Poor Long-term Functional Outcome Research Articles

A Mediation Analysis of the Association Between Systemic Inflammation Response Index, in-Hospital Complications, and Poor Long-Term Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: Insights from a Large Prospective Cohort Study.

Early systemic inflammatory changes are increasingly recognized as factors influencing outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Systemic inflammation response index (SIRI), an inflammation biomarker, was thought to be associated with adverse outcomes in many other diseases. However, in aSAH, research on SIRI remains limited. Thus, our objective was to investigate the association between SIRI and poor long-term functional outcomes while evaluating the mediating role of in-hospital complications in this association. SIRI was defined as neutrophil count × monocyte count/lymphocyte count. Patients were categorized according to SIRI quartiles. Stabilized inverse probability of treatment weighting (sIPTW) was utilized to minimize group differences. The association between SIRI and in-hospital complications as well as poor 90-day functional outcomes (mRS 3-6) was estimated by multivariable logistic regression analyses. Mediation analysis was performed to investigate the relationship between SIRI and poor functional outcomes mediated by in-hospital complications. A total of 650 patients were prospectively included. After sIPTW, compared to the lowest quartile, an elevated SIRI was associated with delayed cerebral ischemia (DCI) (OR 2.12, 95% CI 1.20-3.74), post-operative pneumonia (POP) (OR 2.16, 95% CI 1.29-3.62) and poor 90-day functional outcomes (OR 3.03, 95% CI 1.55-5.91). In-hospital complications including DCI (mediation proportion, 18.18% before sIPTW and 20.0% after sIPTW) and POP (mediation proportion, 18.18% before sIPTW and 26.7% after sIPTW) partially mediated the association between SIRI and poor 90-day functional outcomes. Mediation analysis yielded comparable results in subgroups stratified by age and sex. In this study, SIRI was associated with poor long-term functional outcomes in aSAH, which was partially mediated by DCI and POP with a mediation proportion exceeding 18%. Our findings might underscore the potential utility of SIRI in prompting physicians to address systemic inflammatory status timely to prevent in-hospital complications, including DCI and POP, and ultimately improve long-term functional outcomes.

Contact x-ray brachytherapy for the treatment of rectal cancer: A systematic review and meta-analysis.

e15628 Background: Rectal cancer is a highly prevalent disease, particularly among the elderly and frail populations. While surgical resection has traditionally been the primary management approach, it carries inherent risks, including operative mortality, morbidity, and poor long-term functional outcomes. These risks are particularly pronounced in older, co-morbid individuals. Evidence presented in the 2023 phase III OPERA randomised trial suggests that Contact X-ray Brachytherapy (CXB) is a viable organ-preserving alternative to radical surgery. We conducted a systematic review and meta-analysis to assess the clinical effectiveness of CXB in the treatment of rectal cancer. Methods: This systematic review was prospectively registered (CRD42021284969) and reported in accordance with PRISMA guidelines. PubMed, EMBASE, SCOPUS and Cochrane CENTRAL Libraries were interrogated using the search terms “Rectal cancer”, “Contact Brachytherapy”, and synonym terms. Literature search and data extraction were conducted by two reviewers, with recourse to a senior author for resolution of conflicts. Clinical complete response (cCR) was the primary outcome. Secondary outcomes include local regrowth, regional recurrence, salvage surgery rates, long-term disease control post-salvage surgery and survival outcomes. Proportional meta-analyses were conducted and presented as forest plots with summary proportions and 95% confidence intervals. The Higgins I2 statistic was used to assess for heterogeneity. The random effects model was employed in studies reporting substantial heterogeneity (I2> 50%). Results: The literature search identified 973 studies, of which 48 studies encompassing 5,447 patients were included in the meta-analysis. Pooled estimates of outcomes were as follows: cCR rate = 80% (95% CI 76-88%), local regrowth = 15% (95% CI 12-18%), regional failure rate = 3% (95% CI 2-4%), salvage surgery rate = 14% (95% CI 11-18%), long-term disease control post-salvage surgery rate = 88% (95% CI 78-96%) and organ preservation 82% (95% CI 75-88%). A subgroup analysis was conducted and stratified by concomitant therapy (CXB alone, CXB & EBRT, CXB & EBCRT). CXB, in conjunction with EBCRT, leads to a statistically significant reduction in both local regrowth and regional failure. The local regrowth rates were 16% (95% CI 11-21%), 17% (95% CI 11-23%), and 10% (95% CI 8-13%) respectively, with a p-value of 0.05. The regional failure rates were 4% (95% CI 2-8%), 4% (95% CI 2-5%), and 1% (95% CI 0-2%), p = 0.02. Conclusions: CXB, combined with EBCRT, in the appropriately selected patient can achieve long-term disease control whilst avoiding major surgery. Salvage surgery is a viable option for patients who experience disease regrowth, with excellent long-term disease control. CXB may be considered a safe alternative to surgery in the appropriately selected patient.

Long-Term Clinical Implications of High-Risk Cardiac Computed Tomography Findings in Patients With Acute Ischemic Stroke.

Cardiac computed tomography (CT) acquired during the initial acute stroke imaging protocol (acute cardiac CT) is increasingly used to screen for cardioembolism, but information on the long-term clinical implications of its findings is lacking. We performed a prospective, single-center cohort study in which consecutive patients with ischemic stroke underwent ECG-gated acute cardiac CT and were followed up for 2 years. The primary outcome was functional outcome assessed using the modified Rankin Scale. Secondary outcomes were death and occurrence of major adverse cardiovascular events (composite of recurrent ischemic stroke, myocardial infarction, and cardiovascular death). We compared patients with and without a high-risk structural source of embolism on acute cardiac CT. Of 452 included patients, 55 (12.2%) had a high-risk source of embolism, predominantly cardiac thrombi (38 patients) and signs of endocarditis (8 patients). Follow-up at 2 years was complete for 430 (95.1%) patients. Patients with a high-risk source of embolism had a worse functional outcome (median modified Rankin Scale, 6 [IQR, 2-6] versus 2 [IQR, 1-5]; adjusted common odds ratio, 2.92 [95% CI, 1.62-5.25]), increased mortality rate (52.7% versus 23.7%; adjusted hazard ratio [HR], 3.28 [95% CI, 1.94-5.52]), and major adverse cardiovascular events (38.9% versus 17.5%; adjusted HR, 3.20 [95% CI, 1.80-5.69]). A high-risk source of embolism was not associated with recurrent ischemic stroke (11.1% versus 9.6%; adjusted HR, 1.30 [95% CI, 0.49-3.44]). Structural high-risk sources of embolism on acute cardiac CT in patients with ischemic stroke were associated with poor long-term functional outcome and occurrence of major adverse cardiovascular events but not with recurrent stroke.

Atrial Cardiomyopathy Predicts the Functional Outcome and Mortality in Stroke Patients.

Atrial cardiomyopathy (ACM) is characterized by atrial dysfunction. This study aims to assess the prognostic significance of ACM in patients with noncardioembolic stroke (NCS). Patients with NCS within seven days of onset were prospectively enrolled between January 2019 and December 2020. ACM was defined as either an N-terminal pro-brain natriuretic peptide (NT-pro BNP) ＞250 pg/ml or a P-terminal force in precordial lead V1 (PTFV1) ≥ 5000µV·ms. A poor functional outcome was determined as a score of 3-6 on the modified Rankin Scale (mRS) within a 2-year follow-up period. Logistic regression and Cox regression analyses were employed to examine the relationship between ACM and the long-term prognosis of patients with NCS. A total of 1,346 patients were enrolled, of whom 299 (22.2%) patients were diagnosed with ACM. A total of 207(15.4%) patients experienced a poor functional outcome, and 58 (4.3%) patients died. A multivariate logistic regression analysis indicated that ACM was significantly associated with a poor functional outcome in NCS patients [adjusted odds ratio (aOR): 2.01; 95% confidence interval (CI): 1.42-2.87; p＜0.001]. Additionally, a multivariate Cox regression analysis showed that an NT-pro BNP ＞250 pg/ml was significantly associated with an increased risk of all-cause mortality [adjusted hazard ratio (aHR), 2.51; 95% CI: 1.42-4.43; p=0.001]. ACM may serve as a novel predictor of a poor long-term functional outcome in patients with NCS. Elevated NT-pro BNP levels (＞250 pg/ml) were found to be associated with a higher risk of all-cause mortality. These findings warrant further validation in multicenter studies.

438 Lesion Combination on Susceptibility-Weighted MRI Predicts Functional Recovery After Diffuse Axonal Injury

INTRODUCTION: Early prediction of long-term functional outcome after diffuse axonal injury (DAI) remains controversial. METHODS: In a retrospective observational study, axonal injuries on MRI were correlated with long-term functional outcome. The predictive value of poor functional outcome (GOSE < 5) was determined by ROC analysis for clinical factors and location of combinations of DAI lesions in the connectome. RESULTS: Over a 10-year period, 451 patients underwent MRI within 30 days of severe blunt TBI of which 322 (71.4%) survived to = 6-month clinical follow-up. The mean age was 38.4 and 242 (75%) patients were male. Mechanisms of injury were motor vehicle crash (53%) and falls (26%). Mean Glasgow coma scale (GCS) score was 4.7. At 6-24 months, quality MRI and functional outcome data were available for 213 and 104 patients, respectively. The best single-area predictors of early and late long-term functional outcome were the ventral midbrain (AUC6mo 0.65 (95% CI 0.56-0.74), p = 0.010) and dorsal pons (AUC24mo 0.68 (95% CI 0.51-0.86) p = 0.001). The best multiple-lesion predictors of poor long-term functional outcome (GOSE < 5) were dorsal pons and splenium of corpus callosum (AUC24mo 0.92 (95% CI 0.84-0.99), p < 0.0001) and the dorsal and ventral pons (AUC24mo 0.91 (95% CI 0.79-1.00), p < 0.0001). The strength of these combinations’ predictive value was not improved by considering three or more areas. The 6-area cluster of internal capsule, corpus callosum genu, body, and splenium; and dorsal and ventral midbrain lesions was a good predictor of outcome at 24 months (AUC24mo 0.82 (95% CI 0.66-0.98), p < 0.0001). CONCLUSIONS: In patients with severe TBI, the strongest predictors of poor long-term functional outcome were combined lesions in the splenium and dorsal pons and the dorsal and ventral pons.

Public and Clinician Perspectives on Ventilator Withdrawal in Vegetative State Following Severe Acute Brain Injury: A Vignette Survey.

The vegetative state (VS) after severe acute brain injury (SABI) is associated with significant prognostic uncertainty and poor long-term functional outcomes. However, it is generally distinguished from imminent death and is exempt from the Life-Sustaining Treatment (LST) Decisions Act in Korea. Here, we aimed to examine the perspectives of the general population (GP) and clinicians regarding decisions on mechanical ventilator withdrawal in patients in a VS after SABI. A cross-sectional survey was undertaken, utilizing a self-reported online questionnaire based on a case vignette. Nationally selected by quota sampling, the GP comprised 500 individuals aged 20 to 69 years. There were 200 doctors from a tertiary university hospital in the clinician sample. Participants were asked what they thought about mechanical ventilator withdrawal in patients in VS 2 months and 3 years after SABI. Two months after SABI in the case, 79% of the GP and 83.5% of clinicians had positive attitudes toward mechanical ventilator withdrawal. In the GP, attitudes were associated with spirituality, household income, religion, the number of household members. On the other hand, clinicians' attitudes were related to their experience of completing advance directives (AD) and making decisions about LST. In this case, 3 years after SABI, 92% of the GP and 94% of clinicians were more accepting of ventilator withdrawal compared to previous responses, based on the assumption that the patient had written AD. However, it appeared that the proportion of positive responses to ventilator withdrawal decreased when the patients had only verbal expressions (82% of the GP; 75.5% of clinicians) or had not previously expressed an opinion regarding LST (58% of the GP; 39.5% of clinicians). More than three quarters of both the GP and clinicians had positive opinions regarding ventilator withdrawal in patients in a VS after SABI, which was reinforced with time and the presence of AD. Legislative adjustments are needed to ensure that previous wishes for those patients are more respected and reflected in treatment decisions.

Long-term outcomes of deep pediatric arteriovenous malformations.

Multimodality treatment has been shown to be the optimal management strategy for pediatric arteriovenous malformations (AVMs). Deep AVMs represent a subset of AVMs for which optimal management may be achieved with a combination of radiosurgery and highly selective embolization, in the absence of compelling features requiring operative intervention. The objective of this study was to identify predictors of good functional outcomes in pediatric patients with deep AVMs. A retrospective cohort study of the outcomes of 79 patients with deep AVMs from January 1988 through December 2021 was performed. Deep AVMs were defined as those with the majority of the nidus centered in the basal ganglia, thalamus, or brainstem. Collected data included patient demographics and presenting symptoms, presenting modified Rankin Scale (mRS) score, radiographic findings and outcomes, management strategy, complications, and clinical outcomes as indicated by follow-up mRS score. A good outcome was defined as a follow-up mRS score ≤ 2, while a poor outcome was defined as a follow-up mRS score ≥ 3. Statistical analysis was performed to identify factors associated with functional outcomes. With a mean follow-up duration of 85.6 months, there was a 72.2% angiographic obliteration rate, with 75.9% of patients having a good clinical outcome (mRS score ≤ 2). Presenting symptoms and radiographic characteristics were not significantly associated with long-term functional outcomes. There was a significantly higher rate of posttreatment hemorrhage in patients with a poor versus good outcome (11.8% vs 0%, p = 0.010). On multivariate logistic regression analysis, poor long-term functional outcome was only associated with poor presenting mRS score (p = 0.002). Satisfactory angiographic obliteration rates and good long-term functional outcomes can be achieved for deep AVMs, with stereotactic radiosurgery as the cornerstone of multimodality treatment.

Impact of hypertensive disorders of pregnancy on short- and long-term outcomes of pregnancy-associated hemorrhagic stroke.

Though hypertension disorders of pregnancy (HDP) are recognized as independent pregnancy-associated stroke risk factors, few studies have considered their impact on stroke prognosis. Therefore, we intended to evaluate the impact of HDP on short- and long-term outcomes of pregnancy-associated hemorrhagic stroke (HS). We conducted a retrospective analysis of patients admitted to our hospital from May 2009 to December 2021 with a diagnosis of pregnancy-associated HS. After dividing patients into two groups by the presence of a diagnosis of HDP or not, the short- (at the time of discharge) and long-term (after discharge follow-up) outcomes were compared by mRS (modified Rankin Scale) scores, and poor functional outcome defined as mRS > 2. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported. Twenty-two HDP and 72 non-HDP pregnancy-associated HS patients were enrolled and follow-up after 4.7 ± 3.6 years. There was no significant difference between the two groups regarding short-term outcomes, but patients with HDP were more likely to reach poor functional outcomes at long-term follow-up (aOR = 4.47, 95% CI = 1.28-15.67, p = 0.019). In this retrospective study, women with hypertension disorders of pregnancy did not show worse short-term outcomes of pregnancy-associated hemorrhagic stroke compared to those without but had poorer long-term functional outcomes. This underlines the importance of prevention, recognition, and treatment of hypertension disorders in these women.

Effect of polygenic risk score, family load of schizophrenia and exposome risk score, and their interactions, on the long-term outcome of first-episode psychosis.

Consistent evidence supports the involvement of genetic and environmental factors, and their interactions, in the etiology of psychosis. First-episode psychosis (FEP) comprises a group of disorders that show great clinical and long-term outcome heterogeneity, and the extent to which genetic, familial and environmental factors account for predicting the long-term outcome in FEP patients remains scarcely known. The SEGPEPs is an inception cohort study of 243 first-admission patients with FEP who were followed-up for a mean of 20.9 years. FEP patients were thoroughly evaluated by standardized instruments, with 164 patients providing DNA. Aggregate scores estimated in large populations for polygenic risk score (PRS-Sz), exposome risk score (ERS-Sz) and familial load score for schizophrenia (FLS-Sz) were ascertained. Long-term functioning was assessed by means of the Social and Occupational Functioning Assessment Scale (SOFAS). The relative excess risk due to interaction (RERI) was used as a standard method to estimate the effect of interaction of risk factors. Our results showed that a high FLS-Sz gave greater explanatory capacity for long-term outcome, followed by the ERS-Sz and then the PRS-Sz. The PRS-Sz did not discriminate significantly between recovered and non-recovered FEP patients in the long term. No significant interaction between the PRS-Sz, ERS-Sz or FLS-Sz regarding the long-term functioning of FEP patients was found. Our results support an additive model of familial antecedents of schizophrenia, environmental risk factors and polygenic risk factors as contributors to a poor long-term functional outcome for FEP patients.

A Prospective Observational Study on Short and Long-Term Outcomes of COVID-19 Patients with Acute Hypoxic Respiratory Failure Treated with High-Flow Nasal Cannula.

(1) The use of high-flow nasal cannula (HFNC) combined with frequent respiratory monitoring in patients with acute hypoxic respiratory failure due to COVID-19 has been shown to reduce intubation and mechanical ventilation. (2) This prospective, single-center, observational study included consecutive adult patients with COVID-19 pneumonia treated with a high-flow nasal cannula. Hemodynamic parameters, respiratory rate, inspiratory fraction of oxygen (FiO2), saturation of oxygen (SpO2), and the ratio of oxygen saturation to respiratory rate (ROX) were recorded prior to treatment initiation and every 2 h for 24 h. A 6-month follow-up questionnaire was also conducted. (3) Over the study period, 153 of 187 patients were eligible for HFNC. Of these patients, 80% required intubation and 37% of the intubated patients died in hospital. Male sex (OR = 4.65; 95% CI [1.28; 20.6], p = 0.03) and higher BMI (OR = 2.63; 95% CI [1.14; 6.76], p = 0.03) were associated with an increased risk for new limitations at 6-months after hospital discharge. (4) 20% of patients who received HFNC did not require intubation and were discharged alive from the hospital. Male sex and higher BMI were associated with poor long-term functional outcomes.

Use of testosterone replacement therapy in the rehabilitation of patients with intensive care unit-associated weakness and hospital-associated deconditioning: the Singapore General Hospital rehabilitation experience.

Rehabilitation medicine in a tertiary care hospital involves attending to many patients affected by intensive care unit (ICU)-associated weakness (ICU-AW) and hospital-associated deconditioning (HAD). These conditions contribute to poor long-term functional outcomes and increased mortality. We explored the role of short-term adjunctive androgen therapy in this group of patients in improving the rehabilitative outcomes. This was a retrospective analysis of five patients with either ICU-AW or HAD who were given testosterone replacement therapy (TRT) or oxandrolone for a total of 2 weeks during the period from April to November 2020 was undertaken. During the 2-week trial period, the subjects underwent standard rehabilitation therapy. Grip strength was used as the primary outcome measure, and the mean improvement was 4.2 kg (+24.9%), which is encouraging in a 2-week timeframe. This was matched with good functional recovery in terms of distance ambulated and less assistance needed for ambulation. Sex hormone analysis was also done before initiation of TRT, and it showed that four out of five of the subjects were biochemically hypogonadal. None of the subjects dropped out or experienced any significant adverse events over the 2-week trial period. All the subjects except one improved to full independence at 3 months post-discharge. TRT has the potential to be used as a useful adjunct to standard rehabilitation in enhancing functional recovery in critically ill patients. A multidisciplinary approach would ensure that suitable patients benefit from optimal nutrition, optimal rehabilitation and synergistic testosterone therapy in a clinically sound and resource-efficient fashion.

Prognostic Value of Combined Radiomic Features from Follow-Up DWI and T2-FLAIR in Acute Ischemic Stroke.

The biological pathways involved in lesion formation after an acute ischemic stroke (AIS) are poorly understood. Despite successful reperfusion treatment, up to two thirds of patients with large vessel occlusion remain functionally dependent. Imaging characteristics extracted from DWI and T2-FLAIR follow-up MR sequences could aid in providing a better understanding of the lesion constituents. We built a fully automated pipeline based on a tree ensemble machine learning model to predict poor long-term functional outcome in patients from the MR CLEAN-NO IV trial. Several feature sets were compared, considering only imaging, only clinical, or both types of features. Nested cross-validation with grid search and a feature selection procedure based on SHapley Additive exPlanations (SHAP) was used to train and validate the models. Considering features from both imaging modalities in combination with clinical characteristics led to the best prognostic model (AUC = 0.85, 95%CI [0.81, 0.89]). Moreover, SHAP values showed that imaging features from both sequences have a relevant impact on the final classification, with texture heterogeneity being the most predictive imaging biomarker. This study suggests the prognostic value of both DWI and T2-FLAIR follow-up sequences for AIS patients. If combined with clinical characteristics, they could lead to better understanding of lesion pathophysiology and improved long-term functional outcome prediction.

Risk Factors and Neurological Outcomes Associated With Circulatory Shock After Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study.

Extracranial multisystem organ failure is a common sequela of severe traumatic brain injury (TBI). Risk factors for developing circulatory shock and long-term functional outcomes of this patient subset are poorly understood. To identify emergency department predictors of circulatory shock after moderate-severe TBI and examine long-term functional outcomes in patients with moderate-severe TBI who developed circulatory shock. We conducted a retrospective cohort study using the Transforming Clinical Research and Knowledge in TBI database for adult patients with moderate-severe TBI, defined as a Glasgow Coma Scale (GCS) score of <13 and stratified by the development of circulatory shock within 72 hours of hospital admission (Sequential Organ Failure Assessment score ≥2). Demographic and clinical data were assessed with descriptive statistics. A forward selection regression model examined risk factors for the development of circulatory shock. Functional outcomes were examined using multivariable regression models. Of our moderate-severe TBI population (n = 407), 168 (41.2%) developed circulatory shock. Our predictive model suggested that race, computed tomography Rotterdam scores <3, GCS in the emergency department, and development of hypotension in the emergency department were associated with developing circulatory shock. Those who developed shock had less favorable 6-month functional outcomes measured by the 6-month GCS-Extended (odds ratio 0.36, P = .002) and 6-month Disability Rating Scale score (Diff. in means 3.86, P = .002) and a longer length of hospital stay (Diff. in means 11.0 days, P < .001). We report potential risk factors for circulatory shock after moderate-severe TBI. Our study suggests that developing circulatory shock after moderate-severe TBI is associated with poor long-term functional outcomes.

Perilunate dislocation and fracture dislocation of the wrist: Outcomes and long-term prognostic factors

IntroductionPerilunate dislocations and fracture-dislocations are severe injuries that often have serious functional sequelae. Our goal was to evaluate the long-term clinical and radiological results of these perilunate injuries, and to look for prognostic factors of a poor clinical outcome. HypothesisAll patients who suffered perilunate injuries in their wrist have functional sequelae and long-term radiographic changes despite optimal treatment with anatomical surgical reduction. Materials and methodsWe did a single-center, retrospective study of 32 patients who had either an isolated perilunate dislocation (n=7) or fracture-dislocation (n=25) in their wrist. Pain, range of motion, strength and functional scores (MWS, PRWE, QuickDASH) were evaluated. Radiographs were analyzed to look for signs of osteoarthritis or carpal instability. ResultsThe mean follow-up time was 9.9years (3.5–24). The wrist joint had a mean flexion-extension of 86° (0–140), radioulnar deviation of 38° (0–65) and pronosupination of 153° (120–180). The mean grip strength was 35kg (5–56). The mean MWS, PRWE and QuickDASH scores were 65/100, 32/100 and 29/100, respectively. At the final assessment, 23 patients (79%) had radiographic signs of osteoarthritis while 5 patients (16%) had residual carpal instability. Three patients subsequently underwent palliative treatment. Opening the carpal tunnel and the magnitude of the lunate's displacement are significant predictors of a poor long-term functional outcome (p<0.05). Older age at the time of injury was a predictor for the development of osteoarthritis. DiscussionDespite optimal treatment, perilunate dislocations and fracture-dislocations at the wrist cause functional sequelae such as pain, stiffness, strength deficit and posttraumatic arthritis in nearly 80% of patients. The functional outcomes are determined by the amount of lunate displacement (stage) and the patient's age. We do not recommend opening the carpal tunnel, even when signs of median nerve compression are present; reducing the dislocation helps to relieve the neurological symptoms. Level of evidenceIV; retrospective observational study.

A prospective analysis of the postoperative and long-term functional outcomes of a novel technique to perform rectal transection during laparoscopic restorative proctectomy and ileal pouch-anal anastomosis.

Laparoscopic ileal pouch-anal anastomosis (IPAA) technique is not standardized. An irregular division of the rectum could result in poor functional outcomes and residual diseased mucosa. The aim of the study was to develop a new technique for performing the rectal transection via a laparoscopic approach, and to compare the outcomes of this technique with those of the open surgery IPAA. This prospective study included all patients who underwent restorative proctectomy (following a previous subtotal colectomy) for ulcerative colitis in October 2017-November 2020. Rectal division was performed using a 30 mm open linear stapler which was applied laparoscopically across the distal rectum. Postoperative and functional outcomes, length of anal stump and completeness of mucosal removal were compared. Only the patients who had their ileostomy reversed by 31 December 2020 and, therefore, a minimum follow-up of 6months from the ileostomy closure, were included in the analysis of the functional outcomes and quality of life. There were 207 patients (161 laparoscopic, 46 open). Median age was 43 (18-77) years and 85 patients (41.1%) were male. Major complications (9.3 vs. 8.7%, p = 0.89) including anastomotic leaks (3.7 vs 4.4%, p = 0.84) were similar after laparoscopic and open IPAA. Patients reported a comparable number of bowel movements during the day (6 vs. 7, p = 0.21) and at night (2 vs. 2, p = 0.66), and a similar rate of episodes of incontinence during the previous 6months (3.7 vs. 4.3%, p = 0.75). The mean Cleveland Global Quality of Life score was also similar (0.79 vs. 0.74, p = 0.35). Our technique is safe and reproducible, and replicates the results of the open IPAA, while maintaining the advantages of minimally invasive surgery and avoiding any kind of anal manipulation which could result in poor long-term functional outcomes.

FLAIR vessel hyperintensities predict functional outcomes in patients with acute ischemic stroke treated with medical therapy.

The prognostic value of fluid-attenuated inversion recovery vessel hyperintensity (FVH) remains controversial in acute ischemic stroke (AIS). The objective was to investigate whether the presence of FVH could predict long-term functional outcomes in patients with AIS receiving medical therapy. Consecutive AIS patients with anterior circulation large vessel stenosis (LVS) in multiple centers between January 2019 and December 2020 were studied. Presence of FVH was identified and evaluated as FVH (+). Quantification of FVH was performed using an FVH-Alberta Stroke Program Early CT Score (ASPECTS) system and divided into grades: FVH-ASPECTS of 0 = grade 0; 1-2 = grade 1; 3-7 = grade 2. Poor functional outcome was defined as modified Rankin scale > 2 at 3 months. Overall, 175 patients were analyzed (age, 64.31 ± 13.47 years; men, 65.1%), and 78.9% patients presented with FVH. Larger infarct volume (19.90 mL vs. 5.50 mL, p < 0.001), higher rates of FVH (+) (92.0% vs. 65.9%, p < 0.001), and higher FVH grades (grade 2, 34.5% vs. 10.2%, p < 0.001) were more prone to be observed in patients with poor functional outcomes. FVH (+) with infarct volume larger than 6.265 mL (adjusted odds ratio [aOR] 6.03, 95% confidence interval [CI] 1.82-19.98) and FVH grade (grade 1, aOR 3.07, 95% CI 1.12-8.43; grade 2, aOR 5.80, 95% CI 1.59-21.11) were independently associated with poor functional outcomes. FVH (+) combined with large infarct volume and high FVH grade can predict poor long-term functional outcomes in patients with LVS who receive medical therapy. • FVH is expected to be a contrast agent-independent alternative for assessing hemodynamic status in the acute stage of stroke. • FVH (+) and high FVH grade, quantified by FVH-ASPECTS rating system and grades, are associated with large infarct volume. • The combination of FVH and DWI-based infarct volume has independent predictive value for long-term functional outcomes in AIS patients with large artery stenosis treated with medical therapy.

Clinical characteristics, long-term functional outcomes and relapse of anti-LGI1/Caspr2 encephalitis: a prospective cohort study in Western China.

Objective:To study the clinical characteristics of anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis and anti-contactin-associated protein-like 2 (Caspr2) encephalitis and to investigate factors associated with poor long-term neurological functional outcomes and relapse among patients in western China.Methods:In this single-center prospective cohort study, we consecutively enrolled patients with anti-LGI1 encephalitis and anti-Caspr2 encephalitis from April 2014 to February 2021. Patient outcomes were assessed using the modified Rankin scale. Predictors of long-term functional outcomes and relapse were analyzed.Results:Forty-four anti-LGI1 encephalitis patients [median age: 44 years, range: 18–82 years; females: 25 (56.8%)], 35 anti-Caspr2 encephalitis patients [median age: 43 years, range: 14–80 years; females: 19 (54.3%)], and 5 dual-positive patients [median age: 44 years, range: 36–58 years; females: 5 (100%)] were enrolled. Overall, 86.4% anti-LGI1 encephalitis patients and 80% anti-Caspr2 encephalitis had a favorable neurological functional outcome (mRS 0-2). Tumor occurrence and weight loss were associated with poor long-term functional outcomes in anti-LGI1 encephalitis, whereas in anti-Caspr2 encephalitis, predictors included behavioral disorder at acute phase, abnormalities in brain magnetic resonance imaging, higher modified Rankin scale scores at onset, poor response to the initial immunotherapy at 4 weeks, age at onset<30 years, and relapse (p<0.05). Overall, 13.6% of anti-LGI1 encephalitis patients and 20% of anti-Caspr2 encephalitis patients had at least one relapse. Sleep disorder at the acute phase was the risk factor of relapse in anti-LGI1 encephalitis, while female, age at onset <30 years, and behavioral disorder at acute phase were the risk factors of relapse in anti-Caspr2 encephalitis (log rank p<0.05).Conclusion:The clinical characteristics such as age, gender, and tumor occurrence rates of anti-LGI1 encephalitis and anti-Caspr2 encephalitis in western China are different from those in the Western countries. Most patients in our study had favorable long-term functional outcomes. The relapse rates are still high in both types of encephalitis, which warrants caution.

Plasma ADAM-10 levels and functional outcome of acute primary basal ganglia hemorrhage

BackgroundThe a-secretase A disintegrin and metalloprotease-10 (ADAM-10) may have deleterious effects in acute brain injury. This study was designed to discern if a relationship between plasma ADAM-10 levels and functional outcome exists in patients with intracerebral hemorrhage (ICH). MethodsA total of 109 patients with basal ganglia hemorrhage and 100 healthy controls were included. Their plasma ADAM-10 levels were gauged. Ninety-day prognosis was assessed and poor outcome was defined as death or major disability (modified Rankin Scale score of 3 or greater). ResultsPlasma ADAM-10 levels were substantially elevated in patients, as compared to controls. ADAM-10 levels were independently correlated with hematoma size and National Institutes of Health Stroke Scale (NIHSS) score. Plasma ADAM-10, NIHSS score and hematoma size emerged as the independent predictors for 90-day poor outcome. Under receiver operating characteristic curve, plasma ADAM-10 levels exhibited similar prognostic capability, as compared to hematoma size and NIHSS score; moreover, it significantly improved prognostic abilities of NIHSS and hematoma size. ConclusionsRising plasma ADAM-10 levels are independently related to increasing severity and poor long-term functional outcome after hemorrhagic stroke, substantializing serum ADAM-10 as a useful prognostic biomarker of ICH.

Healing After Moderate to Severe TBI Takes Time

Healing After Moderate to Severe TBI Takes Time

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty.

Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.