Interobserver agreement of Medical Research Council sum-score and handgrip strength in the intensive care unit

Introduction: Muscle weakness often complicates critical illness and is associated with devastating short‐ and long‐term consequences. For interventional studies, reliable measurements of muscle force in the intensive care unit (ICU) are needed. Methods: To examine interobserver agreement, two observers independently measured Medical Research Council (MRC) sum‐score (n = 75) and handgrip strength (n = 46) in a cross‐sectional ICU sample. Results: The intraclass correlation coefficient (ICC) for MRC sum‐score was 0.95 (0.92–0.97). The kappa coefficient for identifying “significant weakness” (MRC sum‐score <48, MRC subtotal upper limbs <24) and “severe weakness” (MRC sum‐score <36) was 0.68 ± 0.09, 0.88 ± 0.07, and 0.93 ± 0.07, respectively. The ICC for left and right handgrip strength was 0.97 (0.94–0.98) and 0.93 (0.86–0.97), respectively. Conclusions: Interobserver agreement on MRC sum‐score and handgrip strength in the ICU was very good. Agreement on “severe weakness” (MRC sum‐score <36) was excellent and supports its use in interventional studies. Agreement on “significant weakness” (MRC sum‐score <48) was good, but even better using the equivalent cut‐off in the upper limbs. It remains to be determined whether this may serve as a substitute. Muscle Nerve 45: 18–25, 2012     

Immunoglobulin G level variations in treated chronic inflammatory demyelinating polyneuropathy: clues for future treatment regimens?

Intravenous immunoglobulins (IVIg) are effective for treating chronic inflammatory demyelinating polyneuropathy (CIDP), although treatment needs are variable and need to be individualized. Dose and frequency requirements are not currently predictable in advance. In Guillain–Barré syndrome, IVIg interpatient pharmacokinetic variations have been demonstrated in relation to clinical outcome. We studied 15 patients with CIDP following two routine courses of IVIg. IgG levels were assessed pretreatment and 14 days post-treatment. Best clinical response (BCR) was ascertained in each case, predefined, according to individual patients’ circumstances, on the 10 m walk, or MRC sum score, or Jamar grip dynamometry. Correlations between IgG level variations, doses administered, weight, body mass index, BCR and infusion interval were determined. Postinfusion rise in IgG levels were correlated in individual patients (p = 0.005), but interpatient variability was high. No correlations were ascertained between IgG level variation and weight, body mass index, BCR, total dose of IVIg administered, or dose of IVIg administered per kilogram per week. There were significant correlations between total dose administered and post-infusion IgG level at 14 days (p = 0.004) and between infusion interval and mean rise in IgG level (p = 0.001) These findings suggest significant variability in IgG metabolism between patients, unrelated to minimal effective dose administered, weight, body mass index or degree of functional improvement. Required frequency of IVIg infusions may, however, importantly relate to patient-specific post-infusion rise in IgG levels hence possibly explaining inter-patient differences in treatment frequency needs. IgG level monitoring may be helpful in establishing optimum treatment regimens in individual cases.     

Influence of critical illness on axonal loss in Guillain–Barré syndrome

In this study we sought to determine whether axonal damage in severe Guillain–Barré syndrome (GBS) was secondary to critical illness polyneuropathy (CIP) in the intensive care unit (ICU) by reviewing comorbidities in patients who had initial and follow‐up electromyographic (EMG) studies. Patients were classified as demyelinating (EMG‐D) or axonal (EMG‐A) according to findings on the second EMG. A critical illness (CI) score, derived from components of the APACHE II score, assessed the severity of critical illness in the ICU. Forty‐one patients were admitted to the ICU and had a follow‐up EMG. Of these, 28 (68%) developed an EMG‐A pattern. There was no difference in the timing of the second EMG (mean, 23 days) between the two groups. The mean CI score (10.7 for EMG‐A vs. 9.2 for EMG‐D, P = 0.47) and frequency of sepsis (89% vs. 77%, P = 0.36) were similar between the groups. Mean strength (0–100, Medical Research Council scale) and Hughes disability scores for the EMG‐A group were significantly worse at admission, nadir, and discharge. EMG‐A patients had significantly more days on the ventilator (25 vs. 11), in the ICU (26 vs. 15), and in the hospital (29 vs. 18). Sixty‐eight percent of patients with GBS in the ICU developed axon loss, but this was not related to the usual precipitants of CIP. Muscle Nerve 39: 10–15, 2009     

Motor unit number index (MUNIX) in patients with anti-MAG neuropathy

Objective

To investigate the relationship between Motor Unit Number Index (MUNIX) and functional scales in patients with anti-Myelin Associated Glycoprotein (MAG) neuropathy and to know if MUNIX is modify after rituximab (RTX) therapy.

The FOUR Score Predicts Mortality,Endotracheal Intubation and ICU Length of Stay After Traumatic Brain Injury

Background

The Glasgow Coma Scale (GCS) is the most widely accepted scale for assessing levels of consciousness, clinical status, as well as prognosis of traumatic brain injury (TBI) patients. The Full Outline of UnResponsiveness (FOUR) score is a new coma scale developed addressing the limitations of the GCS. The aim of this prospective cohort study was to compare the performance of the FOUR score vs. the GCS in predicting TBI outcomes.

Methods

From April to July 2011, 60 consecutive adult patients with TBI admitted to the Alexandria Main University Hospital intensive care units (ICU) were enrolled in the study. GCS and FOUR score were documented on arrival to emergency room. Outcomes were in-hospital mortality, unfavorable outcome [Glasgow outcome scale extended (GOSE) 1–4], endotracheal intubation, and ICU length of stay (LOS).

Results

Fifteen (25 %) patients died and 35 (58 %) had unfavorable outcome. When predicting mortality, the FOUR score showed significantly higher area under receiver operating characteristic curve (AUC) than the GCS score (0.850 vs. 0.796, p = 0.025). The FOUR score and the GCS score were not different in predicting unfavorable outcome (AUC 0.813 vs. 0.779, p = 0.136) and endotracheal intubation (AUC 0.961 vs. 0.982, p = 0.06). Both scores were good predictors of ICU LOS (r ² = 0.40 [FOUR score] vs. 0.41 [GCS score]).

Conclusions

The FOUR score was superior to the GCS in predicting in-hospital mortality in TBI patients. There was no difference between both scores in predicting unfavorable outcome, endotracheal intubation, and ICU LOS.     

Factors Associated with the Need for Intensive Care Unit Admission Following Supratentorial Intracerebral Hemorrhage: The Triage ICH Model

Background

Providing the correct level of care for patients with intracerebral hemorrhage (ICH) is crucial, but the level of care needed at initial presentation may not be clear. This study evaluated factors associated with admission to intensive care unit (ICU) level of care.

Methods

This is an observational study of all adult patients admitted to our institution with non-traumatic supratentorial ICH presenting within 72 h of symptom onset between 2009–2012 (derivation cohort) and 2005–2008 (validation cohort). Factors associated with neuroscience ICU admission were identified via logistic regression analysis, from which a triage model was derived, refined, and retrospectively validated.

Results

For the derivation cohort, 229 patients were included, of whom 70 patients (31 %) required ICU care. Predictors of neuroscience ICU admission were: younger age [odds ratio (OR) 0.94, 95 % CI 0.91–0.97; p = 0.0004], lower Full Outline of UnResponsiveness (FOUR) score (0.39, 0.28–0.54; p < 0.0001) or Glasgow Coma Scale (GCS) score (0.55, 0.45–0.67; p < 0.0001), and larger ICH volume (1.04, 1.03–1.06; p < 0.0001). The model was further refined with clinician input and the addition of intraventricular hemorrhage (IVH). GCS was chosen for the model rather than the FOUR score as it is more widely used. The proposed triage ICH model utilizes three variables: ICH volume ≥30 cc, GCS score <13, and IVH. The triage ICH model predicted the need for ICU admission with a sensitivity of 94.3 % in the derivation cohort [area under the curve (AUC) = 0.88; p < 0.001] and 97.8 % (AUC = 0.88) in the validation cohort.

Conclusions

Presented are the derivation, refinement, and validation of the triage ICH model. This model requires prospective validation, but may be a useful tool to aid clinicians in determining the appropriate level of care at the time of initial presentation for a patient with a supratentorial ICH.

     

Prevalence, timing, risk factors, and mechanisms of anterior cerebral artery infarctions following subarachnoid hemorrhage

Anterior cerebral artery (ACA) ischemia may be underdiagnosed following subarachnoid hemorrhage (SAH). The purpose of this study is to characterize the prevalence, timing, and risk factors for ACA infarction, following primary spontaneous SAH. This was a retrospective study of consecutive SAH patients. Final admission CT scans were reviewed for the presence of ACA infarction, and prior scans serially reviewed to determine timing of infarct. Infarctions were categorized as any, early (days 0–3), late (days 4–15), or perioperative (2 days after aneurysm treatment). Demographic and clinical variables were statistically interrogated to identify predictors of infarct types. Of the 474 study patients, ACA infarctions occurred in 8 % of patients, with 42 % occurring during the early period. Multivariate logistic regression identified H/H grade 4/5 (p < 0.001), ACA/ACom aneurysm location (p < 0.001), and surgical clipping (p = 0.011) as independent predictors of any ACA infarct. In Cox hazards analysis, H/H grade 4/5 (p < 0.001), CT score 3/4 (p = 0.042), ACA/ACom aneurysm location (p < 0.001), and surgical clipping (p = 0.012) independently predicted any ACA infarct. Bivariate logistic regression identified non-Caucasian race (p = 0.032), H/H grade 3/4 (p < 0.001), CT score 3/4 (p = 0.006), IVH (p = 0.027), and ACA/ACom aneurysm (p = 0.001) as predictors of early infarct (EI). Late infarct (LI) was predicted by H/H grade 4/5 (p = 0.040), ACA/ACom aneurysm (p < 0.001), and vasospasm (p = 0.027), while postoperative infarct (PI) was predicted by surgical clipping (p = 0.044). Log-rank analyses confirmed non-Caucasian race (p = 0.024), H/H grade 3/4 (p < 0.001), CT score 3/4 (p = 0.003), IVH (p = 0.010), and ACA/ACom aneurysm (p < 0.001) as predictors of EI. LI was predicted by ACA/ACom aneurysm (p < 0.001) while surgical clipping (p = 0.046) again predicted PI. Clinical severity/grade and ACA/ACom aneurysm location are the most consistent predictors of ACA infarctions. Vasospastic and non-vasospastic processes may concurrently contribute to ACA infarcts.     

Seizures Among Long-Term Survivors of Conservatively Treated ICH Patients: Incidence,Risk Factors,and Impact on Functional Outcome

Background

Seizures are a common complication after intracerebral hemorrhage (ICH) but there is a substantial lack of information on the long-term incidence in ICH survivors and whether post-ICH seizures affect functional long-term outcome.

Methods

Over a five-year period 464 consecutive patients with spontaneous ICH were analyzed. Focussing on 1-year ICH survivors, clinical, and radiological parameters were retrieved from institutional prospective databases. The occurrence of seizures was categorized as early (≤7 days) or late (>7 days). Functional outcome was assessed by mailed questionnaires and telephone interviews, and was categorized into good vs. poor (mRS: 0–2 vs. 3–5) and favorable vs. unfavorable (mRS: 0–3 vs. 4–5). Multivariate regression models were calculated to investigate risk factors associated with post-ICH seizures including an a priori defined subgroup analysis of lobar ICH patients.

Results

Among 203 long-term ICH survivors, 19.7 % developed seizures of which 55 % occurred late. Factors associated with seizures were lobar location (OR 8.10; 95 % CI 3.04–21.59; p < 0.001), sepsis (OR 4.59; 95 % CI 1.20–17.53; p = 0.026), and history of alcohol abuse (OR 3.36; 95 % CI 1.25–9.06; p = 0.017). Subgroup analysis of lobar ICH patients revealed history of alcohol abuse as the only independent predictor of post-ICH seizures (OR 5.22; 95 % CI 1.25–21.78; p = 0.024). Functional long-term outcome among survivors was slightly worse in patients with post-ICH seizures (p = 0.059). In multivariate regression modeling for prediction of poor outcome, the parameter “post-ICH seizures” again reached a statistical trend (p = 0.065), and established parameters such as age, GCS, and hemorrhage volume were independently related to poor outcome.

Conclusions

Post-ICH seizures among long-term ICH survivors are common and may contribute to unfavorable functional outcome. Especially lobar ICH patients with a history of alcohol abuse are at risk to develop post-ICH seizures. Therefore, this subgroup may represent a target population for a prophylactic anticonvulsive treatment approach, preferably investigated in a prospective randomized trial.

     

Factors predicting the Montreal cognitive assessment (MoCA) applicability and performances in a stroke unit

The evaluation of cognitive status is not routine in the acute stroke setting. We aimed to investigate feasibility, applicability, and performances of the Montreal cognitive assessment (MoCA) in acute stroke patients. Consecutive stroke patients (ischemic or hemorrhagic) admitted to one stroke unit were evaluated 5–9 days after stroke with MoCA (score range: 0–30; higher scores indicate better cognitive performance). Pre-morbid functional and cognitive status was assessed by a structured interview to caregivers. Neuroimaging data regarding index stroke and pre-existing lesions were collected. From December 2009 to December 2010, out of 207 patients with stroke, 137 (66 %) were enrolled [mean age 69.2 ± 14.8 years; males 62 %; mean National Institute of Health and Stroke Scale (NIHSS) score 5.9 ± 7.9]. The most common reason for non-enrolment was unfitting the time window inclusion criteria. MoCA was entirely applicable to 113/137 (82.5 %) patients and the mean score was 17.8 ± 7.1. Multivariate analyses showed that non-applicability was associated with higher NIHSS scores [OR (95 % CI) = 1.4 (1.2–1.7) for each point], left sided lesions [OR (95 % CI) = 18.8 (2.3–155.2)], and worse pre-morbid functional status [OR (95 % CI) = 0.7 (0.6–0.9) for each point of the instrumental activity of daily living scale]. Factors influencing MoCA performance were low education (β = 0.264, p < 0.01), higher NIHSS scores (β = ?0.277, p < 0.01) and worse pre-morbid functional status (β = 0.504, p < 0.001). MoCA administration is feasible in acute patients with mild-to-moderate stroke, with lesion location, stroke severity, and pre-morbid functional status as major determinants of its applicability and performance. MoCA seems to reveal some degree of cognitive deficit even in patients with mild stroke.     

Clinimetric evaluation of a new overall disability scale in immune mediated polyneuropathies

OBJECTIVES: To determine the validity, reliability, and responsiveness of a new overall disability sum score in immune mediated polyneuropathies. METHODS: Three impairment measures (MRC sum score, sensory sum score, grip strength (Vigorimeter)) and three disability scales (an overall disability sum score (ODSS), Hughes' functional scale (f score), Rankin scale) were assessed in a cross sectional group of 113 clinically stable patients (83 with Guillain-Barré syndrome, 22 with chronic inflammatory demyelinating polyneuropathy (CIDP), eight with a gammopathy related polyneuropathy). The ODSS was also used serially in 20 patients with recently diagnosed Guillain-Barré syndrome (n = 7) or CIDP (n = 13) and changing clinical conditions. Multiple regression studies were performed to compare the impact of impairment disturbances (independent variables) on the various disability scales (dependent variable). RESULTS: Moderate to good construct validity (stable group: Spearman's rank test (absolute values), r = 0.41-0.79; longitudinal group: multiple correlation coefficient, R = 0.69-0.89; p < 0.006 for all associations) and reliability (intraclass correlation coefficient, R = 0.90-0.95; p < 0.0001) were demonstrated for the ODSS. Its SRM values were high (> 0.8), indicating good responsiveness. Impairment measures accounted for a higher variance proportion of the ODSS compared with the f score and Rankin (R = 0.64 v 0.56 and 0.45, respectively). CONCLUSIONS: All clinimetric requirements were met by the overall (arm and leg) disability sum score in immune mediated polyneuropathies. Its use is therefore suggested in evaluating immune mediated polyneuropathies.     

Mortality and functional disability after spontaneous intracranial hemorrhage: the predictive impact of overall admission factors

To determine the effects of different prognostic factors, including previous antiplatelet therapy, admission data, and radiographic findings on discharge and 3-month neurological condition using modified Rankin scale (mRS) and mortality at 30 days and 3-month follow-up in patients presenting to the emergency department with spontaneous intracranial hemorrhage (sICH). Between January and July 2012, 120 consecutive patients (males 62 %, females 38 %), who were admitted within 48 h of symptoms onset, were included. We recorded the following data on admission: demographics; functional scores of ICH, Glasgow Coma Scale, and National Institutes of Health Stroke Scale; vital signs; smoking status; use of illicit drug; preadmission antiplatelet treatment; results of laboratory tests (platelet count, serum glucose, sodium and creatinine levels, and prothrombin time); and primary neuroimaging findings [intraventricular hemorrhage (IVH), midline shift, and hydrocephalus]. In multivariate analysis using adjusted model for demographics and prior antiplatelet therapy; functional scores, laboratory results, and diabetes history correlated with mortality during 30 days after the event. Moreover, the parameters on the initial computed tomography scan significantly increased 30-day fatality rate and was correlated with increase in the discharge mRS score of survivors. The odds ratio (OR) and 95 % confidence interval (CI) of early mortality associated with IVH presentation was 2.34 (CI 1.76–3.02, p = 0.003). The corresponding ORs in those with midline shift displacement and hydrocephalus were 2.18 (95 % CI 2.08–3.80, p = 0.01) and 1.62 (95 % CI 1.01–2.63, p = 0.02), respectively. In patients with ICH, prognostic factors, include various clinical parameters and paraclinical findings of admission time.     

The risk stratification based on the CHA2DS2-VASc may predict the response to intravenous thrombolysis after stroke

CHA₂DS₂-VASc score influences the outcome in stroke patients with or without atrial fibrillation (AF). We assessed whether the risk stratification based on the prestroke CHA₂DS₂-VASc score may predict the response to intravenous (IV) thrombolysis in stroke patients. We conducted an analysis on prospectively collected data of 516 consecutive AF and non-AF patients treated with IV thrombolysis. Outcome measures were major improvement (NIH Stroke Scale [NIHSS] ≤8 points from baseline or NIHSS score 0) and deterioration (death or NIHSS ≥1 points from baseline) or no improvement (NIHSS score equivalent to baseline) at 24 h; excellent (modified Rankin Scale [mRS] score ≤1) and unfavorable outcome (mRS score >2) at 3 months. Multivariate analysis showed that ORs for major improvement and excellent outcome were lower in patients with intermediate risk (CHA₂DS₂-VASc = 1) (OR 0.39, 95 % CI 0.16–0.92, p = 0.032; OR 0.10, 95 % CI 0.02–0.56, p = 0.009), moderately high risk (CHA₂DS₂-VASc = 2) (OR 0.43, 95 % CI 0.19–0.96, p = 0.040; OR 0.16, 95 % CI 0.03–0.76, p = 0.022), and very high risk (CHA₂DS₂-VASc > 3) (OR 0.31, 95 % CI 0.15–0.65, p = 0.002; OR 0.17, 95 % CI 0.04–0.81, p = 0.026), whereas ORs for deterioration or no improvement and unfavorable outcome were higher only in patients with very high risk (OR 4.26, 95 % CI 1.24–14.65, p = 0.021; OR 9.26, 95 % CI 1.15–74.65, p = 0.037), compared with low risk (CHA₂DS₂-VASc = 0). Low-risk level based on the prestroke CHA₂DS₂-VASc score was predictor of effective response to IV thrombolysis. Very high-risk level was predictor of failed response, compared with low-risk level.     

Early Predictors of Prolonged Stay in a Critical Care Unit Following Aneurysmal Subarachnoid Hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a neurologic emergency that typically warrants initial monitoring in a critical care setting. The aim of this study is to identify clinical and radiologic features on admission that predict a protracted critical care admission following aSAH.

Methods

Exploratory posthoc analysis was performed on the 413 patients enrolled in Clazosentan to Overcome Neurological iSChemia and Infarction OccUrring after Subarachnoid hemorrhage (CONSCIOUS-1), a prospective randomized control trial of clazosentan for the prevention of vasospasm after aSAH. The association between potential clinical and radiographic covariates, and the length of stay (LOS) in a critical care unit after aSAH was determined using a Cox proportional hazards model. Covariates with a significance level of p < 0.20, on univariate analysis, were entered into a multivariate forward conditional analysis to identify independent predictors of prolonged LOS.

Results

The mean LOS was 12.6 ± 10.6 days. On multivariate analysis, age (hazard ratio [HR] 1.01, 95 % confidence interval [CI] 1.00–1.02; p = 0.032), a history of hypertension (HR 1.30, CI 1.01–1.67; p = 0.045), and a World Federation of Neurosurgical Societies Score of IV–V on admission (HR 1.38, CI 1.05–1.81; p = 0.02) were the clinical features associated with a greater critical care LOS following aSAH. Intracerebral hemorrhage (HR 1.50, CI 1.03–2.21; p = 0.004) and increasing intraventricular clot burden (HR 1.08, CI 1.03–1.14; p = 0.037) on admission computed tomography were the radiologic features associated with prolonged LOS.

Conclusions

We have identified several early risk factors associated with a prolonged critical care stay following aSAH.     

Racial disparities in early mortality in 1,134 young patients with acute stroke

We sought to investigate potential racial disparities in early outcomes of young individuals with stroke in an international multicenter study. We evaluated consecutive patients with first-ever acute stroke aged 18–45 years from prospective databases involving 12 tertiary-care stroke centers in North America (n = 2), Europe (n = 6), and Asia (n = 4). Demographics, vascular risk factors, stroke subtypes, pre-stroke functional status, stroke severity, blood pressure parameters, and serum glucose at hospital admission were documented. The outcome events of interest were 30-day mortality and 30-day favorable functional outcome (FFO) defined as modified-Rankin Scale score of 0–1. A total of 1,134 young adults (mean age 37.4 ± 7.0 years; 58.8 % men; 48.6 % Whites, 23.9 % Blacks, and 27.5 % Asians; median baseline National Institutes of Health Stroke Scale score 6 points, interquartile range 2–13) were included in the analyses. The 30-day stroke mortality and FFO rates differed (p < 0.001) across races. After adjusting for potential confounders, race was independently associated with 30-day mortality (p = 0.026) and 30-day FFO (p = 0.035). Blacks had a fourfold higher odds of 30-day stroke mortality in comparison to Asians (OR 4.00; 95 % CI 1.38–11.59; p = 0.011). Whites also had an increased likelihood of 30-day stroke mortality in comparison to Asians (OR 3.59; 95 % CI 1.28–10.03; p = 0.015). Blacks had a lower odds of 30-day FFO in comparison to Whites (OR 0.57; 95 % CI 0.35–0.91; p = 0.018). Racial disparities in early outcomes following first-ever stroke in young individuals appear to be independent of other known outcome predictor variables. Whites appear to have higher likelihood of 30-day FFO and Asians have lower odds of 30-day stroke mortality.     

Risk Stratification for the In-Hospital Mortality in Subarachnoid Hemorrhage: The HAIR Score

Background

The intracerebral hemorrhage (ICH) score is a simple grading scale that can be used to stratify risk of 30 day mortality in ICH patients. A similar risk stratification scale for subarachnoid hemorrhage (SAH) is lacking. We sought to develop a risk stratification mortality score for SAH.

Methods

With approval from the Institutional Review Board, we retrospectively reviewed 400 consecutive SAH patients admitted to our institution from August 1, 2006 to March 1, 2011. The SAH score was developed from a multivariable logistic regression model which was validated with bootstrap method. A separate cohort of 302 SAH patients was used for evaluation of the score.

Results

Among 400 patients with SAH, the mean age was 56.9 ± 13.9 years (range, 21.5–96.2). Among the 366 patients with known causes of SAH, 292 (79.8 %) of patients had aneurysmal SAH, 65 (17.8 %) were angiogram negative, and 9 (2 %) were other vascular causes. The overall in-hospital mortality rate was 20 %. In multivariable analysis, the variables independently associated with the in-hospital mortality were Hunt and Hess score (HH) (p < 0.0001), age (p < 0.0001), intraventricular hemorrhage (IVH) (p = 0.049), and re-bleed (p = 0.01). The SAH score (0–8) was made by adding the following points: HH (HH1-3 = 0, HH4 = 1, HH5 = 4), age (<60 = 0, 60–80 = 1, ≥80 = 2), IVH (no = 0, yes = 1), and re-bleed within 24 h (no = 0, yes = 1). Using our model, the in-hospital mortality rates for patients with score of 0, 1, 2, 3, 4, 5, 6, and 7 were 0.9, 4.5, 9.1, 34.5, 52.9, 60, 82.1, and 83.3 % respectively. Validation analysis indicates good predictive performance of this model.

Conclusion

The SAH score allows a practical method of risk stratification of the in-hospital mortality. The in-hospital mortality increases with increasing SAH mortality score. Further investigation is warranted to validate these findings.     

Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis

Background

The optimal timing of tracheostomy placement in acutely brain-injured patients, who generally require endotracheal intubation for airway protection rather than respiratory failure, remains uncertain. We systematically reviewed trials comparing early tracheostomy to late tracheostomy or prolonged intubation in these patients.

Methods

We searched 5 databases (from inception to April 2015) to identify randomized controlled trials comparing early tracheostomy (≤10 days of intubation) with late tracheostomy (>10 days) or prolonged intubation in acutely brain-injured patients. We contacted the principal authors of included trials to obtain subgroup data. Two reviewers extracted data and assessed risk of bias. Outcomes included long-term mortality (primary), short-term mortality, duration of mechanical ventilation, complications, and liberation from ventilation without a tracheostomy. Meta-analyses used random-effects models.

Results

Ten trials (503 patients) met selection criteria; overall study quality was moderate to good. Early tracheostomy reduced long-term mortality (risk ratio [RR] 0.57. 95 % confidence interval (CI), 0.36–0.90; p = 0.02; n = 135), although in a sensitivity analysis excluding one trial, with an unclear risk of bias, the significant finding was attenuated (RR 0.61, 95 % CI, 0.32–1.16; p = 0.13; n = 95). Early tracheostomy reduced duration of mechanical ventilation (mean difference [MD] ?2.72 days, 95 % CI, ?1.29 to ?4.15; p = 0.0002; n = 412) and ICU length of stay (MD ?2.55 days, 95 % CI, ?0.50 to ?4.59; p = 0.01; n = 326). However, early tracheostomy did not reduce short-term mortality (RR 1.25; 95 % CI, 0.68–2.30; p = 0.47 n = 301) and increased the probability of ever receiving a tracheostomy (RR 1.58, 95 % CI, 1.24–2.02; 0 < 0.001; n = 377).

Conclusions

Performing an early tracheostomy in acutely brain-injured patients may reduce long-term mortality, duration of mechanical ventilation, and ICU length of stay. However, waiting longer leads to fewer tracheostomy procedures and similar short-term mortality. Future research to explore the optimal timing of tracheostomy in this patient population should focus on patient-centered outcomes including patient comfort, functional outcomes, and long-term mortality.

     

The Discriminative Ability of the Azeri Version of the Strengths and Difficulties Questionnaire in Outpatient Practice

In this study we examined the validity of the Azeri version of the Strengths and Difficulties Questionnaire (SDQ). The SDQ was administered to the parents of two samples of 4–16-year-old children: the case group was drawn from children presenting to the psychiatric outpatient service (n = 347) and the comparison group from the pediatric outpatient service (n = 267). The total difficulties score and the scores for each subscale were compared between two groups. The proportion of children with the total difficulties score in the abnormal range was higher in the case group than in the comparison group (74 and 34 %, p < 0.001). The mean difficulties score difference between two groups was significant (mean difference = 6.3, p < 0.001). The Receiver Operating Characteristics analysis showed good discriminative ability for the total difficulties score and difficulties subscales (p < 0.001). SDQ distinguished well between groups.     

A Critical Analysis of Intra-arterial Thrombolytic Doses in Acute Ischemic Stroke Treatment

Background

Intra-arterial thrombolytics (IAT) such as Alteplase, Tenecteplase, and Reteplase are currently used in patients with acute ischemic stroke in varying doses. We evaluated the relationship of IA thrombolytic dose with angiographic recanalization, intracerebral hemorrhage (ICH) rates, and clinical outcomes at three comprehensive stroke centers.

Methods

We stratified patients who underwent endovascular treatment into tertiles based on intra-arterial thrombolytic dose administered: lower tertile (range 1.5–5 mg), middle tertile (range 6–10 mg), and upper tertile (range 10.3–68.5 mg) of rt-PA equivalent. The rates of angiographic recanalization, ICH, and favorable clinical outcomes (discharge modified Rankin score [mRS] = 0–2) were ascertained and compared within the three tertiles. Logistic regression analyses were performed to determine the association between IA thrombolytic dosages and angiographic recanalization, ICH, and favorable clinical outcomes after adjusting for potential confounders.

Results

A total of 197 patients were treated with IAT; mean age ±SD was 65.6 ± 16 years; 105 (53.3 %) were women. Ninety-one (46.2 %) patients received both IVT and IAT. IA rt-PA equivalent dose was not different between the patients with and without ICH [mean (mg) ± SD, 9.8 ± 6.1 versus 9.8 ± 9.5, p = 0.9]. We did not find any relation between increasing doses of IAT (from 2 to 69 mg rt-PA equivalent) and symptomatic or asymptomatic ICH: (p = 0.1630) and (p = 0.6702), respectively. Multivariate analysis demonstrated that IAT dose was not associated with ICH (OR 1.0, 95 % CI 0.97–1.07, p = 0.3919) or favorable outcome (OR, 1.00, 95 % CI 0.95–1.06, p = 0.7375). In a subset analysis of IVT patients, total doses ranged from 48.2 to 149 mg and were not associated with either symptomatic (p = 0.23) or asymptomatic (p = 0.24) ICHs.

Conclusion

Our study demonstrates that IAT in doses up to 69 mg is safe without any evidence of dose-related ICHs even in those patients who had received IVT.     

Delayed Fever and Neurological Outcome after Cardiac Arrest: A Retrospective Clinical Study

Background

The aim of this study was to evaluate the association between fever after the first days of ICU stay and neurological outcome after cardiac arrest (CA).

Methods

We retrospectively analyzed CA patients admitted to intensive care unit (ICU). Inclusion criteria: age ≥18 years, Glasgow Coma Scale score ≤8 at ICU admission and assessment of body core temperature (BCT) using bladder or intravascular probes. Exclusion criteria: ICU length of stay (LOS) <3 days and pregnancy. The primary endpoint was neurological outcome assessed with Cerebral Performance Category (CPC) scale 6 months after CA.

Results

One hundred thirty-two patients were analyzed. Fever was present in 105 (79.6 %) patients. Variables associated with unfavorable outcome were (1) older age (p < 0.0025); (2) non-shockable cardiac rhythms (p < 0.0001); (3) higher Simplified Acute Physiology Score (SAPS) II (p < 0.0001); (4) pupillary abnormalities at ICU admission (p < 0.018); and (5) elevated degree of maximal BCT (Tmax) during ICU stay (p < 0.046). After multivariate analysis, Tmax maintained a significant relationship with neurological outcome. An increase of 1 °C in Tmax during ICU stay decreased the odds ratio for a favorable outcome by a factor of 31 % (p < 0.001). Moreover, we discovered a significant interaction between the day of Tmax (t-Tmax) and Tmax (p = 0.004); the later Tmax occurs, the more deleterious effects are observed on outcome.

Conclusions

Fever is frequent after CA, and Tmax in ICU is associated with worsened neurological outcome. This association becomes stronger as the timing of Tmax extends further from the CA.

     

Effect of previous statin therapy on severity and outcome in ischemic stroke patients: a population-based study

Although statin therapy has been shown to be effective in the prevention of ischemic stroke, its effect on stroke severity and early outcome is still controversial. We aimed to evaluate the association between statin use before onset and both initial severity and functional outcome in ischemic stroke patients. All cases of first-ever ischemic stroke that occurred in Dijon, France (151,000 inhabitants) between 2006 and 2011 were prospectively identified from the Dijon Stroke Registry. Vascular risk factors, clinical severity at onset assessed by the NIHSS score, stroke subtypes, prestroke statin use, and lipid profile were collected. Functional outcome was defined by a six-level categorical outcome using the modified Rankin scale. Analyses were performed using ordinal logistic regression models. Among the 953 patients with first-ever ischemic stroke, 127 (13.3 %) had previously been treated with statins. Initial stroke severity did not differ between statin users and non-users [median NIHSS score (interquartile range) 4.0 (7.0) versus 4.0 (9.0) p = 0.104]. In unadjusted analysis, statin use was associated with a lower risk of an unfavorable functional outcome at discharge (OR 0.69; 95 % CI 0.49–0.96; p = 0.026) that was no longer significant in multivariate analyses (OR 0.76; 95 % CI 0.53–1.09; p = 0.134). After adjustment for admission plasma LDL cholesterol levels, the non-significant association was still observed (OR 0.76; 95 % CI 0.49–1.18; p = 0.221). This population-based study showed that prestroke statin therapy did not affect initial clinical severity but was associated with a non-significant better early functional outcome after ischemic stroke.