Xin; Qin, Xin-Yue; Xie, Peng

2017-01-01

Introduction Blend sign has been recently described as a novel imaging marker that predicts hematoma expansion. The purpose of our study was to investigate the prognostic value of CT blend sign in patients with ICH. Objectives and methods Patients with intracerebral hemorrhage who underwent baseline CT scan within 6 hours were included. The presence of blend sign on admission nonenhanced CT was independently assessed by two readers. The functional outcome was assessed by using the modified Rankin Scale (mRS) at 90 days. Results Blend sign was identified in 40 of 238 (16.8%) patients on admission CT scan. The proportion of patients with a poor functional outcome was significantly higher in patients with blend sign than those without blend sign (75.0% versus 47.5%, P = 0.001). The multivariate logistic regression analysis demonstrated that age, intraventricular hemorrhage, admission GCS score, baseline hematoma volume and presence of blend sign on baseline CT independently predict poor functional outcome at 90 days. The CT blend sign independently predicts poor outcome in patients with ICH (odds ratio 3.61, 95% confidence interval [1.47–8.89];p = 0.005). Conclusions Early identification of blend sign is useful in prognostic stratification and may serve as a potential therapeutic target for prospective interventional studies. PMID:28829797

Improving outcome in schizophrenia: the potential importance of EPS and neuroleptic dysphoria.

PubMed

Gerlach, Jes

2002-03-01

Despite half a century of antipsychotic drug treatment, the outcome of therapy in schizophrenia remains disappointing. Relapse, rehospitalization, limited fulfilment of social roles, and suicide remain frequent, and the economic costs are high. Current relapse rates may be two to three times higher than those that could be achieved with optimal use of therapy. Poor compliance with treatment is considered to be a significant preventable cause of poor outcome and is in turn likely to be influenced by the patient's experience of drug treatment. There is some evidence that extrapyramidal symptoms (EPS), particularly akathisia and neuroleptic dysphoria, are associated with poor compliance and poor treatment outcome. Atypical antipsychotics have a lower risk of EPS than do standard antipsychotics. Some (risperidone, olanzapine, and ziprasidone) show evidence of a dose-related increase in EPS, but clozapine and quetiapine have demonstrated a placebo-level incidence of EPS across the dose range. Quetiapine does not require the regular blood monitoring mandated for clozapine, and results from a patient survey indicate a high degree of patient satisfaction with treatment. While further research is needed, it is possible that wider use of medications with low EPS and high patient acceptability could promote better compliance and improve the outcome of schizophrenia treatment.

Adolescent and parent motivation for change affects psychotherapy outcomes among youth with poorly controlled diabetes.

PubMed

Ellis, Deborah A; Berio, Heidi; Carcone, April Idalski; Naar-King, Sylvie

2012-01-01

Investigate effect of baseline motivation for change on treatment fidelity, therapeutic alliance, treatment dose, and treatment outcome in a randomized controlled trial of family therapy for youth with poorly controlled diabetes. Seventy-four adolescents and caregivers completed measures of motivation for change. Measures of fidelity, alliance, dose, and youth health status were collected. Structural equation modeling was used to test the direct and indirect effects of motivation on treatment outcomes. Parent motivation was significantly related to alliance and fidelity. Only alliance was significantly related to posttreatment metabolic control. In adolescent models, only motivation was significantly related to alliance. In both models, motivation had a significant indirect effect on metabolic control through alliance. Findings demonstrate the importance of parent and youth initial motivational status and treatment alliance to treatment outcome among youth with poorly controlled diabetes. Additional research on treatment techniques that promote motivation for change is needed.

Risk factors for unplanned and crash dialysis starts: a protocol for a systematic review and meta-analysis.

PubMed

Molnar, Amber O; Hiremath, Swapnil; Brown, Pierre A; Akbari, Ayub

2016-07-19

Many patients with kidney failure "crash" onto dialysis or initiate dialysis in an unplanned fashion. There are varying definitions, but essentially, a patient is labeled as having a crash dialysis start if he or she has little to no care by a nephrologist prior to starting dialysis. A patient is labeled as having an unplanned dialysis start when he or she starts dialysis with a catheter or during a hospitalization. Given the high prevalence and poor outcomes associated with crash and unplanned dialysis starts, it is important to establish a better understanding of patient risk factors. We will conduct a systematic review and meta-analysis with a focus on both crash and unplanned dialysis starts. The first objective will be to determine patient risk factors for crash and unplanned dialysis starts. Secondary objectives will be to determine the most common criteria used to define both crash and unplanned dialysis starts and to determine outcomes associated with crash and unplanned dialysis starts. We will search MEDLINE, EMBASE and Cochrane Library from inception to the present date for all studies that report the characteristics and outcomes of patients who have crash vs. non-crash dialysis starts or unplanned vs. planned dialysis starts. We will also extract from included studies the criteria used to define crash and unplanned dialysis starts. If there are any eligible randomized controlled trials, quality assessment will be performed using the Cochrane Risk of Bias Assessment Tool. Observational studies will be evaluated using the Newcastle-Ottawa Scale. Data will be pooled in meta-analysis if deemed appropriate. The results of this review will inform the design of strategies to help reduce the incidence of crash and unplanned dialysis starts. Prospero CRD42016032916.

Increased trunk extension endurance is associated with meaningful improvement in balance among older adults with mobility problems.

PubMed

Suri, Pradeep; Kiely, Dan K; Leveille, Suzanne G; Frontera, Walter R; Bean, Jonathan F

2011-07-01

To determine whether trunk extension endurance changes with training are associated with clinically meaningful improvements in balance among mobility-limited older adults. Longitudinal data from a randomized controlled trial. Outpatient rehabilitation research center. Community-dwelling older adults (N=64; mean age, 75.9y) with mobility limitations as defined by a score of 4 to 10 on the Short Physical Performance Battery. Sixteen weeks of progressive resistance training. Outcomes were the Berg Balance Scale (BBS) and the Unipedal Stance Time (UST). Predictors included leg strength, leg power, trunk extension endurance, and the product of heart rate and blood pressure (RPP) at the final stage of an exercise tolerance test. We performed an analysis of data from participants who completed 16 weeks of training by using binary outcomes defined by a clinically meaningful change (CMC) from baseline to completion of the intervention (BBS=4 units; UST=5s). The association of predictor variables with balance outcomes was examined separately and together in multivariate adjusted logistic regression models. Trunk extension endurance in seconds (1.04 [1.00-1.09]) was independently associated with CMC on the BBS. Trunk extension endurance (1.02 [1.00-1.03]) was independently associated with CMC on the UST. Other physical attributes were not associated with meaningful change in balance. Improvements in trunk extension endurance were independently associated with CMCs in balance in older adults. Leg strength, leg power, and RPP were not associated with CMC in balance. Poor trunk extension endurance may be a rehabilitative impairment worthy of further study as a modifiable factor linked to balance among older adults. Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.