Prestroke family interaction as a predictor of stroke outcome

The Family of Assessment Device and clinical data for 60 stroke patients were used to predict outcome at six months and one year poststroke. Ratings of behavior control and affective responsiveness of the family predicted number of days of rehospitalization during the study. Problem solving scores, family communication skills, and patient self-care ability predicted family-rated patient adjustment. Family function was a better predictor of hospital stay than baseline ratings of typical predictors of stroke outcome. Family function represents an area for potential stroke intervention that may have more relevance to efficient health care delivery and the clinical status of stroke patients than has previously been noted.     

The visual aura rating scale as an outcome predictor for persistent visual aura without infarction

Persistent visual aura without infarction is rare. Its pathogenic mechanism is unknown, and the response to migraine prophylactic agents varies. A systematic analysis of 29 patients (23 from the literature and six in the present report; 6M/23F, mean age 37.6 years) was carried out in terms of demographics, headache and visual symptom profiles, treatment regimens and outcomes. Patterns of visual disturbances (VDs) were re-assessed with the Visual Aura Rating Scale (VARS, score 0-10). Even though the majority of patients had headache improvement, only eight (27.6%) had complete resolution of persistent VD, without definite relevance to any specific agent. Patients with complete resolution of VD tended to have scotoma (50.0% vs. 0%; P = 0.003), unilateral/homonymous involvement (62.5% vs. 9.5%; P = 0.008), higher VARS scores (1.88 +/- 1.73 vs. 0.10 +/- 0.30; P < 0.001) and shorter duration of illness (10.0 +/- 12.9 vs. 60.2 +/- 90.9 months, P = 0.008) compared with those without. These findings remained even when the six current patients were not included for analyses. In conclusion, the prognosis of persistent VD was poor, and higher VARS scores, i.e. more typical of migraine visual aura, predicted a better outcome. For those with a potential for complete resolution, improvement would occur early in the course.     

Vestibulo-ocular monitoring as a predictor of outcome after severe traumatic brain injury

Introduction  

Based on the knowledge that traumatic brainstem damage often leads to alteration in brainstem functions, including the vestibulo-ocular reflex, the present study is designed to determine whether prediction of outcome in the early phase after severe traumatic brain injury is possible by means of vestibulo-ocular monitoring.     

Embryonal heart rate as a predictor of pregnancy outcome: a prospective analysis

To evaluate the association between embryonal heart rate and pregnancy outcome, we prospectively followed 50 very early pregnancies (4.5 to 7.3 weeks of gestation) through the first trimester. Of the 11 embryos that miscarried, 6 had initial heart rates below 85 beats per minute (bpm); in contrast, none of the viable embryos had initial heart rates of or below 85 bpm (P less than 0.0001). A rise in mean heart rate was seen among the viable embryos with increasing gestational age, in concordance with previously reported rates.     

The abbreviated injury scale as a predictor of outcome of severe head injury

Objective This study examined the correlation between the worst abbreviated injury scale 1990 (AIS) intracranial severity score and outcome following severe head injury.Design The initial CT scans of 109 severly head injury patients were examined by a neuroradiologist and classified according to the worst applicable intracranial severity code from the AIS. This score was then correlated with the glasgow outcome scale (GOS) at 6 months. For comparison, the GOS was also correlated with the diffuse injury scale (DIS) described by L.F. Marshall et al. [5], the worst post-resuscitation Glasgow coma score (GCS) in the first 24 h, and the head injury outcome prediction tree described by Choi et al. [1].Results Our results show Spearman rank correlation coefficients of 0.58 (p<0.001), 0.47 (p<0.001), 0.45 (p<0.001), and 0.31 (p<0.01) for the correlation between the AIS, prediction tree, DIS, and GCS respectively and the GOS. Independent outcome (i.e. GOS good or moderate) was strongly predicted by an AIS of 3 or less (positive predictive value 95%, specificity 98%, sensitivity 40%, likelihood ratio 251). Death or vegetative survival was less strongly predicted in patients with an AIS of 5 (positive predictive value 71%, specificity 75%, sensitivity 67%, likelihood ratio 2.71).Conclusion The AIS, based on initial CT scan, provides useful prognostic information in patients with severe head injury.     

Abnormal troponin level as short-term predictor of poor outcome in acute atrial fibrillation

Background

The link between minor troponin (cardiac troponin I [cTnI]) elevations and atrial fibrillation (AF) is still debated.

Methods

A total of 948 patients with AF lasting less than 48 hours participated in the study and were required to undergo 1-month and 12-month follow-up. The exclusion criteria were represented by younger than 18 years, the presence of hemodynamic instability, or severe comorbidity. Primary end point was the composite of ischemic vascular events inclusive of stroke, acute coronary syndrome, revascularization, and death.

Results

In the short term, 4 patients (5%) of 78 with abnormal cTnI reached the primary end point (P = .001 vs others). Conversely, in the long term, 13 patients (17%) with abnormal cTnI, 21 (10%) with known ischemic vascular disease, and 50 (5%) aged patients (75 ± 10 years) reached the primary end point (P < .001, P < .001, and P = .002, respectively). At multivariate analysis, abnormal cTnI (hazard ratio [HR], 2.84; 95% confidence interval, 1.38-5.84; P = .005), known ischemic vascular disease (HR, 2.03; 95% confidence interval, 1.11-3.70; P = .021), and age (HR, 1.05; 95 confidence interval, 1.02-1.08; P = .002) were predictors of the primary end point. Minimal or minor cTnI elevation (< 0.45 or ≥ 0.45 ng/mL, respectively) showed no differences when associated with the primary end point. The C-statistic demonstrated the significant prognostic value of older age and known ischemic vascular disease, beyond troponin. Clinical parameters inclusive of heart rate, blood pressure, and risk factors for arteriosclerosis showed no relationship with adverse events. Readmission rate did not differ between groups.

Conclusions

In patients with acute AF, minor cTnI elevations link to short-term adverse events. Known ischemic vascular disease and older age showed prognostic value only in the long term.     

Speed of finger tapping as a predictor of functional outcome after unilateral stroke

OBJECTIVES: To determine (1) if the speed of finger tapping of the hand ipsilateral to the lesion (ie, unaffected hand) remains stable during the first 6 months after stroke and (2) if the speed of finger tapping of the unaffected hand is related to functional outcome after neurorehabilitation, which is of relevance to clinical practice. DESIGN: Prospective cohort study with measurements at admission to inpatient rehabilitation (t0), 4 weeks after admission (t1), at discharge (t2), and 3 months after discharge (t3). SETTING: Neurorehabilitation unit of a Dutch rehabilitation center. PARTICIPANTS: Fifty-seven patients with a unilateral first-ever stroke and 42 spouses (controls) of stroke patients without history of neurologic disorders were administered the finger-tapping test to generate normative scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Finger-tapping speed of the ipsilateral hand from the Amsterdam Neuropsychological Test battery. The Barthel Index, Frenchay Activities Index (FAI), and Sickness Impact Profile-68 (SIP-68) were also used as outcome measures. RESULTS: The speed of finger tapping of the ipsilateral hand improved significantly from t0 (mean, 44.13) to t1 (mean, 47.30, P=.02) but consecutively remained stable until 3 months after discharge. Four weeks after admission, the speed of finger tapping was comparable to the scores of the controls. The speed of finger tapping at admission was significantly correlated with the Barthel Index score at discharge (r=.39) and the FAI score at discharge (r=.32) and follow-up (r=.37) but not with the SIP-68 score (r=.28). Regression analyses showed that the Barthel Index score at discharge could be predicted by the initial Barthel Index score and finger tapping at admission (R(2)=.49); the variance of FAI score at discharge and follow-up was largely explained by the initial Barthel Index score. CONCLUSIONS: The speed of finger tapping improved over the first 4 weeks postadmission until normative speeds were reached and remained stable during the next 4 months. The speed of finger tapping correlated with functional outcome but not with quality of life; it was a predictor of activity of daily living functioning, although not a strong one. These findings suggest that the speed of finger tapping of the ipsilateral hand is a useful measure of recovery, although other variables such as the initial level of independent functioning are of more importance.     

Serum albumin as a predictor of course and outcome on a rehabilitation service

To determine the effect of nutritional status on the medical course and rehabilitation outcome of patients on an adult rehabilitation service, serum albumin (SA) and total lymphocyte count (TLC) were prospectively studied on 36 patients. Readings were taken on admission (T-1), at which time a Barthel Index Mobility Goal (BIMG) was assigned, and again 4 to 8 weeks after admission (T-2). A Barthel Index Mobility Score (BIMS) was assigned at discharge. Rehabilitation program restrictions due to medical complications correlated negatively with both the SA level at T1 (r = -.328, p less than 0.05) and at T2 (r = -.523, p less than 0.01). The SA level at T2 correlated positively with the BIMS:BIMG ratio (r = .416, p less than 0.05) at discharge, suggesting that SA levels may predict patient mobility outcome.     

Resolution of ventilator-associated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome

OBJECTIVES: To prospectively evaluate the performance of the Clinical Pulmonary Infection Score (CPIS) and its components to identify early in the hospital course of ventilator-associated pneumonia (VAP) which patients are responding to therapy. DESIGN: Prospective, multicenter, in a cohort of mechanically ventilated patients. SETTING: The intensive care unit of six hospitals located in the metropolitan area of Buenos Aires, Argentina. PATIENTS: Sixty-three patients, from a cohort of 472 mechanically ventilated patients hospitalized for >72 hrs, had clinical evidence of VAP and bacteriologic confirmation by bronchoalveolar lavage (BAL) or blood cultures. INTERVENTIONS: Bronchoscopy with BAL fluid culture and blood cultures after establishing a clinical diagnosis of VAP. All patients received antibiotics, 46 before bronchoscopy and 17 immediately after bronchoscopy. MEASUREMENTS AND RESULTS: CPIS was measured at 3 days before VAP (VAP-3); at the onset of VAP (VAP); and at 3 (VAP+3), 5 (VAP+5), and 7 (VAP+7) days after onset. CPIS rose from VAP-3 to VAP and then fell progressively in the population as a whole (p <.001), and the fall in CPIS was significant in 31 survivors, but not in 32 nonsurvivors. From the individual components of the CPIS, only the Pao /Fio ratio distinguished survivors from nonsurvivors, beginning at VAP+3. When CPIS was <6 at 3 or 5 days after VAP onset, mortality was lower than in the remaining patients (p =.018). These differences also related to the finding that those receiving adequate therapy had a slight fall in CPIS and a significant increase of Pao /Fio at VAP+3, whereas those getting inadequate therapy did not. CONCLUSIONS: Serial measurements of CPIS can define the clinical course of VAP resolution, identifying those with good outcome as early as day 3, and could possibly be of help to define strategies to shorten the duration of therapy.     

Gestational sac diameter in very early pregnancy as a predictor of fetal outcome.

OBJECTIVE: To determine whether transvaginal sonographic measurement of gestational sac diameter in pregnancies 28-42 days from the last menstrual period can predict whether a pregnancy results in a normal term birth or a spontaneous miscarriage. DESIGN: Gestational sac diameter was measured during the 4th and 5th weeks of gestation from the last menstrual period in 67 women who had a total of 102 ultrasound scans. These pregnancies were followed until one of two outcomes occurred: term gestation (n = 32) or spontaneous miscarriage (n = 35). Gestational sac diameter as a function of gestational age was compared in each of the groups. RESULTS: The mean diameter of the gestational sac at 28-35 days from the last menstrual period among normal pregnancies did not differ significantly from that in those that subsequently miscarried (2.6 mm vs. 2.7 mm; P = 1.00). In pregnancies 36-42 days from the last menstrual period, the mean sac diameter was significantly different between the two groups (normal group, mean sac diameter, 8.2 mm and miscarriage group, mean sac diameter, 4.5 mm; P < 0.001). CONCLUSION: There is no difference in gestational sac diameter at 28-35 days from the last menstrual period in normal and abnormal pregnancies. However, smaller than expected sac diameter in pregnancies 36-42 days from the last menstrual period is predictive of spontaneous miscarriage.     

Cell-free plasma DNA as a predictor of outcome in severe sepsis and septic shock

BACKGROUND: Increased concentrations of cell-free DNA have been found in plasma of septic and critically ill patients. We investigated the value of plasma DNA for the prediction of intensive care unit (ICU) and hospital mortality and its association with the degree of organ dysfunction and disease severity in patients with severe sepsis. METHODS: We studied 255 patients with severe sepsis or septic shock. We obtained blood samples on the day of study inclusion and 72 h later and measured cell-free plasma DNA by real-time quantitative PCR assay for the beta-globin gene. RESULTS: Cell-free plasma DNA concentrations were higher at admission in ICU nonsurvivors than in survivors (median 15 904 vs 7522 genome equivalents [GE]/mL, P < 0.001) and 72 h later (median 15 176 GE/mL vs 6758 GE/mL, P = 0.004). Plasma DNA values were also higher in hospital nonsurvivors than in survivors (P = 0.008 to 0.009). By ROC analysis, plasma DNA concentrations had moderate discriminative power for ICU mortality (AUC 0.70-0.71). In multiple regression analysis, first-day plasma DNA was an independent predictor for ICU mortality (P = 0.005) but not for hospital mortality. Maximum lactate value and Sequential Organ Failure Assessment score correlated independently with the first-day plasma DNA in linear regression analysis. CONCLUSIONS: Cell-free plasma DNA concentrations were significantly higher in ICU and hospital nonsurvivors than in survivors and showed a moderate discriminative power regarding ICU mortality. Plasma DNA concentration was an independent predictor for ICU mortality, but not for hospital mortality, a finding that decreases its clinical value in severe sepsis and septic shock.     

The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis

Criteria defining the <it>systemic inflammatory response syndrome</it> (SIRS) were used to assess prospectively 270 clinical episodes in which blood cultures were taken from patients in general medicine. SIRS, severe sepsis and septic shock occurred in 149 (55%), 13 (5%) and 9 (3%) episodes, respectively. However, evidence of organ hypoperfusion indicating severe sepsis was recorded as sought in only 26% of episodes of SIRS. Crude mortality at 28 days increased sequentially as more SIRS criteria were met, rising from 12% in non-SIRS blood culture episodes, to 36% when all four criteria were met. Mortality from severe sepsis and septic shock was 38% and 56%, respectively. In 61/64 (95%) episodes of clinically important bacteraemia, patients fulfilled SIRS criteria when the blood culture was taken. However, the positive predictive value of SIRS for predicting bacteraemia was only 7%. Patients who did not fulfill SIRS criteria when blood cultures were taken were at low risk of bacteraemia and comprised 45% (121/270) of the study population. Three patients in this low-risk group had bacteraemia. Mortality in bacteraemic patients with severe sepsis or septic shock who were initially treated with ineffective antibiotics for up to 48 h was 80%, compared to 42% in those always treated appropriately.      

Preoperative quadriceps strength as a predictor for short-term functional outcome after total hip replacement

Holstege MS, Lindeboom R, Lucas C. Preoperative quadriceps strength as a predictor for short-term functional outcome after total hip replacement.

Objective

To determine the preoperative strength of the muscle group of the lower extremity that is most important in predicting functional recovery after primary unilateral total hip replacement (THR).

Design

Prospective observational study with inception cohort.

Settings

Joint care program (hospital care/clinical division of a nursing home/outpatient physical therapy).

Participants

Patients (N=55) undergoing primary unilateral THR.

Interventions

Not applicable.

Main Outcome Measures

Baseline measures within 2 weeks preoperative and follow-up at 6 and 12 weeks postoperative included isometric strength measurement of the hip (flexors, extensors, abductors, adductors) and knee (flexors, extensors) musculature using a handheld dynamometer. Functional outcome was tested using performance-based (Timed Up and Go Test, 6-Minute Walk Test) and self-report measures (Western Ontario and McMaster Universities Osteoarthritis Index, subscale Physical Function [WOMAC PF], 36-Item Short Form Health Survey subscale Mental Health, visual analog scale for pain).

Results

Of the patients (N=55; mean age, 72.7±6.8y; 41 women) included; 18 dropped out, leaving 37 patients for analyses. After correction for WOMAC PF score at baseline, body mass index, sex, and age, the preoperative knee extensors strength measure of the operated site was the only muscle group showing a significant effect on functional outcome measured by using the WOMAC PF at 12 weeks postoperatively (R²=.355; β=−.105; P for β=.004).

Conclusion

Preoperative greater knee extensor strength of the operated site is associated with better physical function, measured by using the WOMAC PF at 12 weeks postoperative.