Effect of participation-focused strategy training on post-stroke cognitive functions and quality of life: results from a randomized trial.

General population preferences for standardized health states are usually obtained for chronic health states. The primary objective of this study was to analyze the feasibility and validity of using time trade-off (TTO) and a visual analog scale (VAS) to elicit preference values for temporary health states (THS=1 year duration, followed by normal health). Subjects were a random sample (n=300) of the general population. 43 health states generated by the EuroQo-5D were valued. The VAS proved slightly more feasible than the TTO. At aggregate level, correlations between VAS and TTO values were high (Spearman r=0.98), and VAS ratings had slightly greater internal consistency and agreement with rank order preferences than the TTO. TTO values were higher than VAS values, and compression of TTO values suggested substantial reluctance to trade. The effect of age on values was reversed between methods, with older respondents scoring higher on the VAS and lower on the TTO, than other age groups. In conclusion, although the VAS proved to be slightly more feasible than the TTO, with slightly greater empirical validity, further research using a wider range of methods to test validity is required before a definitive conclusion on the relative empirical validity of the two valuation techniques can be drawn.

Estimating an EQ-5D Value Set for Malaysia Using Time Trade-Off and Visual Analogue Scale Methods

Background: Elevated blood pressure variability (BPV) has been associated with worse outcomes in stroke survivors. This study aimed to investigate the relationship between systolic and diastolic BPV and post-stroke cognitive impairment (PSCI) in patients with acute cardioembolic stroke due to atrial fibrillation. Methods: Using data from a prospective stroke registry, we consecutively enrolled 143 patients with acute cardioembolic stroke. Cognitive function was evaluated three months post-stroke using the Korean version of the Vascular Cognitive Impairment Harmonization Standards. PSCI was defined as a z-score of less than -2 standard deviations for age, sex, and education-adjusted means in at least one cognitive domain. Multiple logistic regression was used to assess the association between BPV during the first 7 days of admission and PSCI, adjusting for age, sex, education, vascular risk factors, initial stroke severity, and neuroimaging characteristics. Results: Among the 143 participants (mean age 70 years; 60.1% male; median initial NIHSS score of 5), PSCI was identified in 67 patients (46.9%). The standard deviations of both systolic and diastolic blood pressures were significant predictors of PSCI (aOR 1.09; 95% CI 1.01–1.17 and aOR 1.14; 95% CI 1.01–1.29, respectively). The mean values of both SBP and DBP were also significantly associated with PSCI. Conclusions: Our findings demonstrate that both systolic and diastolic BPV in the acute phase of cardioembolic ischemic stroke are independently associated with PSCI at three months. These results underscore the importance of monitoring and managing blood pressure variability in the acute stroke setting to reduce the risk of cognitive decline.

Simple SummaryProton radiation therapy is a radiation oncology innovation expected to produce superior health-related quality of life (HRQoL) outcomes for children with cancer, compared to conventional photon radiation therapy. The review aim is to identify if clinical evidence exists to support the anticipated HRQoL improvements for children receiving proton radiation therapy. HRQoL outcomes of 1986 childhood cancer survivors are described. There is insufficient quality evidence to compare HRQoL outcomes between proton and photon radiation therapy. Therefore, the current state of the literature does not conclude that proton radiation therapy produces superior HRQoL outcomes for childhood cancer survivors. Despite recommendations, no evidence of routine HRQoL assessment using patient-reported outcomes in paediatric radiation oncology are identified. Further rigorous collection and reporting of HRQoL data is essential to improve patient outcomes, and to adequately compare HRQoL between radiation therapy modalities.Paediatric cancer patients have a risk of late side effects after curative treatment. Proton radiation therapy (PRT) has the potential to reduce the incidence and severity of toxicities produced by conventional photon radiation therapy (XRT), which may improve the health-related quality of life (HRQoL) in children. This systematic review aimed to identify the evidence of HRQoL outcomes in childhood cancer survivors following XRT and PRT. Medline, Embase, and Scopus were systematically searched. Thirty studies were analysed, which described outcomes of 1986 childhood cancer survivors. Most studies (n = 24) described outcomes for children with a central nervous system (CNS) tumour, four studies reported outcomes for children with a non-CNS tumour, and two studies combined CNS and non-CNS diagnoses within a single cohort. No studies analysed routine HRQoL collection during paediatric radiation oncology clinical practice. There is insufficient quality evidence to compare HRQoL outcomes between XRT and PRT. Therefore, the current state of the literature does not conclude that PRT produces superior HRQoL outcomes for childhood cancer survivors. Standardised clinical implementation of HRQoL assessment using patient-reported outcomes is recommended to contribute to improvements in clinical care whilst assisting the progression of knowledge comparing XRT and PRT.

Preoperative mood disorders such as depression and anxiety are known to be associated with poor health-related quality of life (HRQOL) outcomes after lumbar spine surgery. However, the effects of preoperative depression and anxiety on postoperative HRQOL outcomes and patient satisfaction in cervical compressive myelopathy are yet to be clarified. This study aimed to investigate the effect of depression and anxiety on HRQOL outcomes and patient satisfaction following surgery for cervical compressive myelopathy. The authors reviewed the cases of all consecutive patients with cervical compressive myelopathy who had undergone surgical treatment in the period between January 2012 and March 2017 at their institution. Using the Hospital Anxiety and Depression Scale (HADS), the authors classified patients as depressed (HADS-D+) or not depressed (HADS-D-) and anxious (HADS-A+) or not anxious (HADS-A-). Patient HRQOL was evaluated preoperatively and at the end of at least 1 year after surgery using the physical and mental component summaries of the SF-12 Health Survey, EQ-5D (EuroQol health survey of five dimensions), Neck Disability Index, and Japanese Orthopaedic Association scale. Patient satisfaction was evaluated on the basis of a seven-item questionnaire and divided into two categories: satisfied and dissatisfied. Preoperative HRQOL statuses, postoperative improvements in HRQOL outcomes, and patient satisfaction were compared between the groups. Among the 121 patients eligible for inclusion in the study, there were 69 patients (57.0%) without depression (HADS-D-) and 52 (43.0%) with depression (HADS-D+) and 82 patients (67.8%) without anxiety (HADS-A-) and 39 (32.2%) with anxiety (HADS-A+). All patients who completed both the preoperative and postoperative questionnaires had significant postoperative improvements in all HRQOL outcomes. The HADS-D+ and HADS-A+ patients had poorer preoperative HRQOL statuses than the HADS-D- and HADS-A- patients, respectively. However, statistically significant improvements in all HRQOL outcomes were observed in both HADS-D+ and HADS-A+ patients. Patient satisfaction was comparable between the HADS-D or HADS-A groups. Cervical compressive myelopathy patients with preoperative depression or anxiety according to the HADS tool had worse preoperative HRQOL statuses. However, patients with cervical compressive myelopathy showed significant improvements in HRQOL outcomes and had sufficient levels of satisfaction after surgery regardless of the presence of preoperative depression or anxiety.

Stroke survivors often experience serious cognitive impairment which may impact on their functional activity and the ability to lead an independent life. However, there is paucity of information on the relationship between post-stroke cognitive impairment (PSCI) and functional activity of Nigerian stroke survivors. This study therefore examined the relationship between post-stroke cognitive impairment (PSCI) and functional activity of stroke survivors attending physiotherapy clinics in Maiduguri, north-eastern Nigeria. A cross sectional study design was utilized and a purposive sampling technique was used to recruit participants for this study. One hundred stroke patients from Physiotherapy clinics in Maiduguri, north-eastern Nigeria participated in this study. Data forms were used to obtain information on socio-demographic and clinical characteristics of the participants while Mini-Mental State Examination (MMSE) and Barthel Index (BI) scale were used to obtain information on cognitive impairment and functional activity of the participants respectively. Descriptive statistics of mean, standard deviation, frequency and percentages were used to summarise the socio-demographic and clinical characteristics of the participants. Spearman’s Rank Order Correlation was used to investigate the relationship between PSCI and overall functional activity of the participants on one hand and between PSCI and components of functional activity of the participants. Out of the 100 stroke survivors that participated in the study, 55% were male while 45% were female. The mean age and post-stroke duration of the participants were 55.16 ± 10.01 years and 9.90 ± 10.07 months respectively. The results showed that a positive and significant relationship existed between PSCI and overall functional activity of the participants (r = 0.55, p = 0.00). Similarly, there was a significant and positive correlation between PSCI and the components of functional activity except with the bowel control component of functional activity. The correlations were varied with the highest correlation observed between PSCI and mobility component (r = 0.58, p = 0.001) while the lowest correlation was between PSCI and the bowel control component (r = 0.17, p= 0.10). the correlation coefficient for the other components namely the feeding, bathing, grooming, dressing, bladder control, toilet use, transfer and stair climbing were 0.40, 0.45, 0.40, 0.41, 0.39, 0.44, 0.50 and 0.53 respectively. The outcome of this study showed that the relationship between PSCI and functional activity of the stroke survivors was significant and positive. Furthermore, correlation was highest between PSCI and mobility component of functional activity. It is concluded that reducing PSCI could positively impact on the functional activity of stroke survivors, and enhancing functional activity could also reduce Post-Stroke Cognitive Impairment (PSCI) and therefore Physiotherapists should endeavor to assess cognitive impairment among stroke patients and incorporate treatment strategies that will enhance functional outcome.

BackgroundWe assessed preferences for current health using the visual analogue scale (VAS), standard gamble (SG), time trade-off (TTO), and willingness to pay (WTP) in patients with cerebral aneurysms, a population vulnerable to cognitive deficits related to aneurysm bleeding or treatment.MethodsWe measured VAS, SG, TTO, and WTP values for current health in 165 outpatients with cerebral aneurysms. We assessed cognitive impairment with the Mini Mental State Examination (MMSE; scores < 24 = cognitive impairment). We examined the distributions of preference responses stratified by cognitive status, and the relationship between preferences and cognitive impairment, patient characteristics, and aneurysm history.ResultsEleven patients (7%) had MMSE scores < 24. The distribution of preferences responses from patients with cognitive impairment had greater variance (SG, 0.39 vs. 0.21, P = 0.001; TTO, 0.36 vs. 0.24, P = 0.017) and altered morphology (VAS, P = 0.012; SG, P = 0.023) compared to the responses of unimpaired patients. There was good correlation between most preference measures for unimpaired patients (VAS:TTO, rho = 0.19, P = 0.018; SG:TTO, rho = 0.36, P < 0.001; SG:WTP, rho = -0.33, P < 0.001) and a trend towards significance with another pairing (VAS:WTP, rho = 0.16, P = 0.054). In subjects with cognitive impairment, there was a significant correlation only between VAS and TTO scores (rho = 0.76, P = 0.023). Separate regression models showed that cognitive impairment was associated with lower preferences on the VAS (β = -0.12, P = 0.048), SG (β = -0.23, P = 0.002), and TTO (β = -0.17, P = 0.035).ConclusionCognitive impairment is associated with lower preferences for current health in patients with cerebral aneurysms. Cognitively impaired patients have poor inter-preference test correlations and different response distributions compared to unimpaired patients.

Introduction: Post-stroke cognitive impairment (PSCI) has a considerable impact on patients and society. However, the characteristics and prevalence of long-term PSCI may be influenced by assessment methods and selection bias. We therefore used two cognitive screening methods to assess PSCI in ten-year stroke survivors, made comparisons with non-stroke individuals, and compared these screening methods. Methods: The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were administered and compared in a population-based consecutive sample of ten-year stroke survivors. In addition, age- and sex-matched non-stroke controls were assessed with the MMSE. Regression analyses adjusting for education compared the stroke survivors’ MMSE performance with the controls. Moderate/severe cognitive impairment, approximating to dementia, was defined using MMSE&lt;24 and MoCA&lt;20 as cut-offs. To detect those with mild cognitive impairment, alternative cut-offs of MMSE&lt;27 and MoCA&lt;25 were also used. Results: In total, 127 of 145 stroke survivors participated. The total MMSE-scores were similar for stroke survivors (median 27) and 354 controls (median 27; p =0.922); as well as proportions with MMSE&lt;24 (23% vs. 17%; p =0.175) or MMSE&lt;27 (47% vs. 49%; p =0.671). After adjustment for education, stroke survivors showed an increased risk for moderate/severe cognitive impairment defined by MMSE&lt;24 (OR=1.82; p =0.036). Executive dysfunction was seen in 42% of the stroke survivors vs. 16% of the controls as evaluated by MMSE ( p &lt;0.001). According to MoCA, moderate/severe cognitive impairment (MoCA&lt;20) was observed in 28% of the stroke survivors; any degree of cognitive impairment (MoCA&lt;25) was seen in 61%; and 45-61% displayed executive function deficits. Conclusions: PSCI including executive dysfunction is common among ten-year stroke survivors, who have an increased risk of moderate/severe cognitive impairment compared to non-stroke controls. The prevalence of long-term PSCI may have been previously underestimated, and MoCA may be more suitable for post-stroke cognitive assessment.

PurposeTo estimate Swedish experience-based value sets for EQ-5D health states using general population health survey data.MethodsApproximately 45,000 individuals valued their current health status by means of time trade off (TTO) and visual analogue scale (VAS) methods and answered the EQ-5D questionnaire, making it possible to model the association between the experience-based TTO and VAS values and the EQ-5D dimensions and severity levels. The association between TTO and VAS values and the different severity levels of respondents’ answers on a self-rated health (SRH) question was assessed.ResultsAlmost all dimensions (except usual activity) and severity levels had less impact on TTO valuations compared with the UK study based on hypothetical values. Anxiety/depression had the greatest impact on both TTO and VAS values. TTO and VAS values were consistently related to SRH. The inclusion of age, sex, education and socioeconomic group affected the main effect coefficients and the explanatory power modestly.ConclusionsA value set for EQ-5D health states based on Swedish valuations has been lacking. Several authors have recently advocated the normative standpoint of using experience-based values. Guidelines of economic evaluation for reimbursement decisions in Sweden recommend the use of experience-based values for QALY calculations. Our results that anxiety/depression had the greatest impact on both TTO and VAS values underline the importance of mental health for individuals’ overall HRQoL. Using population surveys is in line with recent thinking on valuing health states and could reduce some of the focusing effects potentially appearing in hypothetical valuation studies.Electronic supplementary materialThe online version of this article (doi:10.1007/s11136-013-0496-4) contains supplementary material, which is available to authorized users.

The feasibility, validity and reliability of the Time Trade-Off (TTO) and Visual Analogue Scale (VAS) methods in obtaining preference values for health states were compared in a random sample of the Spanish population (n = 294). Respondents valued 43 EuroQol-5D health states in face-to-face interviews. Convergent validity was assessed by examining the relationship between values, and the effect of sociodemographic and health variables on values was used as a means of assessing construct validity. Test-retest reliability was analysed in a subgroup of 50 respondents, using the intraclass correlation coefficient (ICC) and generalisability theory. Rates of non-response and missing data were low on both methods, though the VAS took considerably less time to administer. VAS and TTO values correlated highly (r = 0.92), though there were differences in the ordering of health states between methods, and in the number of health states rated worse than death. VAS values were compressed into a considerably smaller valuation space than TTO values. Respondents in higher educational categories assigned higher TTO values to 12 health states. Mean ICCs (95% CI) at individual level were 0.90 (0.88-0.92) and 0.84 (0.81-0.87) for the VAS and TTO, respectively. Generalisability analysis showed variance due to time to be 0 for both methods. In conclusion, the VAS was more feasible and slightly more reliable than the TTO, whilst doubt can be cast on the degree of convergent validity existing between the two methods. The compression of VAS values means that the TTO is likely to discriminate better between health states, and it may have greater construct validity if results from larger samples confirm that there are genuine differences between sociodemographic subgroups.

OBJECTIVE The emphasis on health-related quality of life (HRQOL) outcomes is increasing, along with an emphasis on evidence-based medicine. However, there is a notable paucity of validated HRQOL instruments for the pediatric population. Furthermore, no standardization or consensus currently exists concerning which HRQOL outcome measures ought to be used in pediatric neurosurgery. The authors wished to identify HRQOL outcomes used in pediatric neurosurgery research over the past 10 years, their frequency, and usage trends. METHODS Three top pediatric neurosurgical journals were reviewed for the decade from 2005 to 2014 for clinical studies of pediatric neurosurgical procedures that report HRQOL outcomes. Similar studies in the peer-reviewed journal Pediatrics were also used as a benchmark. Publication year, level of evidence, and HRQOL outcomes were collected for each article. RESULTS A total of 31 HRQOL studies were published in the pediatric neurosurgical literature over the study period. By comparison, there were 55 such articles in Pediatrics. The number of publications using HRQOL instruments showed a significant positive trend over time for Pediatrics (B = 0.62, p = 0.02) but did not increase significantly over time for the 3 neurosurgical journals (B = 0.12, p = 0.5). The authors identified a total of 46 different HRQOL instruments used across all journals. Within the neurosurgical journals, the Hydrocephalus Outcome Questionnaire (HOQ) (24%) was the most frequently used, followed by the Health Utilities Index (HUI) (16%), the Pediatric Quality of Life Inventory (PedsQL) (12%), and the 36-Item Short Form Health Survey (SF-36) (12%). Of the 55 articles identified in Pediatrics, 22 (40%) used a version of the PedsQL. No neurosurgical study reached above Level 4 on the Oxford Centre for Evidence-Based Medicine (OCEBM) system. However, multiple studies from Pediatrics achieved OCEBM Level 3, several were categorized as Level 2, and one reached Level 1. CONCLUSIONS The frequency of studies using HRQOL outcomes in pediatric neurosurgical research has not increased over the past 10 years. Within pediatric neurosurgery, high-quality studies and standardization are lacking, as compared with contemporary studies in Pediatrics. In general, although the HOQ, HUI, PedsQL, and SF-36 instruments are emerging as standards in pediatric neurosurgery, even greater standardization across the specialty is needed, along with the design and implementation of more rigorous studies.

Health state values are by convention anchored to 'perfect health' and 'death.' Attitudes toward death may consequently influence the valuations. We used attitudes toward euthanasia (ATE) as a sub-construct for attitudes toward death. We compared the influence on values elicited with time trade-off (TTO), lead-time TTO (LT-TTO) and visual analogue scale (VAS).Since the 'death' anchor is most explicit in TTO, we hypothesized that TTO values would be most influenced by ATE. Respondents valued eight EQ-5D health states with VAS, then TTO (n=328) or LT-TTO (n=484). We measured ATE on a scale from -2 (fully disagree) to 2 (fully agree) and used multiple linear regressions to predict VAS, TTO, and LT-TTO values by ATE, sex, age, and education. A one-point increase on the ATE scale predicted a mean TTO value change of -.113 and LT-TTO change of -.072. Demographic variables, but not ATE, predicted VAS values. TTO appears to measure ATE in addition to preferences for health states. Different ways of incorporating death in the valuation may impact substantially on the resulting values. 'Death' is a metaphysically unknown concept, and implications of attitudes toward death should be investigated further to evaluate the appropriateness of using 'death' as an anchor.

ABSTRACTBackground: The analgesic effect of long-acting opioids, such as transdermal fentanyl, has been demonstrated in patients with cancer, neuropathic pain and chronic low back pain (CLBP). However, the broader effect of long-acting opioids on the patient's health-related quality of life (HRQoL) is less well known.Objective: To evaluate HRQoL outcomes in CLBP patients treated with transdermal fentanyl.Research design and methods: An observational study was conducted at 17 clinical centers in the US. Eligible patients had CLBP diagnosis for at least 3 months and were taking short-acting opioids chronically, and then initiated transdermal fentanyl treatment. Patients completed the Treatment Outcomes in Pain Survey (TOPS), which includes the SF‐36 Health Survey, at baseline and ≥ 9 weeks of treatment. The HRQoL burden of CLBP was determined by comparing CLBP patients’ SF‐36 scores to the general US population and low back pain patient norms. HRQoL outcomes were determined by comparing baseline and follow-up TOPS and SF‐36 scores. Additionally, HRQoL outcomes were evaluated across patient groups stratified by changes in pain intensity ratings as measured by an 11-point numerical rating scale.Results: At baseline CLBP patients (N = 131) scored one-to-two standard deviations (SD) below age and gender adjusted SF‐36 general population norms (MANOVA F = 127.1, p < 0.0001) and significantly lower than low back pain norms (MANOVA F = 125.3, p < 0.0001). At follow-up, significant improvement ( p < 0.05) was observed on six of the SF‐36 scales and both SF‐36 summary measures and five of the six TOPS pain-related scales. The magnitude of change in scores in effect size units among these scales ranged from 0.17 to 0.80, which are considered small to large effect size changes. HRQoL score improvement was greatest among patients experiencing the greatest pain relief.Conclusion: CLBP patients who chronically used short-acting opioids showed tremendous HRQoL burden. Favorable HRQoL outcomes were observed among patients who reported pain relief.

IntroductionThere have been increasing efforts aimed at enhancing patient-centered care and incorporating patients' voice into clinical practice. As such, a growing body of literature has recognized the importance of Health-Related...

225. Severity of cervical disc degeneration and health-related quality of life outcomes following anterior cervical discectomy and fusion