Issues in selecting outcome measures to assess functional recovery after stroke

Most patients who survive a stroke experience some degree of physical recovery. Selecting the appropriate outcome measure to assess physical recovery is a difficult task, given the heterogeneity of stroke etiology, symptoms, severity, and even recovery itself. Despite these complexities, a number of strategies can facilitate the selection of functional outcome measures in stroke clinical trial research and practice. Clinical relevance in stroke outcome measures can be optimized by incorporating a framework of health and disability, such as the International Classification of Functioning, Disability, and Health (ICF). The ICF provides the conceptual basis for measurement and policy formulations for disability and health assessment. All outcome measures selected should also have sound psychometric properties. The essential psychometric properties are reliability, validity, responsiveness, sensibility, and established minimal clinically important difference. It is also important to establish the purpose of the measurement (discriminative, predictive, or evaluative) and to determine whether the purpose of the study is to evaluate the efficacy or effectiveness of an intervention. In addition, when selecting outcome measures and time of assessment, the natural history of stroke and stroke severity must be regarded. Finally, methods for acquiring data must also be considered. We present a comprehensive overview of the issues in selecting stroke outcome measures and characterize existing measures relative to these issues.     

Health-seeking behavior and the meaning of medications in Balochistan, Pakistan

A wide variety of health care options--home-based, indigenous, and cosmopolitan--exists in northern Balochistan, Pakistan. This paper examines health-seeking behavior in the area of mother and child health for villagers in this pluralistic medical setting. The analysis of a specific series of illness episodes shows that the majority of cases obtain treatment from different medical systems for a single episode. Interest in medications takes precedence over practitioners, and the meaning the villagers attach to such substances is explored. Long-established patterns of behavior relating to indigenous medicine continue to occur when cosmopolitan medicine is utilized. Information presented here helps to explain problems in utilization of cosmopolitan pharmaceuticals and delineates areas for future health programme activity.     

Modulation of fear-potentiated startle and vocalizations in juvenile rhesus monkeys by morphine, diazepam, and buspirone.

BACKGROUND: Modulation of the acoustic startle response by aversive sensory stimulation is a simple and objective indicator of emotionality in rodents and human beings that has been extremely valuable for the analysis of neural systems associated with fear and anxiety. We have described a paradigm for measuring fear-potentiated, whole-body acoustic startle in nonhuman primates and have developed a protocol for maintaining fear-potentiated startle over repeated sessions with minimal extinction to allow measurement of pharmacological effects on fear-potentiated startle by using within-subjects designs in relatively small groups of monkeys. METHODS: A novel, within-subjects testing protocol was used to examine the effects of three compounds in rhesus monkeys that have anxiolytic effects in rodents on fear-potentiated startle but that differ in their mechanism of action. Spontaneous vocalizations during testing also were recorded. Juvenile monkeys that were trained to associate a visual stimulus with a fear-inducing air blast to the face were tested after acute administration of different doses of buspirone diazepam, morphine, or vehicle. RESULTS: Monkeys rapidly developed a robust and persistent elevation of startle response in the presence of the CS during repeated testing sessions. Diazepam and morphine produced dose-related reductions of fear-potentiated startle. Buspirone did not significantly reduce fear-potentiated startle at the doses tested, although a trend was evident at the highest dose. All drugs reduced rates of coo vocalizations during startle testing. CONCLUSIONS: These fear-potentiated startle results suggest that rhesus monkeys have a pharmacological profile with respect to these compounds that is closer to humans than to rats. This demonstrates the value of examining the effects of drugs on fear-potentiated startle in nonhuman primates.     

Normalized protein catabolic rate versus serum albumin as a nutrition status marker in pediatric patients receiving hemodialysis.

BACKGROUND: Protein-energy malnutrition occurs commonly in patients receiving hemodialysis (HD). Although serum albumin (sAlb) is recommended to monitor nutrition status in patients receiving HD, many processes unrelated to nutrition status can affect albumin concentrations. METHODS: We previously showed normalized protein catabolic rate (nPCR) to be superior to sAlb to reflect improvement in nutrition status in pediatric patients receiving maintenance HD after treatment with intradialytic parenteral nutrition for severe protein-energy malnutrition. We now compare nPCR and sAlb as nutrition status markers for pediatric patients on HD irrespective of current nutrition status. RESULTS: Forty-four patients comprising 840 months of HD provision were assessed. nPCR was higher for younger patients. Mean nPCR values were significantly lower for adolescent patients with persistent weight loss of at least 2% for at least 3 consecutive months versus patients without persistent weight loss (1.03 +/- 0.29 g/kg/d vs. 1.15 +/- 0.27 g/kg/d, P < .002), and the odds for developing persistent weight loss were four times greater for adolescent patients with nPCR less than 1 g/kg/d. No association between nPCR and weight loss was observed for younger patients. Mean sAlb levels were greater than 4 g/dL for all patient age groups and did not demonstrate a clinically significant difference between patients with or without weight loss. CONCLUSION: We suggest that nPCR may be useful for monthly nutrition status in adolescent patients receiving maintenance HD and that adolescents with nPCR less than 1 g/kg/d may be at increased risk for subsequent weight loss.     

Care of the child in a body cast

Caring for a child in a body cast is a stressful situation for most families and many families state they do not receive adequate information on how to care for their child. This paper presents a comprehensive guide on caring for a child in a body cast. It examines the physical care issues, transportation and cast care. An instrument for assessing the family’s ability to cope with caring for a child in a body cast is described, and further resources for parents and nurses are presented.     

Prognostic factors in surgically resected N2 non-small cell lung cancer: the importance of patterns of mediastinal lymph nodes metastases.

OBJECTIVE: Patients with non-small cell lung cancer (NSCLC) with metastases to ipsilateral mediastinal lymph nodes (N2) are an heterogeneous group of patients as regard to prognosis and treatment. Indication and timing of surgery remain controversial. The present study investigates the prognostic factors, in order to identify homogenous subgroups of patients. METHODS: Histologically proven N2-NSCLC patients, who underwent a complete surgical resection were retrospectively reviewed. Clinical and pathological features were reported and analyzed, and survival study was performed. RESULTS: One hundred eighty-three patients were analyzed. Overall 1.3 and 5 years survival rates were, respectively, 70, 35 and 20%, with a median survival time of 24 months. Univariate analysis showed a significant better prognosis for: incidental N2 respect to clinical N2 (5-years 35.4 vs 17.4%); single level lymph node involvement respect to multiple levels (5-years 23.8 vs 14.7%); metastases to superior mediastinal or aortic nodes respect to lower mediastinal nodes (5-years 32 and 24.3 vs 16.3%); right upper lobe tumors with superior mediastinal nodes and left upper lobe tumors with aortic nodes respect to lower lobes tumors with lower mediastinal nodes (5-years 31.8 and 26.9 vs 15.7%). Skip metastases had not a significant survival advantage respect to continuous lymphatic spread. N2 clinical status, the number of levels involved and the two specific patterns of lymphatic spread resulted significant prognostic factors at multivariate analysis. CONCLUSIONS: Clinical N2 status, number of lymph nodes levels involved and specific patterns of lymphatic spread identify homogenous subgroups of patients that can be proposed for different therapeutic strategies.     

Issues of obesity in kidney transplantation.

The purpose of this literature review is to evaluate the scientific evidence regarding the relationship between obesity and outcome of renal transplant recipients. The impact of obesity on kidney transplant outcomes continues to be controversial. Obesity seems to influence delayed graft failure, graft survival, and patient survival. A body mass index of 35 kg/m(2) or more is significant for greater posttransplant complications, especially new-onset transplant diabetes mellitus, wound complications, and posttransplant weight gain. Several important advances in the general medical management of the patient, both before and after transplantation, have occurred over the last decade. The decrease in mortality may be related to better patient management, whereas the improvement in graft survival is most likely the result of more effective immunotherapy and better management of hypertension and hyperlipidemia, which overall lessens the risk of obesity among kidney transplant recipients.