Odds Of Good Clinical Outcome Research Articles

Sex and Racial Disparity in Outcome of Aneurysmal Subarachnoid Hemorrhage in the United States: A 20-Year Analysis

Aneurysmal subarachnoid hemorrhage is associated with high rate of morbidity and mortality. We aimed to assess prognostic impact of sex, race, and ethnicity in these patients. Nationwide Inpatient Sample (2000-2019) was used to identify patients presenting with aneurysmal subarachnoid hemorrhage as primary diagnosis. Patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities, type of the hospital, and treatment modality used for aneurysm repair were extracted. The previously validated Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale was used to estimate the clinical severity. Discharge destination and in-hospital mortality was used as outcome measured. The impact of race/ethnicity and sex on clinical outcome was analyzed using multivariate regression models. A total of 161 086 patients with aneurysmal subarachnoid hemorrhage were identified. Mean age was 55.0±13.8 years. Sixty-nine percent of the patients were female, 60% White patients, and 17% Black patients. There was no difference in the Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale score between the 2 sexes. Women had significantly lower odds of good clinical outcome (defined as discharge to home or acute rehabilitation facility; RR, 0.83 [95% CI, 0.74-0.94]; P=0.004). Hispanic patients (RR, 1.12 [95% CI, 1.07-1.17]; P<0.001) had higher odds of excellent clinical outcome compared with White patients, and lower risk of mortality were observed in Black patients (RR, 0.73 [95% CI, 0.66-0.81]) and Hispanic patients (RR, 0.78 [95% CI, 0.70-0.86]) compared with the White patients. In this nationally representative study, women were less likely to have excellent outcomes following aneurysmal subarachnoid hemorrhage, and White patients had disproportionately higher likelihood of worse clinical outcomes. Lower rates of mortality were seen among Black and Hispanic patients.

The Prognostic Roles of Perihematomal Edema and Ventricular Size in Patients with Intracerebral Hemorrhage.

Conflicting data exist regarding the association of perihematomal edema (PHE) with outcomes after intracerebral hemorrhage (ICH). We performed a post hoc analysis of the ICH Deferoxamine trial to examine whether an early change in ventricular size (VS), as a composite measure of PHE growth and mass effect, intraventricular hemorrhage, and hydrocephalus, is a more accurate predictor of outcome than PHE measures alone. Computerized tomography scans were performed at baseline and after 72-96h. We evaluated measures of PHE and change in VS as predictors of outcome, assessed by a dichotomized modified Rankin Scale score (0-2 versus 3-6), primarily at 90days and secondarily at 30days. A multivariable logistic regression model was fitted for each predictor, with adjustment for the same confounders. A total of 248 participants were included after we excluded those requiring external ventricular drains. On univariate analyses, older age, female sex, lower Glasgow Coma Scale score and baseline temperature, greater ICH volume, absolute PHE volume, edema extension distance at presentation, lesser changes in relative PHE volume and edema extension distance, and an increase in VS were associated with poor outcome. In multivariable analyses, only the increase in VS was associated with lower odds of modified Rankin Scale scores 0-2 at 90days (odds ratio 0.927, 95% confidence interval 0.866-0.970, p = 0.001) and 30days (odds ratio 0.931, 95% confidence interval 0.888-0.975, p = 0.003). Within the context of a randomized controlled trial with standardized imaging and functional assessments, we did not find significant associations between measures of PHE and outcome but documented an independent association between early increase in VS and lower odds of good clinical outcome.

Stroke Patients With Faster Core Growth Have Greater Benefit From Endovascular Therapy.

This study aimed to explore whether the therapeutic benefit of endovascular thrombectomy (EVT) was mediated by core growth rate. This retrospective cohort study identified acute ischemic stroke patients with large vessel occlusion and receiving reperfusion treatment, either EVT or intravenous thrombolysis (IVT), within 4.5 hours of stroke onset. Patients were divided into 2 groups: EVT versus IVT only patients (who had no access to EVT). Core growth rate was estimated by the acute core volume on perfusion computed tomography divided by the time from stroke onset to perfusion computed tomography. The primary clinical outcome was good outcome defined by 3-month modified Rankin Scale score of 0-2. Tissue outcome was the final infarction volume. A total of 806 patients were included, 429 in the EVT group (recanalization rate of 61.6%) and 377 in the IVT only group (recanalization rate of 44.7%). The treatment effect of EVT versus IVT only was mediated by core growth rate, showing a significant interaction between EVT treatment and core growth rate in predicting good clinical outcome (interaction odds ratio=1.03 [1.01-1.05], P=0.007) and final infarct volume (interaction odds ratio=-0.44 [-0.87 to -0.01], P=0.047). For patients with fast core growth of >25 mL/h, EVT treatment (compared with IVT only) increased the odds of good clinical outcome (adjusted odds ratio=3.62 [1.21-10.76], P=0.021) and resulted in smaller final infarction volume (37.5 versus 73.9 mL, P=0.012). For patients with slow core growth of <15 mL/h, there were no significant differences between the EVT and the IVT only group in either good clinical outcome (adjusted odds ratio=1.44 [0.97-2.14], P=0.070) or final infarction volume (22.6 versus 21.9 mL, P=0.551). Fast core growth was associated with greater benefit from EVT compared with IVT in the early <4.5-hour time window.

Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy: Beyond the First-Pass Effect.

Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort. For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0-2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders. The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0-10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7-7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8-5.6]). Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03356392.

Anemia Predicts Poor Clinical Outcome in Mechanical Thrombectomy Patients with Fair or Good Collateral Circulation

Background and Purpose: Anemia predicts poor clinical outcome of ischemic stroke in the general stroke population. We studied whether this applies to those treated with mechanical thrombectomy for proximal anterior circulation occlusion in the setting of differing collateral circulation. Methods: We collected the data of 347 consecutive anterior circulation stroke patients who underwent mechanical thrombectomy after multimodal CT imaging in a single tertiary stroke care center. Patients with occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. We recorded baseline clinical, laboratory, procedural, and imaging variables, and the technical, imaging, and clinical outcomes. Differences between anemic and nonanemic patients were studied with appropriate statistical tests and binary logistic regression analysis. Results: Ninety-four out of the 285 patients eligible for analysis had anemia, and 243 had fair or good collateral circulation (collateral score, CS, >0). Fifty-four percent of the patients experienced good 3-month clinical outcome (modified Rankin Scale ≤2). In pooled analyses of the CS 1–4 and 2–4 ranges, nonanemic patients had good clinical outcome significantly more often (p < 0.001 for both). This effect was not seen in patients with poor collateral circulation (CS = 0). Nonanemic patients had significantly better odds of good clinical outcome (OR = 2.6, 95% CI 1.377–5.030, p = 0.004) in a binary regression model. A 0.1 g/dL increase in hemoglobin improved the odds of good clinical outcome by 2% (OR = 1.02, 95% CI 1.002–1.044, p = 0.03). Conclusions: Low hemoglobin on admission predicts poor clinical outcome in mechanical thrombectomy patients with fair or good collateral circulation.

Endovascular aneurysm closure during out of office hours is not related to complications or outcome

PurposeA possible disadvantage of endovascular occlusion outside work hours is that complex procedures might expose patients to additional risk when performed in a suboptimal setting. In this prospective cohort study, we evaluated whether treatment during out of office hours is a risk factor for per-procedural complications and clinical outcome.MethodsWe included 471 endovascular-treated, consecutive aneurysmal subarachnoid hemorrhage patients (56.6 ± 13.1, 69% female), from two prospective observational databases which were retrospectively analyzed. Primary outcome was the occurrence of per-procedural complications. Secondary outcomes were good clinical outcome (modified ranking scale ≤ 2) and death at 6-month follow-up. We determined odds ratios (OR) with 95% confidence intervals (CI) by ordered polytomous logistic regression analysis and adjusted odds ratios (aOR) for age, World Federation of Neurosurgical Societies grade, and time to treatment.ResultsMost patients were treated during office hours (363/471; 77.1%). Treatment during out of office hours did not result in an increased risk of per-procedural complications (OR 0.85 (95% CI 0.53–1.37; p = 0.51). Patients treated during out of office hours displayed similar odds of good clinical outcome and death after 6 months (OR 1.14, 95% CI 0.68–1.97 and 1.16 95% CI 0.56–2.29, respectively) compared to patients treated during office hours.ConclusionIn our study, endovascular coil embolization during out of office hours did not expose patients to an increased risk of procedural complications or affect functional outcome after 6 months.

Chronic Infarcts Predict Poor Clinical Outcome in Mechanical Thrombectomy of Sexagenarian and Older Patients

The impact of lacunar and cortical chronic ischemic lesions (CILs) on the clinical outcome of mechanical thrombectomy (MT) has been little studied. Clinical trials suggest that older patients benefit from MT. We investigated the effect of CILs on the clinical outcome of sexagenarian and older patients with acute middle cerebral artery (MCA) or distal internal carotid artery (ICA) stroke who received MT to treat large-vessel occlusion (LVO). We prospectively collected the clinical and imaging data of 130 consecutive MT patients of which 68 met the inclusion criteria. We limited the analysis to sexagenarian and older subjects and occlusions no distal than the M2 segment. Baseline clinical, procedural and imaging variables, technical outcome, 24-hour imaging outcome, and the clinical outcome were recorded. Differences between patients with and without CILs were studied with appropriate statistical tests and binary logistic regression analysis. Twenty-one patients (31%) had at least 1 CIL. Thirty-eight percent of patients with CIL(s) compared with 62% without (P = .06) experienced good clinical outcome (3-month modified Rankin Scale ≤ 2). A similar nonsignificant trend was seen when lacunar lesions, lesion multiplicity, and chronic white matter lesions were examined separately. Absence of CIL increased the odds of good clinical outcome 3.7-fold (95% confidence interval 1.0-10.7, P = .05) in logistic regression modeling. Chronic cortical and lacunar infarcts in admission imaging are associated with poor clinical outcome in sexagenarian and older patients treated with MT for LVO of the MCA or distal ICA.

Time-resolved CT assessment of collaterals as imaging biomarkers to predict clinical outcomes in acute ischemic stroke.

Collateral circulation plays a pivotal role in the pathophysiology of acute ischemic stroke and is increasingly recognized as a promising biomarker for predicting the clinical outcome. However, there is no single established grading system. We designed a novel machine-learning software that allows non-invasive, objective, and quantitative assessment of collaterals according to their vascular territories. Our goal is to investigate the prognostic and predictive value of this collateral score for the prediction of acute stroke outcome. This is a retrospective study of 135 patients with anterior circulation stroke treated with IV TPA. An equation using this collateral score (adjusting for age, baseline NIHSS, and recanalization) was derived to predict the clinical outcome (90-day mRS). The primary analyses focused on determining the prognostic value of our newly developed collateral scores. Secondary analyses examined the interrelationships between the collateral score and other variables. The collateral score emerged as a statistically significant prognostic biomarker for good clinical outcome (p<0.033) among recanalized patients, but not among non-recanalized patients (p<0.497). Our results also showed that collateral score was a predictive biomarker (p<0.044). These results suggest that (1) patients with good collateral score derive more benefit from successful recanalization than patients with poor collateral score and (2) collateral status is inconsequential if recanalization is not achieved. Our data results reinforce the importance of careful patient selection for recanalization therapy to avoid futile recanalization. The paucity of collaterals predicts poor clinical outcome despite recanalization. On the other hand, robust collaterals warrant consideration for recanalization therapy given the better odds of good clinical outcome.

Abstract 104: Good Collateral Status and Favorable Clinical Outcome in Acute Ischemic Stroke: First Systematic Review and Meta-analysis

Background: Leptomeningeal collaterals preserve ischemic brain beyond an occluded artery until reperfusion is achieved. This systematic review and meta-analysis seeks to update current state of knowledge on the use of collateral imaging as a prognostic and patient selection tool in patients with acute ischemic stroke. Methods: We searched all published studies measuring collateral status in patients with acute ischemic stroke and its association with clinical outcome using MEDLINE, EMBASE and the Cochrane Systematic Review database between Jan 1951- May 2014. Imaging modality, collateral score type, time from stroke onset to evaluation and other parameters that assess study quality were collected. Association between collateral status and clinical outcome was estimated using random effects models. Meta-regression was then used to analyze heterogeneity. Results: Of 2,424 studies reviewed, 10 studies that fulfilled all inclusion/exclusion criteria, had all necessary data elements and reported adjusted point estimates were included in the final meta-analysis. Four studies used DSA to measure collaterals vs. 5 that used CTA and 1 dCTA; 6 studies included patients &lt; 6 hours of symptom onset, 5 studies adjusted for reperfusion status while reporting point estimate while 5 studies used consensus reading. Pooled adjusted odds of good clinical outcome with good collateral status were 4.69 (95% CI 2.73-8.05) (Attached Figure 1). Only 36.3% of the variance in the pooled estimate is attributed to study heterogeneity (Q statistic p value=0.12). Meta-regression did not reveal any statistically significant difference in heterogeneity based on imaging modality (p=0.96), time from symptom onset to imaging (p=0.3), reperfusion status (p=0.82) or consensus reads (p=0.51). Begg’s test and funnel plot for small study effects suggests asymmetry (p&lt;0.01). Conclusion: Collateral imaging is a reliable prognostic and patient selection tool in acute ischemic stroke.

Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study.

We report on workflow and process-based performance measures and their effect on clinical outcome in Solitaire FR Thrombectomy for Acute Revascularization (STAR), a multicenter, prospective, single-arm study of Solitaire FR thrombectomy in large vessel anterior circulation stroke patients. Two hundred two patients were enrolled across 14 centers in Europe, Canada, and Australia. The following time intervals were measured: stroke onset to hospital arrival, hospital arrival to baseline imaging, baseline imaging to groin puncture, groin puncture to first stent deployment, and first stent deployment to reperfusion. Effects of time of day, general anesthesia use, and multimodal imaging on workflow were evaluated. Patient characteristics and workflow processes associated with prolonged interval times and good clinical outcome (90-day modified Rankin score, 0-2) were analyzed. Median times were onset of stroke to hospital arrival, 123 minutes (interquartile range, 163 minutes); hospital arrival to thrombolysis in cerebral infarction (TICI) 2b/3 or final digital subtraction angiography, 133 minutes (interquartile range, 99 minutes); and baseline imaging to groin puncture, 86 minutes (interquartile range, 24 minutes). Time from baseline imaging to puncture was prolonged in patients receiving intravenous tissue-type plasminogen activator (32-minute mean delay) and when magnetic resonance-based imaging at baseline was used (18-minute mean delay). Extracranial carotid disease delayed puncture to first stent deployment time on average by 25 minutes. For each 1-hour increase in stroke onset to final digital subtraction angiography (or TICI 2b/3) time, odds of good clinical outcome decreased by 38%. Interval times in the STAR study reflect current intra-arterial therapy for patients with acute ischemic stroke. Improving workflow metrics can further improve clinical outcome. http://www.clinicaltrials.gov. Unique identifier: NCT01327989.

Early experience with stent retrievers and comparison with previous-generation mechanical thrombectomy devices for acute ischemic stroke

OBJECT.: There is limited information regarding patient outcomes following interventions for stroke during the window for endovascular therapy. Studies have suggested that recently approved stent retrievers are safer and more effective than earlier-generation thrombectomy devices. The authors compared cases in which the Solitaire-FR device was used to those in which a MERCI or Penumbra device was used. This study is a single-center retrospective review of 102 consecutive cases of acute stroke in which patients were treated with mechanical thrombectomy devices between 2007 and 2013. Multivariate models, adjusted for confounding factors, were used to investigate functional independence (modified Rankin Scale [mRS] score ≤ 2, and successful reperfusion (thrombolysis in cerebral infarction [TICI] score ≥ 2b). Thrombectomy device had a significant impact on functional independence (mRS score ≤ 2) at discharge from the hospital (p = 0.040). Solitaire-FR treatment resulted in significantly more patients being discharged as functionally independent in comparison with MERCI treatment (p = 0.016). A multivariate model found the use of Solitaire-FR to improve the odds of good clinical outcome in comparison with prior-generation devices (OR 6.283, 95% CI 1.785-22.119, p = 0.004). Additionally, the use of Solitaire-FR significantly increased the odds of successful reperfusion (OR 3.247, 95% CI 1.160-9.090, p = 0.025). The stent retriever Solitaire-FR significantly improved the odds of functional independence and successful revascularization of the arterial tree. New interventional technology for stroke continues to mature, but randomized trials are needed to establish the actual benefit to specific patient populations.

Abstract 146: Optimal Workflow and Process Based Performance Measures for Endovascular Therapy in Acute Ischemic Strokes From the Star Registry

Introduction: We report on workflow and process based performance measures and its impact on clinical outcome in STAR, a recent international, multi-center, prospective, single-arm study of Solitaire FR thrombectomy in patients with large vessel anterior circulation strokes treated within 8 hrs of symptom onset. Methods: A total of 202 patients were enrolled across 14 comprehensive stroke centers in Europe, Canada and Australia. The following time intervals were measured: stroke onset to ED arrival; ED to baseline CT; CT to groin puncture; groin puncture to thrombus identification; thrombus identification to start of IA therapy and start of IA therapy to reperfusion. Effects of time of day, general anesthesia (GA) utilization and multi-modal imaging on workflow were evaluated. Patient characteristics and workflow processes associated with prolonged interval times and good clinical outcome (90-day mRS 0-2) were analyzed. Results: Distribution of all interval times are illustrated in Figure 1a. Median hospital arrival to final DSA run time was 150 mins (IQR=97 mins). Hospital arrival to final DSA run time was faster in women than men (158 vs. 139 mins). General anesthesia increased CT to groin puncture time by 22 mins and groin puncture to final DSA run by 13 minutes. Time of day or week did not effect interval times. CT based multi-modal imaging reduced time from CT to groin puncture by 24 mins. For each 60-minute increase in time from symptom onset to TICI 2b/3 (or final DSA run), a 33% decrease in odds of good clinical outcome (p&lt;0.01) was noted independent of the effect of increased age (p&lt;0.01), higher baseline NIHSS (p=0.02), and lower ASPECTS score (p=0.02). (Figure 1b) Conclusion: Interval times in the STAR study is a reflection of current IA therapy for patients with acute ischemic stroke. Improving workflow processes and reducing time to reperfusion could improve clinical outcomes further.

Factors Associated With Intracerebral Hemorrhage After Thrombolytic Therapy for Ischemic Stroke

A number of factors have been associated with postthrombolysis intracerebral hemorrhage, but these have varied across studies. We examined patients with acute ischemic stroke treated with intravenous tissue plasminogen activator within 3 hours of symptom onset who were enrolled in the placebo arms of 2 trials (Stroke-Acute Ischemic NXY Treatment [SAINT] I and II Trials) of a putative neuroprotectant. Early CT changes were graded using the Alberta Stroke Program Early CT Score (ASPECTS). Post-tissue plasminogen activator symptomatic intracerebral hemorrhage was defined as a worsening in National Institutes of Health Stroke Scale of > or =4 points within 36 hours with evidence of hemorrhage on follow-up neuroimaging. Good clinical outcome was defined as a modified Rankin scale of 0 to 2 at 90 days. Symptomatic intracerebral hemorrhage occurred in 5.6% of 965 patients treated with tissue plasminogen activator. In multivariable analysis, symptomatic intracerebral hemorrhage was increased with baseline antiplatelet use (single antiplatelet: OR, 2.04, 95% CI, 1.07 to 3.87, P=0.03; double antiplatelet: OR, 9.29, 3.28 to 26.32, P<0.001), higher National Institutes of Health Stroke Scale score (OR, 1.09 per point, 1.03 to 1.15, P=0.002), and CT changes defined by ASPECTS (ASPECTS 8 to 9: OR, 2.26, 0.63 to 8.10, P=0.21; ASPECTS < or =7: OR, 5.63, 1.66 to 19.10, P=0.006). Higher National Institutes of Health Stroke Scale was associated with decreased odds of good clinical outcome (OR, 0.82 per point, 0.79 to 0.85, P<0.001). There was no relationship between baseline antiplatelet use or CT changes and clinical outcome. Along with higher National Institutes of Health Stroke Scale and extensive early CT changes, baseline antiplatelet use (particularly double antiplatelet therapy) was associated with an increased risk of post-tissue plasminogen activator symptomatic intracerebral hemorrhage. Of these factors, only National Institutes of Health Stroke Scale was associated with clinical outcome.

Combined Treatment Reduces Drinking Problems

Back to table of contents Previous article Next article Professional NewsFull AccessCombined Treatment Reduces Drinking ProblemsEve BenderEve BenderSearch for more papers by this authorPublished Online:2 Jun 2006https://doi.org/10.1176/pn.41.11.0006A multisite clinical trial of treatments for alcohol dependence shows that when combined with medical management, the medication naltrexone is as effective as up to 20 sessions of a type of behavioral therapy in terms of reducing drinking.Findings from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) study also showed that the medication acamprosate had no effect on reducing drinking and no added benefit when combined with naltrexone.The findings appear in the May 3 Journal of the American Medical Association.Naltrexone is an opiate antagonist. Although it was originally used to treat opioid dependence, the Food and Drug Administration also approved it for alcoholism.Acamprosate is a glutamate receptor modulator and is thought to reduce the discomfort associated with protracted abstinence from alcohol.Roger Weiss, M.D., principal investigator for the McLean Hospital study site, told Psychiatric News that he found the results encouraging and said he thought it would be feasible to treat alcohol-dependent patients with naltrexone and/or combined behavioral therapy with medical management in both primary care offices and mental health treatment centers.To assess the effect of a number of treatments on alcohol addiction, researchers at 11 treatment centers across the United States gathered data on 1,383 recently abstinent alcohol-dependent subjects recruited through advertisements or referrals.The more than 1,000 subjects were randomly placed in one of nine treatment groups (of about 150 patients each) for 16 weeks of outpatient treatment: patients in eight of the groups received medical management from a clinician who reviewed patients' diagnosis of alcohol dependence with them, recommended abstinence from alcohol, and discussed patients' overall functioning and medication adherence.Patients in four of the groups also received up to 20 50-minute sessions of a combined behavioral intervention (CBI), which integrated motivational interviewing, aspects of cognitive-behavioral therapy, and encouragement to participate in 12-step groups.Motivational interviewing was described as a nonconfrontational style of interviewing patients that involved empathy, helped patients to reflect on their choices, and assessed the patient's strengths.Four groups of patients also received one of the following: naltrexone (100 mg a day), acamprosate (3 g a day), a combination of the two drugs, or placebo. The placebo group received CBI alone.Researchers assessed the patients at several time points during the 16-week treatment trial and up to a year after the treatment trial to determine the percentage of days abstinent from alcohol and the time to the first heavy-drinking day (defined as four or more drinks a day for women and five or more for men).They also assessed the odds of good clinical outcome, defined as abstinence or moderate drinking with no alcohol-related problems.During the treatment period, patients receiving naltrexone plus medical management (n=302), CBI plus medical management and placebo (n=305), or both naltrexone and CBI plus medical management (n=309) had a higher percentage of days abstinent (80.6 percent, 79.2 percent, and 77.1 percent, respectively) than the 75 percent of days abstinent in groups receiving placebos and medical management only (n=305).The interaction of naltrexone and CBI was statistically significant at p=.009, according to the study.Naltrexone plus medical management was also found to reduce the risk of having a heavy-drinking day over the study period (p=.02).The study also found that those receiving CBI without medication or medical management (n=157) had a lower percentage of days abstinent from alcohol (66.6 percent) than did those receiving placebo plus medical management alone (n=153) or placebo plus medical management and CBI (n=156) (73.8 percent and 79.8 percent, respectively).One year after treatment, there were similar differences between the groups, but none was statistically significant. Moreover, acamprosate showed no effect on drinking, either alone or with any combination of naltrexone, CBI, or both.Weiss noted that while CBI is best conducted by a specialist with training in alcohol dependence treatment, medical management can be conducted in the primary care setting by a wide range of health clinicians.He said that researchers are continuing to analyze data from the COMBINE study to identify predictors of good clinical outcomes in regard to recovery from alcohol dependence.The study was funded by the National Institute on Alcohol Abuse and Alcoholism.An abstract of “Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence: The COMBINE Study: A Randomized Controlled Trial” is posted at<http://jama.ama-assn.org/cgi/content/abstract/295/17/2003>.▪ ISSUES NewArchived

Prognostic significance of uric acid serum concentration in patients with acute ischemic stroke.

We sought to assess in 881 consecutive patients with acute ischemic stroke the clinical relevance in regard to functional outcome of the natural antioxidant uric acid measured at hospital admission. Patients had serum uric acid (mg/dL) measured by standard procedures 18.2+/-15.5 hours from clinical onset. At hospital discharge (11.0+/-6.0 days), neurological impairment was classified as moderate/severe (Mathew score < or =75; n=304) or mild/absent (Mathew score >75; n=577). Demographics, atherosclerotic risk factors, history of organ disease, baseline neurological score, stroke subtype, infarction size, renal function, aspirin use before stroke, stroke therapy, diuretic use, and laboratory markers, including erythrocyte sedimentation rate, were analyzed in both outcome groups with the use of backward logistic regression. Increased uric acid values were found in men, hypertensives, alcohol drinkers, and patients with coronary, pulmonary, or renal diseases. Diabetic patients had lower uric acid levels on admission. Uric acid was directly associated with hematocrit (P=0.001), sodium (P=0.001), creatinine (P=0.001), and triglycerides (P=0.001) and inversely related with nonfasting glucose (P=0.001) levels. Neurological impairment on admission (P=0.001) and final infarction size on CT/MRI (P=0.01) were also inversely associated with uric acid. A logistic regression adjusted for confounders confirmed the following independent (odds ratio, 95% CI) good outcome predictors: age (0.97, 0.96 to 0.99), Mathew score on admission (1.14, 1.12 to 1.17), erythrocyte sedimentation rate (0.98, 0.97 to 0.99), infarction volume (0.98, 0.98 to 0.99), and uric acid (1.12, 1.00 to 1.25). In patients with acute ischemic stroke, there is a 12% increase in the odds of good clinical outcome for each milligram per deciliter increase of serum uric acid. This finding reinforces the relevance of oxidative damage in ischemic stroke.