Predicting long-term outcome in poor grade aneurysmal subarachnoid haemorrhage patients utilising the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is the most universally accepted system for grading level of consciousness. Predicting outcome is particularly difficult in poor grade aneurysmal subarachnoid haemorrhage (aSAH) patients. We hypothesised that the GCS and individual examination components would correlate with long-term outcome and have varying prognostic value depending on assessment time points. GCS scores of 160 aSAH patients presenting in stupor or coma were prospectively recorded on admission and each subsequent day until hospital day 14. Early treatment was planned for each patient unless the patient’s family refused aggressive intervention or the patient died before surgery. Outcomes were assessed by the modified Rankin scale (mRS) at 14 days, 3 months, and one year.All patients who did not receive surgical treatment died within one year. Of the 104 patients who received surgical treatment, 13.5% of them had a favourable outcome at 14 days, 38.5% at 3 months, and 51% at one year (p < 0.0001). Admission GCS scores significantly correlated with outcome (Spearman rank test, rs = 0.472, p < 0.0001). On admission, motor examination correlated best with one-year outcome (rs = 0.533, p < 0.0001). Each point increase in motor examination predicted a 1.8-fold increased odds of favourable long-term outcome (95% confidence interval [CI], 1.4–2.3). At discharge, eye examination (rs = 0.760, p < 0.0001) correlated best with one-year outcome, and a one point increase in eye examination predicted a 3.1-fold increased odds of favourable outcome (95% CI, 1.8–5.4). During hospitalisation, the best eye exam (rs = 0.738, p < 0.0001) and worst motor exam (rs = 0.612, p < 0.0001) were the most highly correlated with the one-year outcome.Long-term follow-up is necessary when evaluating recovery after aSAH, as outcomes improve significantly during the first year. The GCS and its individual components correlate well with long-term outcome. Admission motor examination and spontaneous eye opening during hospitalisation are most predictive of favourable recovery.     

Cerebral inflammatory response and predictors of admission clinical grade after aneurysmal subarachnoid hemorrhage

Poor admission clinical grade is the most important determinant of outcome after aneurysmal subarachnoid hemorrhage (aSAH); however, little attention has been focused on independent predictors of poor admission clinical grade. We hypothesized that the cerebral inflammatory response initiated at the time of aneurysm rupture contributes to ultra-early brain injury and poor admission clinical grade. We sought to identify factors known to contribute to cerebral inflammation as well as markers of cerebral dysfunction that were associated with poor admission clinical grade. Between 1997 and 2008, 850 consecutive SAH patients were enrolled in our prospective database. Demographic data, physiological parameters, and location and volume of blood were recorded. After univariate analysis, significant variables were entered into a logistic regression model to identify significant associations with poor admission clinical grade (Hunt–Hess grade 4–5). Independent predictors of poor admission grade included a SAH sum score >15/30 (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.5–3.6), an intraventricular hemorrhage sum score >1/12 (OR 3.1, 95% CI 2.1–4.8), aneurysm size >10 mm (OR 1.7, 95% CI 1.1–2.6), body temperature ?38.3 °C (OR 2.5, 95% CI 1.1–5.4), and hyperglycemia >200 mg/dL (OR 2.7, 95% CI 1.6–4.5). In a large, consecutive series of prospectively enrolled patients with SAH, the inflammatory response at the time of aneurysm rupture, as reflected by the volume and location of the hemoglobin burden, hyperthermia, and perturbed glucose metabolism, independently predicts poor admission Hunt–Hess grade. Strategies for mitigating the inflammatory response to aneurysmal rupture in the hyper-acute setting may improve the admission clinical grade, which may in turn improve outcomes.     

A cohort study of patients with anemia on admission and fatality after acute ischemic stroke

Reduced blood hemoglobin levels may impair oxygen delivery to the brain and hinder neurological improvement. We prospectively registered consecutively hospitalized Chinese patients with acute ischemic stroke within 24 hours of symptom onset to investigate whether anemia on admission influences case fatality and functional outcome of acute ischemic stroke at 12 months. Anemia was defined as a blood hemoglobin level of < 120 g/L for women, and < 130 g/L for men. We also performed a meta-analysis of the current cohort and previously published studies. We included 1176 patients, of whom 351 patients (29.8%) had anemia. Age (odds ratio [OR] = 1.02, 95% confidence interval [CI]: 1.01–1.03), history of hemorrhagic stroke (OR = 3.34, 95% CI: 1.17–9.56), alcohol consumption (OR = 0.59, 95% CI: 0.38–0.92), and estimated glomerular filtration rate < 60 mL/minute per 1.73 m² (OR = 1.34, 95% CI: 1.00–1.80) were the independent predictors of anemia. After adjustment for potential confounders, anemia on admission was shown to be an independent predictor of death at discharge and at 12 months (OR = 1.66, 95% CI, 1.08–2.56; OR = 1.56, 95% CI, 1.05–2.31). A meta-analysis of six included studies involving 3810 participants confirmed that anemia on admission was an independent predictor of death at the end of follow-up (OR = 1.67, 95% CI, 1.25–2.08). Further studies are required to confirm these findings.     

Sleep-disordered breathing: Impact on functional outcome of ischemic stroke patients

Background and purposeSleep-disordered breathing (SDB) is more prevalent in stroke patients than age- and sex-matched controls, but the relationship between SDB and functional outcome of stroke patients is unclear. The aim of our study was to determine the prevalence of SDB in ischemic stroke and its influence on functional outcome at 3 and 6 months after stroke onset.MethodsIn a prospective study, 60 patients were selected by polysomnography (PSG). The apnea–hypopnea index (AHI) was determined 6.5 ± 3.2 days after stroke onset. Neurologic severity at admission was assessed by the Scandinavian Stroke Scale (SSS) and outcome by the Barthel Index (BI). Patients were evaluated on admission, 3 and 6 months after stroke onset.ResultsAmong the 60 patients, 39 (65%) patients had SDB (AHI ? 5); of these, 30 patients (50%) had AHI ? 15 and 18 (30%) > 30. On Logistic regression analysis, the BI at 3 months was independently predicted by SSS (OR = 0.74, 95% CI [0.62–0.88], P = 0.001) and AHI (OR = 1.09, 95% CI [1.02–1.17], P < 0.05). At 6 months, the BI was predicted only by SSS (OR = 0.83, 95% CI [0.74–0.92], P = 0.001).ConclusionsSDB is common in patients during acute phase after stroke onset. SDB appears to be associated with a worse functional outcome during the early recovery period following stroke, increasing the likelihood of dependency.     

Should we treat patients with impaired consciousness and periodic patterns on EEG?

PurposeThe significance of periodic EEG patterns in patients with impaired consciousness is controversial. We aimed to determine if treating these patterns influences clinical outcome.MethodWe studied all patients who had periodic discharges on their EEG recordings from January 2007 to December 2009. Patients with clinical seizures within the preceding 24 h, or with unequivocal electrographical seizure activity were excluded. Logistic regression was performed to analyze for factors associated with (a) mortality (b) functional status (c) resolution of EEG pattern.ResultsOf the 4246 patients who had EEG, 111 (2.6%) had periodic EEG patterns. 64 met inclusion criteria. In adjusted analysis, higher mortality was associated with acute symptomatic etiology (OR 17.74, 95% CI 1.61–196.07, p = 0.019), and presence of clinical seizures (OR 4.73, 95% CI 1.10–20.34, p = 0.037). For each unit decrement of GCS, the odds of inpatient mortality and a poorer functional state on discharge increased by 23% (95% CI 7–37%, p = 0.009) and 33% (95% CI 9–51%, p = 0.011) respectively. Administration of abortive therapy was an independent risk factor for poorer functional status on discharge (adjusted OR 41.39, 95% CI 2.88–594.42, p = 0.006), while patients with history of pre-existing cerebral disease appeared more likely to return to baseline functional status on discharge (unadjusted OR 5.00, 95% CI 1.40–17.86, p = 0.013).ConclusionTreatment of periodic EEG patterns does not independently improve clinical outcome of patients with impaired conscious levels. Occurrence of seizures remote to the time of EEG and lower GCS scores independently predict poor prognoses.     

Association of ischemic and hemorrhagic strokes hospital admission with extreme temperature in Nanchang,China—A case-crossover study

Despite consistent evidence of a higher short-term risk of stroke mortality associated with ambient temperature, there are no findings on the association between extreme temperature and stroke. A total of 16,264 stroke hospital admissions were observed in three hospitals of Nanchang between 2008 and 2015. The case-crossover design was utilized for our study. Conditional logistic regression models were used to calculate the odds ratios. Extreme high temperature exposure during the 3 days before the stroke was associated with both ischemic (OR = 1.18; 95% CI: 1.07–1.36) and hemorrhagic stroke admissions (OR = 1.34; 95% CI: 1.26–1.42) as compared to 3-day control periods (1–3 days last week before the onset of stroke). Extreme low temperature was associated with hemorrhagic stroke admission (OR = 1.42; 95% CI: 1.28–1.58) but not ischemic stroke (OR = 1.06; 95% CI: 0.93–1.13). This study suggests that extreme high temperature might be a risk factor for both hemorrhagic and ischemic strokes, and that extreme low temperature might be a risk factor of hemorrhagic stroke. Further studies are necessary in order to clarify this relationship and provide evidence for stroke prevention.     

MTHFR C677T polymorphism and migraine risk: A meta-analysis

Many molecular epidemiological studies were carried out in recent years to assess the association between the MTHFR C677T polymorphism and migraine risk in diverse populations. However, the results remain controversial rather than conclusive. The objective of this study was to investigate the role of C677T MTHFR polymorphism in migraine pathogenesis. We performed a meta-analysis of published case–control studies concerning the association of the C677T MTHFR polymorphism and migraine. Pooled ORs were established using both random and fixed effects models. This meta-analysis on 17 studies with 8903 cases and 27,637 controls showed that the allele 677T was associated with a significantly increased risk of total migraine in Asians (TT vs. CT + CC: OR = 1.62, 95% CI: 1.13–2.32, P_H = 0.573, I² = 0.0%; T vs. C: OR = 1.18, 95% CI: 1.00–1.40, P_H = 0.147, I² = 44.1%). Similar results were also presented in Asian populations with MA (TT vs. CC: OR = 1.62, 95% CI: 1.11–3.75; TT vs. CT + CC: OR = 2.00, 95% CI: 1.01–3.95; T vs. C: OR = 1.31, 95% CI: 1.02–1.69) without significant heterogeneity. We conclude that the C677T MTHFR polymorphism, responsible for a reduction of the MTHFR activity in folate metabolism, may act as a genetic susceptibility factor for migraine, MA in particular among the subjects of Asian descent.     

Rs3761389 polymorphism in autoimmune regulator (AIRE) gene is associated with susceptibility of myasthenia gravis in Chinese patients

Polymorphism in autoimmune regulator (AIRE) gene is associated with various autoimmune disorders. Abnormal AIRE expression is associated with the development of myasthenia gravis (MG). We investigated the association of polymorphism in AIRE gene and the clinical features and severity of MG. The frequencies of alleles and genotypes were compared between 480 MG patients and 487 healthy controls, as well as among subgroups of MG patients. The frequencies of rs3761389 G allele in MG group (OR = 1.213, CI 95% 1.014–1.451, p = 0.035) and in mild (Oosterhuis score 0–2) subgroup (OR = 1.393, CI 95% 1.110–1.751, p = 0.004) were significantly higher than those in the control group. There were significant differences in the frequencies of rs3761389 genotypes (OR = 1.20, CI 95% 1.00–1.43, p = 0.046, log-additive model) and mild subgroup (OR = 1.32, CI 95% 1.03–1.69, p = 0.0058, log-additive model) compared with the control group. A Logistic regression analysis did not identify rs3761389 genotype as an independent risk factor to predict the severity of MG. This study provides the necessary preliminary data on the association with rs3761389 in AIRE gene with the susceptibility of MG, but not with the severity of MG.     

Traumatic interhemispheric subdural haematoma: Study of 35 cases

The clinical and radiological findings, management, and outcomes in 35 patients with traumatic interhemispheric subdural haematoma (ISH) were reviewed retrospectively. Twenty-five patients had favourable outcomes and 10 had poor outcomes. All patients were treated conservatively for ISH. Univariate analysis found that the Glasgow Coma Scale (GCS) score (p < 0.001), hypovolemic shock (p = 0.018), skull fracture (p = 0.008), convexity or posterior fossa subdural haematoma (p = 0.008), and subarachnoid haemorrhage (SAH) were correlated with outcome (p < 0.001). Multivariate analysis showed that GCS score (p = 0.031; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3–0.9) and the presence of SAH (p = 0.023; OR, 14.2; 95% CI, 1.5–138.2) were significantly related to poor outcome. This study provides important information on the clinicoradiological findings and prognoses in patients with traumatic ISH.     

Prevalence and risk factors of female sexual dysfunction among healthcare personnel in malaysia

ObjectiveTo determine the prevalence and risk factors of female sexual dysfunction (FSD) among healthcare personnel in selected healthcare facilities in Malaysia.MethodsThis was a cross-sectional study carried out at three large healthcare facilities that were selected by convenience sampling. Within each facility, stratified random sampling was used to select suitable candidates to participate in the study (n = 201). Validated questionnaires were used to assess depression, anxiety, sexual function in women and erectile dysfunction (ED) in their partners.ResultsThe prevalence of FSD was 5.5%. Women with sexual dysfunction were more likely to be married longer (OR = 4.08; 95% CI; 1.15–4.50), had lower frequency of sexual intercourse (OR = 5.00; 95% C; 1.05–23.76) and had a spouse with ED (OR = 24.35; 95% CI; 4.55–130.37). Multivariate analysis showed that ED was the strongest predictor for FSD (AOR = 27.30; 95% CI; 4.706–159.08).ConclusionOne in eighteen female healthcare personnel suffered from FSD and presence of ED in the partner strongly impacted her sexual function, negatively. The findings highlight the importance of including the male partner in clinical assessment of FSD.     

Obstructive Sleep Apnea Syndrome in the Sao Paulo Epidemiologic Sleep Study

ObjectiveTo estimate the prevalence of Obstructive Sleep Apnea Syndrome (OSAS), using current clinical and epidemiological techniques, among the adult population of Sao Paulo, Brazil.MethodsThis population-based survey used a probabilistic three-stage cluster sample of Sao Paulo inhabitants to represent the population according to gender, age (20–80 years), and socio-economic status. Face-to-face interviews and in-lab full-night polysomnographies using a nasal cannula were performed. The prevalence of OSAS was determined according to the criteria of the most recent International Classification of Sleep Disorders (ICDS-2) from American Academy of Sleep Medicine (2005).ResultsA total of 1042 volunteers underwent polysomnography (refusal rate = 5.4%). The mean age ± SD was 42 ± 14 years; 55% were women and 60% had a body mass index > 25 kg/m². OSAS was observed in 32.8% of the participants (95% CI, 29.6–36.3). A multivariate logistic regression model identified several independent and strong associations for the presence of OSAS: men had greater association than women (OR = 4.1; 95% CI, 2.9–5.8; P < 0.001) and obese individuals (OR = 10.5; 95% CI, 7.1–15.7; P < 0.001) than individuals of normal weight. The adjusted association factor increased with age, reaching OR = 34.5 (95% CI, 18.5–64.2; P < 0.001) for 60–80 year olds when compared to the 20–29 year old group. Low socio-economic status was a protective factor for men (OR = 0.4), but was an associated factor for women (OR = 2.4). Self-reported menopause explained this increased association (age adjusted OR = 2.1; 95% CI, 1.4–3.9; P < 0.001), and it was more frequent in the lowest class (43.1%) than either middle class (26.1%) or upper class (27.8%) women.ConclusionsThis study is the first apnea survey of a large metropolitan area in South America identifying a higher prevalence of OSAS than found in other epidemiological studies. This can be explained by the use of the probabilistic sampling process achieving a very low polysomnography refusal rate, the use of current techniques and clinical criteria, inclusion of older groups, and the higher prevalence of obesity in the studied population.     

Immune mediated conditions in autism spectrum disorders

We conducted a case-control study among members of Kaiser Permanente Northern California (KPNC) born between 1980 and 2003 to determine the prevalence of immune-mediated conditions in individuals with autism, investigate whether these conditions occur more often than expected, and explore the timing of onset relative to autism diagnosis. Cases were children and young adults with at least two autism diagnoses recorded in outpatient records (n = 5565). Controls were children without autism randomly sampled at a ratio of 5 to 1, matched to cases on birth year, sex, and length of KPNC membership (n = 27,825). The main outcomes – asthma, allergies, and autoimmune diseases – were identified from KPNC inpatient and outpatient databases. Chi-square tests were used to evaluate case-control differences. Allergies and autoimmune diseases were diagnosed significantly more often among children with autism than among controls (allergy: 20.6% vs. 17.7%, Crude odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.13–1.31; autoimmune disease: 1% vs. 0.76%, OR = 1.36, 95% CI 1.01–1.83), and asthma was diagnosed significantly less often (13.7% vs. 15.9%; OR = 0.83, 95% CI 0.76–0.90). Psoriasis occurred more than twice as often in cases than in controls (0.34% vs. 0.15%; OR = 2.35, 95% CI 1.36–4.08). Our results support previous observations that children with autism have elevated prevalence of specific immune-related comorbidities.     

Association of stress coping strategies with Internet addiction in college students: The moderating effect of depression

BackgroundThis study examined the association between stress-related coping strategies and Internet addiction and the moderating effect of depression in a sample of Taiwanese college students.MethodA total of 500 college students (238 men and 262 women) participated in this study. Internet addiction was assessed using the Chen Internet Addiction Scale. Participants’ stress coping strategies and depressive symptoms were measured using the Coping Orientation to Problems Experienced and the Beck Depression Inventory-II, respectively. We used t and chi-square tests to examine differences in demographic characteristics, depression, and stress coping strategies between participants with and without Internet addiction. Significant variables were used in a logistic regression model to examine the association between stress coping strategies and Internet addiction and the moderating effect of depression on the association.ResultsResults indicated that use of restraint coping was negatively associated with Internet addiction (odds ratio [OR] = 0.886, 95% confidence interval [CI]: 0.802–0.977), whereas denial (OR = 1.177, 95% CI: 1.029–1.346) and mental disengagement (OR = 2.673, 95% CI: 1.499–4.767) were positively associated with Internet addiction. Depression had a moderating effect on the association between denial and Internet addiction (OR = 0.701, 95% CI: 0.530–0.927).ConclusionsStress coping strategies and depression are important factors to evaluate when developing intervention programs targeting college undergraduate students with Internet addiction.     

Frequency and predictors of perioperative psychiatric symptom worsening among patients with psychiatric disorders

ObjectiveThis study aimed to clarify the frequency of perioperative psychiatric symptom worsening among patients with psychiatric disorders and investigate factors predictive of symptom aggravation.MethodThis study adopted a retrospective cohort study design. The sample consisted of perioperative inpatients who were diagnosed with psychiatric disorders on admission and received psychiatric intervention between January 1, 2015 and November 31, 2017.ResultsOf 176 inpatients who met our inclusion criteria, 15 (8.5%) exhibited symptom worsening. Factors associated with symptom worsening included changes in surface morphology during surgery (p < 0.01; odds ratio (OR) = 10.58; 95% confidence interval (CI), 3.40–32.87), otolaryngological surgery (p = 0.01; OR = 6.95; 95% CI, 1.81–26.75), stay in the intensive care unit (p < 0.01; OR = 5.65; 95% CI, 1.79–17.81), and surgery duration longer than 180 min (p = 0.03; OR = 3.40; 95% CI, 1.04–11.13).ConclusionThis was the first retrospective analysis to focus on the perioperative worsening of psychiatric symptoms. As only few inpatients exhibited symptom aggravation, general hospitals without psychiatric beds can receive perioperative patients with psychiatric comorbidity. However, caution should be exercised to address the potential worsening of symptoms in cases of surface-morphology changing surgery, otolaryngological surgery, long-duration operations, and when ICU stay is required.     

Meta-analysis of stent-assisted coiling versus coiling-only for the treatment of intracranial aneurysms

Endovascular coil embolization is a widely accepted and useful treatment modality for intracranial aneurysms. However, the principal limitation of this technique is the high aneurysm recurrence. The adjunct use of stents for coil embolization procedures has revolutionized the field of endovascular aneurysm management, however its safety and efficacy remains unclear. Two independent reviewers searched six databases from inception to July 2015 for trials that reported outcomes according to those who received stent-assisted coiling versus coiling-only (no stent-assistance). There were 14 observational studies involving 2698 stent-assisted coiling and 29,388 coiling-only patients. The pooled immediate occlusion rate for stent-assisted coiling was 57.7% (range: 20.2%–89.2%) and 48.7% (range: 31.7%–89.2%) for coiling-only, with no significant difference between the two (odds ratio [OR} = 1.01; 95% confidence intervals [CI}: 0.68–1.49). However, progressive thrombosis was significantly more likely in stent-assisted coiling (29.9%) compared to coiling-only (17.5%) (OR = 2.71; 95% CI: 1.95–3.75). Aneurysm recurrence was significantly lower in stent-assisted coiling (12.7%) compared to coiling-only (27.9%) (OR = 0.43; 95% CI: 0.28–0.66). In terms of complications, there was no significant difference between the two techniques for all-complications, permanent complications or thrombotic complications. Mortality was significantly higher in the stent-assisted group 1.4% (range: 0%–27.5%) compared to the coiling-only group 0.2% (range: 0%–19.7%) (OR = 2.16; 95% CI: 1.33–3.52). Based on limited evidence, stent-assisted coiling shows similar immediate occlusion rates, improved progressive thrombosis and decreased aneurysm recurrence compared to coiling-only, but is associated with a higher mortality rate. Future randomized controlled trials are warranted to clarify the safety of stent-associated coiling.     

Facteurs individuels et contextuels participant à l’apparition de comportements violents en cours d’hospitalisations psychiatriques

BackgroundThe prevention of Physical Violent Behavior (VB) toward others during psychiatric hospitalization is a major concern of clinicians. These VBs can have a deleterious impact on the victims, inpatients or caregivers, as well as on the therapeutic milieu. Such violence can also have negative consequences for the assailant patients, such as repeatedly being hospitalized under restraint, stigmatization, and difficulties reintegrating into the community.ObjectivesThis study explored individual (age, gender, marital status, living status, diagnostic) and institutional (type of admission, length of stay, number of previous hospitalizations) risk factors, and how their interactions could increase the risk of VB during psychiatric hospitalizations.MethodThe study was carried out over a period of four years in the psychiatry department of the Lausanne University Hospital, on the 15 wards (219 beds) specialized in acute psychiatric care for adults. All the patients admitted to one of these wards during this period (n = 4518), aged between 18 and 65 years, were included in the study. The sample was divided in two groups: non-violent patients (NVPs) and violent patients (VPs). VBs, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale – Revised (SOAS – R). Only physical assaults, associated or not with other types of violence, involving hospitalized patients were analyzed. Personal and institutional factors were extracted from the hospital database. Chi² independence tests were used to assess differences between groups. Logistic regression models were used to identify the links between each factor and the VB. Classification and regression trees were used to study the hierarchical effect of factors, and combinations of factors, on VBs.ResultsDuring the study period, 414 VBs were reported involving 199 patients (4.40 % of all patients). VPs were significantly younger, male, more likely to be unmarried and living in sheltered housing before hospitalization. In this group, the proportion of patients with diagnoses of schizophrenia, and/or schizophrenia with comorbid substance abuse and cognitive impairment, were higher compared to NVPs. VPs were more frequently admitted involuntarily, had a longer average length of stay and a greater number of previous hospitalizations. The logistic regression model performed on individual factors have shown a significant link between age (OR = 0.99; CI: 0.97–1.00; P-value = 0.024), living in sheltered housing before admission (OR = 2.46; CI: 1.61–3.75; P-value < 0.000), schizophrenic disorders (OR = 2.18; CI: 1.35–3.57; P-value = 0.001), schizophrenic disorders with substance abuse comorbidity (OR = 2.00; CI: 1.16–3.37; P-value = 0.016), cognitive impairment (OR = 3.41; CI: 1,21–8.25; P-value = 0.010), and VBs. The logistic regression model on institutional factors have shown a significant link between involuntary hospitalization (OR = 4.38; CI: 3.20–6.08; P-value < 0.000), length of previous stay (OR = 1.01; CI: 1.00–1.01; P-value < 0.000), number of previous hospitalizations (OR = 1.06; CI: 1.00–1.12; P-value = 0.031), and VBs. The logistic regression model on individual and institutional factors have shown a significant link between age (OR = 0.99; CI: 0.97–1.00; P-value = 0.008), living in sheltered housing before admission (OR = 2.46: CI: 1.61–3.75; P-value = 0.034), cognitive impairment (OR = 3.41; CI: 1.21–8.25; P-value = 0.074), involuntary hospitalization (OR = 3.46; CI: 2.48–4.87; P-value < 0.000), length of previous stay (OR = 1.01; CI: 1.00–1.01; P-value < 0.000), and VBs. The classification and regression trees have shown that the relationship between long length of stay and repeated hospitalizations mainly potentiate the risk of violence.ConclusionThe results of this study have shown the existence of a small group of vulnerable patients who accumulate constrained hospital stays during which violence occurs. Exploring the clinical profiles and institutional pathways of patients could help to better identify these patients and promote a more appropriate mode of support, such as intensive clinical case management. This model could facilitate the development of a clinical network and the links between the structures and partners caring for a patient. This would create a continuous support, avoiding or limiting the lack of continuity of care and care disruption.     

Psychosocial work-related predictors and consequences of personal burnout among staff working with people with intellectual disabilities

The purposes of this study were to investigate the potential predictors of personal burnout among staff working with people with intellectual disabilities and to investigate whether personal burnout is associated with health and work-related outcomes. A cross-sectional survey was carried out in 2011 in 30 residential facilities in northern Germany (N = 409, response rate 45%). The German standard version of the Copenhagen Psychosocial Questionnaire was used. In a multiple logistic regression analysis, we identified factors which were predictive of personal burnout, such as work–privacy conflict (OR = 1.04, 95% CI 1.03, 1.05), emotional demands (OR = 1.03, 95% CI 1.01, 1.05), role conflicts (OR = 1.02, 95% CI 1.02, 1.03), job insecurity (OR = 1.03, 95% CI 1.01, 1.05) and feedback (OR = 0.98, 95% CI 0.97, 0.99). These factors explained 49% of the total variance. Higher levels of personal burnout were significantly correlated with higher rates of intention to leave the job and cognitive stress symptoms (p < .01). Low values of personal burnout were associated with greater job satisfaction, good general health, and higher satisfaction with life (p < .01). The present study indicates that improving the psychosocial work environment at the organizational level may reduce personal burnout and may also diminish unfavorable outcomes, such as intention to leave or job dissatisfaction.     

Anticoagulation-related reduction of first-ever stroke severity in Chinese patients with atrial fibrillation

Atrial fibrillation (AF) is an independent risk factor for ischemic stroke and warfarin related anticoagulation has been recommended as an effective treatment for stroke prevention. We aimed to determine whether pre-stroke oral anticoagulation therapy would reduce initial stroke severity in AF patients with first-ever ischemic stroke. We identified consecutive patients who developed first-ever ischemic stroke and were eligible for anticoagulation therapy from the China National Stroke Registry. Multivariate logistic analysis was used to assess the association between warfarin usage and initial stroke severity, measured by the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). Of 9519 patients, 1140 (11.98%) had AF, including 440 (38.6%) without known AF before presentation, 561 (49.2%) with known AF but not taking warfarin, and 139 (12.2%) with known AF who were taking warfarin. Compared to patients with known AF but not on warfarin, the odds ratio (OR) of having a major stroke (NIHSS ⩾4) was lower in patients with known AF who were on warfarin (OR = 0.68; 95% confidence interval [CI] 0.57–0.84). The OR of developing a severe coma (GCS 3–8) was also reduced in the warfarin group (OR = 0.71; 95% CI 0.56–0.91). In conclusion, pre-stroke warfarin therapy lowered the severity of the first-ever ischemic stroke in patients with known AF. Considering its efficacy in stroke prevention and the significant under-usage of warfarin in China, the primary prevention of stroke in AF patients should be reinforced.     

Bidirectionality and gender differences in emotional disturbance associations with obesity among Taiwanese schoolchildren

Childhood obesity is associated with psychological problems, but little is known about its association with emotional disturbance (ED) in the educational setting, especially by gender. In the population representative Elementary School Children's Nutrition and Health Survey in Taiwan 2001–2002 of children aged 6–13 (n = 2283), we have considered whether ED is associated with obesity by gender. Schoolchildren were assessed with the modified scale for assessing emotional disturbance questionnaires. For some subscales, boys and girls had ED associations with obesity which were bidirectional. With normal weight as referent and relevant adjustments, the significant ED subscales predictable by obesity were relationship problems (RP) in boys (odds ratio, OR = 1.89 with 95% CI: 1.08–3.30) and inappropriate behavior (IB) in girls (OR = 2.88: 95% CI: 1.47–5.61). Conversely, with ‘no-specific-ED’ as referent, obesity was predictable by fully-adjusted specific-EDs in the same subscales, namely RP in boys (OR = 1.88 with 95% CI: 1.13–3.13) and IB in girls (OR = 3.03: 95% CI: 1.57–5.85). Child obesity prevalence showed no trend with school grade from 1 to 6, but for aggregate ED and most of its subscales the prevalence increased with grade (P for trend <0.01). Thus, there is some dissociation of obesity and ED as judged by their trend presence with school grade. Where obesity and ED occurred together (for inability-to-learn and unhappiness or depression), there were upward trends with grade (P < 0.01). There are probably some selected bidirectional pathogenicities for obesity-ED associations with different expression in boys and girls and during elementary education. This provides some policy direction while mechanisms and causality require elucidation.