Discharge Functional Status Research Articles

Falls characteristics experienced by working-age adults during inpatient post-stroke rehabilitation and their impact on length of stay, discharge functional status, ambulation and destination

BackgroundIn-hospital falls are frequent post-stroke medical complications and will remain of concern because it may not be possible to prevent all of them. We aimed to i) compare admission clinical and sociodemographic characteristics between fallers and non-fallers ii) determine falls characteristics iii) compare length of stay (LOS), discharge functional independence, ambulation and destination between fallers and non-fallers. MethodsA matched case-control study, comparing individuals (n = 302) who fell during inpatient post-acute rehabilitation, matched (on time to admission, age and motor Functional Independence Measure (mFIM)) to individuals (n = 302) who didn´t fall, admitted within 3 months post-injury to a center between 2008 and 2023. Ambulation was assessed using the Functional Ambulation Category (FAC). ResultsMean age at admission was 50±8 years. No baseline differences were seen between groups in the proportion of patients with aphasia, diabetes, dyslipidemia, hypertension, neglect, atrial fibrillation, dysphagia, dominant side affected, medication for depression, FAC assessment, body mass index and educational level.A first-fall in the first week was experienced by 22.2 % and in the first three weeks by 54.3 %. Most falls occurred at the patients’ room (75.1 %) mostly due to distractions (55.3 %) and transferring without help (32.4 %) with 18 % occurring in the bathroom, fallers were alone in 68.6 % of the cases.Fallers had an 8-day longer mean LOS compared to non-fallers, yet there were no differences in discharge mFIM or FAC scores. While non-fallers had a higher proportion of poor mFIM outcomes (28.5 % vs. 17.9 %) and no ambulation (20.7 % vs. 12.4 %), fallers showed greater mFIM gains (26 vs. 22 points). Discharge destinations were similar across both groups. ConclusionsDespite no baseline differences, fallers experienced longer stays with comparable independence and ambulation scores at discharge. Most falls occurred in patients' rooms during unsupervised activities. Preventive recommendations have been provided to address these risks and enhance patient safety.

The role of emergency department thoracotomy in patients with cranial gunshot wounds.

Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. Therapeutic/Care Management; Level IV.

Post-discharge 6-Month Functional Recovery of Traumatic Brain Injury Survivors with Unfavorable Functional Status at Discharge: A Registry-Based Cohort Study

BackgroundTraumatic Brain Injury (TBI) is a major cause of physical disabilities worldwide. Herein, we aimed to investigate the factors contributing to post-discharge recovery in patients who were discharged with an unfavorable outcome. MethodsWe collected data on the characteristics of patients, with a focus on those who survived TBI but had an unfavorable outcome at discharge as measured by Glasgow Outcome Scale Extended; GOSE categories two, three, and four. Post-discharge recovery was defined as achieving a favorable functional status at six months (GOSE of five or more) with a minimum two-point increase in GOSE. ResultsOf 4011 TBI patients in our registry, 797 had an unfavorable discharge functional status. In severe TBI, 51% achieved recovery, while in mild to moderate TBI, 57% achieved recovery after six months. Older patients and those with shorter intensive care unit length of stay were more likely to experience post-discharge recovery in both mild to moderate and severe TBI groups. The presence of base of skull fracture was also associated with post-discharge recovery in severe TBI patients. Lastly, we showed that, after adjustment for potential confounders, GOSE at discharge is associated with post-discharge recovery in both mild to moderate and severe TBI patients. ConclusionThis study found that the majority of the patients who were discharged with an unfavorable functional status were able to achieve a favorable outcome within six months. The novel post-discharge recovery in TBI patients might be a useful toll for illuminating the factors associated with a significant improvement after discharge.

New Morbidities During Critical Illness and Associated Risk of ICU Readmission: Virtual Pediatric Systems Cohort, 2017-2020.

To describe change in Functional Status Scale (FSS) associated with critical illness and assess associated development of new morbidities with PICU readmission. Retrospective, cross-sectional cohort study using the Virtual Pediatric Systems (VPS; Los Angeles, CA) database. One hundred twenty-six U.S. PICUs participating in VPS. Children younger than 21 years old admitted 2017-2020 and followed to December 2022. None. Among 40,654 patients, 86.2% were classified as having good function or mild dysfunction before illness. Most patients did not have a change in their FSS category during hospitalization. Survival with new morbidity occurred most in children with baseline good/mild dysfunction (8.7%). Hospital mortality increased across categories of baseline dysfunction. Of 39,701 survivors, 14.2% were readmitted within 1 year. Median time to readmission was 159 days. In multivariable, mixed-effects Cox modeling, time to readmission was most associated with discharge functional status (hazard ratio [HR], 5.3 [95% CI, 4.6-6.1] for those with very severe dysfunction), and associated with lower hazard in those who survived with new morbidity (HR, 0.7 [95% CI, 0.6-0.7]). Development of new morbidities occurs commonly in pediatric critical illness, but we failed to find an association with greater hazard of PICU readmission. Instead, patient functional status is associated with hazard of PICU readmission.

Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with Mechanical Ventilation in the Intensive Care Unit.

Intensive care unit (ICU)-acquired weakness often occurs in patients with invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired weakness, improve functional status, and reduce disability. The aim of this study was to investigate whether high-intensity early mobility improves post-ICU discharge functional status of IMV patients. 132 adult patients in the ICU who were undergoing IMV were randomly assigned into two groups with a ratio of 1 : 1, with one group received high-intensity early mobility (intervention group, IG), while the other group received conventional treatment (control group, CG). The functional status (Barthel Index (BI)), capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge. The patient's functional status was improved (BI scores 90.6 ± 18.0 in IG vs. 77.7 ± 27.9 in CG; p=0.005), and capacity of mobility was increased (Perme score 17.6 ± 7.1 in IG vs. 12.2 ± 8.5 in CG, p < 0.001; IMS 4.7 ± 2.6 in IG vs. 3.0 ± 2.6 in CG, p < 0.001). The IG had a higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the CG. The incidence of mortality and delirium was also lower than CG at ICU discharge. However, there were no differences in terms of length of ICU stay, duration of IMV, ventilator-associated pneumonia, and venous thrombosis. High-intensity early mobility improved the patient's functional status and increased capacity of mobility with IMV. The benefits to functional status remained after 3 month of ICU discharge. Other benefits included higher muscle strength, lower incidence of ICUAW, mortality, and delirium in IG.

The Extended Pterional Approach Allows Satisfactory Results for the Resection of Huge Medial Sphenoid Ridge Meningioma

To investigate the surgical method and efficacy of the extended pterional approach in the resection of huge medial sphenoid ridge meningiomas (MSRMs). Retrospective analysis of clinical data from 41 patients diagnosed with MSRMs (diameter ≥4.0cm) from Nanjing Brain Hospital between January 2012 and February 2022 was conducted. Within 24hours after surgery, head computed tomography and magnetic resonance imagingwere reviewed to evaluate the extent of tumor resection based on Simpson grading. Cranial magnetic resonance imagingwas repeated 3 to 60months after surgery to assess tumor recurrence or progression. Preoperative, discharge, and follow-up Karnofsky functional status scores (KPS) were assessed to determine patients' functional status. Repeated-measures analysis of variance was utilized to compare KPS at preoperative, hospital discharge, and final follow-up. The 41 selected cases included 38 cases (92.7%) of Simpson I-III resection and 3 cases (7.3%) of Simpson IV resection. All the cases had typical pathological features and definite pathological diagnoses. There were 2 recurrent tumors and 4 progressed tumors when the patients were followed up from 3months to 60months after operations. The results demonstrated that the KPS score at the final follow-up (91.4±9.6) was higher than at hospital discharge (85.3±8.9) and preoperation (78.2±8.5) (F=69.46, P= 0.033). The use of the extended pterional approach in the resection of huge MSRMs appears to be an effective surgical method. Careful dissection and preservation of vascular and neural structures, as well as meticulous microsurgical techniques in managing cavernous sinus tumors, can lead to reduced surgical complications and improved treatment outcomes.

111 Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via Mobile Stroke Unit

INTRODUCTION: Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data is lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). METHODS: A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means. RESULTS: Seven patients were treated with MT after arriving by MSU. These were compared to 50 date- matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, co-morbidities, stroke characteristics, or tPA administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 mins ± 77.53 vs 483.51 mins ± 322.66, p = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by modified Rankin Scale (mRS) (1.86 ± 1.35 vs 3.57 ± 1.88, p = 0.024). No significant difference in final TICI score, complications, length of stay, or mortality was observed. CONCLUSIONS: Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in discharge mRS. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.

Abstract HUP9: Racial Disparities In Acute Ischemic Stroke At A Large Metropolitan Stroke Center

Background: Race and ethnicity can have a major impact on the quality of care patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of race and ethnicity on quality benchmarks of AIS therapy and clinical outcomes at a comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores, time to thrombolysis, discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent racial-ethnic groups including Non-Hispanic White (NHW), Hispanic, Black, Asian, Other and Unknown. Results: 3,735 AIS patients were identified. NHW represented 53.3% (n=1992),Black 21.3% (n=797), Hispanic 10.4% (n=390), Asian 7.2% (n=267), Other 4.6% (n=170) and Unknown 3.2% (n=119). There were no significant differences in door to needle (P=0.93), door to puncture time (P=0.98), intravenous thrombolysis (P=0.32) and mechanical thrombectomy utilization (P=0.19) by race-ethnicity. In univariable analysis, there was a higher rate of 30-day mortality in Unknown 23.5% vs NHW 7.3% (P&lt; 0.0001). A significantly (P&gt;0.05) higher rate of 30-day readmission was noted in NHW 20.3% vs Black 15.7%, Hispanics 15.6%, Others 11.8% and Unknown 8.4%. Black 67.6%, Hispanic 64.9% and Unknown 80.5% had a significantly (P&lt;0.05) higher rate of post stroke disability (mrs&gt;2) vs NHW 60.3%. A significant difference (P&lt;0.05) in LOS with Black patients staying 8.4, Hispanic 10.8, Asians 11.9 and Unknown 11.2 days vs NHW 7.7.Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression continued to show differences in post stroke disability for Black (OR=1.40, P=0.003), Hispanic (OR=1.49, P=0.008) and Unknown (OR=2.03, P=0.016) vs NHW. Median LOS was 0.85 and 0.77 days longer for Asian and Hispanic (P=0.006, P=0.014) respectively vs NHW. Conclusions: Our analysis reveals persistent disparities in stroke outcomes, with Black and Hispanic patients suffering greater disability post stroke. Further investigation is needed to uncover how race-ethnicity mediates stroke care and outcomes.

Abstract HUP2: Assessment Of Acute Ischemic Stroke Disparities By Primary Language In A High Patient Volume Comprehensive Stroke Center Serving A Diverse Metropolitan City

Background: Language barriers can have a major impact on the quality of care that patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of patient language on quality benchmarks of AIS therapy and clinical outcomes at a high-volume comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores (NIHSS), discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent primary languages including English, Spanish, Russian, Farsi, Korean and Other. All non-English speaking patients received medical interpretation via digital or in-person translation. Results: 3,812 AIS patients were identified. English language represented 80.2% (n=3091), Spanish 7.6% (n=238), Russian 4.1% (n=184), Farsi 3.0% (n=129), Korean 1.5% (n=47) and Other 3.6% (n=122).There were no significant differences in the rate of intravenous thrombolysis (P=0.52), door-to-needle time (P=0.91), door-to-puncture time (P=0.85), LOS (P=0.089) and 30 day readmission (P=0.74) among groups. In univariable analysis, Spanish 74.7%, Korean 84.4%, Russian 73.4%, Farsi 78.2% and Other 70.0% had significantly (P&lt; 0.05) higher rates of post stroke disability (mRS&gt; 2) compared to the English group 60.7%. A higher rate of 30-day mortality was noted in the Korean 17.8% compared to the English group 7.3%. The Spanish group had a higher rate of mechanical thrombectomy than the English group (11.8 vs 6.5%, P=0.009). Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression models for post stroke disability (mRS&gt;2) continued to show significant differences with Spanish (OR=1.66, P=0.008) and Farsi (OR=1.89, P=0.017) vs English. Conclusions: Our analysis reveals persistent disparities in AIS outcomes by primary language, with patients with limited English proficiency suffering worse disability after AIS. The effect of communication barriers on outcomes of stroke care in the inpatient setting requires further evaluation to close this gap.

671: HEAD INJURY DEPTH AND FUNCTIONAL OUTCOMES IN PEDIATRIC TRAUMATIC BRAIN INJURY

Introduction: The centripetal theory of traumatic brain injury (TBI) posits that an inertial mechanism (rotational acceleration and deceleration) injures the brain in an outward-in fashion, where mild injuries affect only the superficial brain and severe injuries affect the deep, subcortical structures of the brain. Neurologic symptoms progressively worsen as depth of injury increases. Depth of brain lesion has been proposed as a potential prediction tool for functional outcome in older children and adolescents, but there is a paucity of data connecting depth of injury and outcome in young children. We hypothesized that functional outcome at hospital discharge will worsen as greatest depth of injury increases in children < 3. Methods: Retrospective chart review including patients < 3 years of age admitted to a tertiary children’s hospital PICU or Intermediate Care Unit between 2015 - 2020 with acute TBI. Patients were divided into 4 cohorts based on greatest depth of injury visible on initial neuroimaging: scalp/skull/epidural vs. subdural/subarachnoid vs. cortical brain vs. subcortical brain injury. Baseline and hospital discharge Functional Status Score (FSS) (score 6-30) and Pediatric Cerebral Performance Category (PCPC) (score 1-5) were assigned. Results: A total of 170 patients were included (scalp/skull/epidural, n=54; subdural/subarachnoid, n=76; cortical brain, n=17; subcortical brain, n=23). Median age was 6 months. Sixty percent of patients were male. Nine patients died, 1 with a cortical injury and 8 with subcortical injuries. Total length of stay (LOS), PICU LOS, and ventilator days all increased as depth of injury increased (p< 0.001). All patients had a normal baseline FSS of 6 and a PCPC of 1. As depth of injury increased from superficial to deepest, patients were more likely to have functional deficits at discharge (FSS: 4% vs. 7% vs. 38% vs. 73%, p< 0.001; PCPC: 2% vs. 8% vs. 44% vs. 73%, p< 0.001). Patients with subcortical injuries had significantly higher median FSS (10, IQR 6.5-13, p< 0.001) and PCPC (2, IQR 1.5-3.5, p< 0.001) at discharge. Conclusions: Functional outcomes at hospital discharge worsen as greatest depth of injury increases in children < 3 with acute TBI, supporting the potential use of depth of brain injury as a prediction tool for functional outcome in this population.

Relationship between cerebral vasospasm vascular territory and functional outcome after aneurysmal subarachnoid hemorrhage

BackgroundVasospasm following aneurysmal subarachnoid hemorrhage (SAH) contributes significant morbidity and mortality after brain aneurysm rupture. However, the association between vascular territory of vasospasm and clinical outcome has not been studied....

Potentially inappropriate medications are negatively associated with functional recovery in patients with sarcopenia after stroke.

Evidence is scarce for potentially inappropriate medications (PIMs) in rehabilitation medicine. To examine the effect of PIMs on functional recovery in older patients with sarcopenia after stroke. We conducted a retrospective cohort study in a post-acute rehabilitation hospital. All patients diagnosed with sarcopenia aged ≥ 65years among all post-stroke patients hospitalized from 2015 to 2020 were included. PIMs were defined based on the 2019 Beers criteria. Sarcopenia was diagnosed using handgrip strength (HG) and skeletal muscle mass index (SMI), according to the criteria of the Asian Working Group for Sarcopenia 2019. The outcomes included functional independence measure motor (FIM-motor), HG, and SMI values at discharge. Multiple linear regression analyses were used to determine whether PIMs used at admission were independently associated with outcomes. Of the eligible patients, 361 were 65years or older, of whom 196 (mean age 81.0years, 44.4% male) presented with sarcopenia and were included in the analysis. Of these, 131 (66.8%) were prescribed PIMs at admission. The most frequently prescribed PIMs were proton pump inhibitors, antipsychotics, benzodiazepines, and nonsteroidal anti-inflammatory drugs. The number of PIMs on admission was independently associated with FIM-motor (β = -0.132, P = 0.001) and HG (β = -0.091, P = 0.048) at discharge, but not with SMI (β = -0.055, P = 0.256). High admission PIMs prescription numbers are negatively associated with favorable discharge functional status and muscle strength in older patients with sarcopenia after stroke.

Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via a Mobile Stroke Unit

Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally. A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means. Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33minutes±77.53 vs. 483.51minutes±322.66, P=0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86±1.35 vs. 3.57±1.88, P=0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed. Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.

Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma

Loss to follow-up (LTF) and unplanned readmission are barriers to recovery after acute subdural hematoma evacuation. The variables associated with these postdischarge events are not fully understood. To determine factors associated with LTF and unplanned readmission, emphasizing socioeconomic status (SES). A retrospective analysis was conducted of surgical patients with acute subdural hematoma managed operatively from 2009 to 2019 at a level 1 regional trauma center. Area Deprivation Index (ADI), which is a neighborhood-level composite socioeconomic score, was used to measure SES. Higher ADI corresponds to lower SES. To decrease the number of covariates in the model, principal components (PCs) analysis was used. Multivariable logistic regression analyses of PCs were performed for LTF and unplanned readmission. A total of 172 patients were included in this study. Thirty-six patients (21%) were LTF, and 49 (28%) patients were readmitted; 11 (6%) patients were both LTF and readmitted ( P = .9). The median time to readmission was 10 days (Q1: 4.5, Q3: 35). In multivariable logistic regression analyses for LTF, increased ADI and distance to hospital through PC2 (odds ratio [OR] 1.49; P = .009) and uninsured/Medicaid status and increased length of stay through PC4 (OR 1.73; P = .015) significantly contributed to the risk of LTF. Unfavorable discharge functional status and nonhome disposition through PC3 were associated with decreased odds of unplanned readmission (OR = 0.69; P = .028). Patients at high risk for LTF and unplanned readmissions, as identified in this study, may benefit from targeted resources individualized to their needs to address barrier to follow-up and to ensure continuity of care.

Evaluating the association between obesity and discharge functional status after pediatric injury

BackgroundChildren with obesity frequently have functional impairment after critical illness. Although obesity increases morbidity risk after trauma, the association with functional outcomes in children is unknown. ObjectiveTo evaluate the association of weight with functional impairment at hospital discharge in children with serious injuries. MethodsThis secondary analysis of a multicenter prospective study included children <15 years old with a serious injury. Four weight groups, underweight, healthy weight, overweight, and obesity/severe obesity were defined by body mass index z-scores. The functional status scale (FSS) measured impairment across six functional domains before injury and at hospital discharge. New domain morbidity was defined as a change ≥2 points. The association between weight and functional impairment was determined using logistic regression adjusting for demographics, physiological measures, injury details, presence of a severe head injury, and physical abuse. ResultsAlthough most patients discharged with good/unchanged functional status, new domain morbidity occurred in 74 patients (17%). New FSS domain morbidity occurred in 13% of underweight, 14% of healthy weight, 15% of overweight, and 26% of obese/severe obese patients. Compared to healthy weight patients, those with obesity had more frequent new domain morbidity (p = 0.01), while the other weight groups had similar morbidity. However, after adjustment for confounders, weight was not associated with new functional morbidity at discharge. ConclusionPatients with obesity have greater frequency of new domain morbidity after a serious injury; however, after accounting for injury characteristics, weight group is not independently associated with new functional morbidity at hospital discharge after injury in children. Level of EvidenceIII

Impact of early mobilization on discharge disposition and functional status in patients with subarachnoid hemorrhage: A retrospective cohort study.

Whereas early rehabilitation improves the patients’ physical function in patients with cerebral infarction and hemorrhage, complications in the early stage are the main barriers in patients with subarachnoid hemorrhage (SAH). Therefore, the clinical impact of early rehabilitation in patients with SAH is not well documented. We sought to investigate whether early mobilization is associated with favorable discharge disposition and functional status in patients with SAH.Hospitalization data of 35 patients (65.7 ± 13.7 years, 37.1% men) were retrospectively reviewed. The early and delayed mobilization groups were defined as those who had and had not participated in walking rehabilitation on day 14, respectively. We investigated whether patients were discharged or transferred to another hospital and assessed their functional status using the Functional Ambulation Categories, Ambulation Index, Glasgow Outcome Scale, and modified Rankin Scale scores.Nine patients (69.2%) in the early mobilization group and one patient (4.5%) in the delayed mobilization group were discharged home directly (P < .001). In multivariate logistic regression analysis, early mobilization was independently associated with home discharge after adjustment using the World Federation of Neurosurgical Societies grade (adjusted odds ratio = 30.20, 95% CI = 2.77–329.00, P < .01). Early mobilization was associated with favorable functional status at discharge through multivariate linear regression analysis (standardized beta = 0.64 with P < .001 for the Functional Ambulation Category and beta = -0.62 with P < .001 for the modified Rankin Scale, respectively).Early mobilization was associated with home discharge and favorable functional status at discharge. Larger prospective studies are warranted.

Diffuse Angiogram-Negative Subarachnoid Hemorrhage is Associated with an Intermediate Clinical Course.

The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype. We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared. Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016). We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise.

All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores

PurposeFunctional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. MethodsChildren with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. ResultsThe study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. ConclusionsAIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. Level of evidence1 (Prognostic and Epidemiological).

Long-Term Outcomes after Pediatric Injury: Results of the Assessment of Functional Outcomes and Health-Related Quality of Life after Pediatric Trauma Study

Disability and impaired health-related quality of life can persist for months among injured children. Previous studies of long-term outcomes have focused mainly on children with specific injury types rather than those with multiple injured body regions. This study's objective was to determine the long-term functional status and health-related quality of life after serious pediatric injury, and to evaluate the associations of these outcomes with features available at hospital discharge. We conducted a prospective observational study at 7 Level I pediatric trauma centers of children treated for at least 1 serious (Abbreviated Injury Scale severity 3 or higher) injury. Patients were sampled to increase the representation of less frequently injured body regions and multiple injured body regions. Six-month functional status was measured using the Functional Status Scale (FSS) and health-related quality of life using the Pediatric Quality of Life Inventory. Among 323 injured children with complete discharge and follow-up assessments, 6-month FSS score was abnormal in 33 patients (10.2%)-16 with persistent impairments and 17 previously normal at discharge. Increasing levels of impaired discharge FSS score were associated with impaired FSS and lower Pediatric Quality of Life Inventory scores at 6-month follow-up. Additional factors on multivariable analysis associated with 6-month FSS impairment included older age, penetrating injury type, severe head injuries, and spine injuries, and included older age for lower 6-month Pediatric Quality of Life Inventory scores. Older age and discharge functional status are associated with long-term impairment of functional status and health-related quality of life. Although most seriously injured children return to normal, ongoing disability and reduced health-related quality of life remained 6 months after injury. Our findings support long-term assessments as standard practice for evaluating the health impacts of serious pediatric injury.

Sex differences in the outcomes of adults admitted to inpatient rehabilitation after stroke.

Several differences have been reported between male and female patients with stroke in clinical and sociodemographic features, treatment, and outcomes. Potential effects in the inpatient rehabilitation population are unclear. To evaluate the differences between male and female patients in discharge functional status, length of stay, and discharge home after inpatient rehabilitation for stroke. Retrospective, population-based cohort study. Inpatient rehabilitation centers in Ontario, Canada. Male (N=10,684) and female (N=9459) patients discharged from acute care between September 1, 2012 and August 31, 2017, with a diagnosis of stroke and subsequently admitted to inpatient rehabilitation. Female sex. Discharge Functional Independence Measure (FIM) score, length of stay, and discharge home. Female patients had a lower functional status at discharge (mean FIM score 94.1 vs. 97.8, p < .001) and a lower proportion were discharged home (81.1% vs. 82.9%, p=.001). Female and male patients had similar rehabilitation length of stay (mean 31.8 vs. 31.7 days, p=.90). In the adjusted analyses, there was no difference in discharge functional status between male and female patients (FIM score β -.20 [95% confidence interval [CI] -0.64 to 0.25]). Female patients had a mean length of stay 2% shorter (0.98 [95% CI 0.96-0.99]) and a higher odds of discharge home (odds ratio [OR] 1.14 [95% CI 1.05-1.24]). There were no clinically significant sex differences in outcomes after inpatient rehabilitation for stroke. Observed sex disparities in the general stroke population may not be directly applicable to individuals undergoing inpatient rehabilitation.