Predictor Of Poor Functional Outcome Research Articles

Abstract WP22: A Scoring System Based on Age and DWI Volume Predicts Poor Functional Outcome Following Endovascular Treatment for Acute Ischemic Stroke

Background: The Houston IAT (HIAT) score predicts poor outcome following endovascular stroke therapy based on clinical variables (age, serum glucose, and NIHSS score). We aimed to validate the HIAT score in an independent cohort of patients treated with endovascular therapy (DEFUSE 2) and determine if prediction of poor outcome could be improved by including neuroimaging variables in the prediction score. Methods: Patients enrolled in the DEFUSE 2 study had a clinical diagnosis of acute ischemic stroke and underwent MRI prior to endovascular treatment. Poor functional outcome was defined as a modified Rankin Scale score of 4 to 6 at day 90. The relationship between baseline clinical and neuroimaging variables and poor functional outcome was assessed using univariate and multivariate logistic regression. Statistically significant variables in the multivariate model were used to create a new scoring system. We evaluated the new scoring system and the HIAT score using ROC analysis. Results: One hundred and ten patients were included in the analysis; forty-two patients had a poor functional outcome. Validation of the HIAT score demonstrated similar ROC properties in the DEFUSE 2 cohort (AUC=0.69) compared to the Houston derivation cohort (AUC=0.73). In DEFUSE 2, age (p=0.001), baseline DWI volume (p=0.09), baseline NIHSS score (p=0.03) and hypertension (p=0.003) were associated with poor functional outcome in univariate analysis. In multivariate analysis, age (p<0.001) and baseline DWI volume (p=0.03) were independent predictors of poor functional outcome. Based on this we developed a new scoring system with a maximum of 3 points awarded for age (0 points, < 55; 1 point, 56-69; 2 points, 70-79; 3 points, ≥ 80) and a maximum of 1 point awarded for baseline DWI volume (0 points, volume ≤ 15 cc; 1 point, volume >15 cc). The percentage of patients with poor functional outcomes increased with the number of points awarded (0% poor outcomes in patients with 0 points, 25% with 1 point, 30% with 2 points, 75% with 3 points, and 89% with 4 points). The AUC for the new scoring system was 0.82. Conclusion: The new scoring system that incorporates baseline DWI volume and age predicts poor outcome more accurately than a scoring system based on clinical variables alone.

Plasma copeptin levels in Chinese patients with acute ischemic stroke: a preliminary study

Copeptin is a stable by-product of arginine-vasopressin synthesis and reflects its secretion. The objective of the study was to evaluate the predictive value of copeptine on functional outcome at 90-day follow-up from stroke onset. We conducted a prospective, observational cohort study in the emergency department of two hospitals and enrolled 125 patients with acute ischemic stroke. Plasma copeptin concentrations, determined by a CT-proAVP-luminescence-immunoassay, were measured. There was a good correlation between levels of plasma copeptin and NIHSS score (r = 0.733, P < 0.01). In the 41 patients (32.8 %) with a poor functional outcome, copeptin levels were higher compared with those in patients with a favorable outcome (27.3; IQR, 14.9-34.8 pmol/L vs. 12.9; IQR, 9.4-21.6 pmol/L; P < 0.0001). Copeptin levels in 18 patients who died were more than two times greater as compared to patients who survived (32.4; IQR, 18.7-38.5 pmol/L vs. 15.1; IQR, 12.4-24.6 pmol/L; P < 0.0001). After adjusting for all other significant outcome predictors, copeptin level remained an independent predictor for poor functional outcome and mortality with an odds ratio of 3.12 (95 % CI 1.54-6.46), 3.16 (95 % CI 0.92-6.15), respectively. Our study suggests that copeptin levels are a useful tool to predict outcome and mortality 3 months after acute ischemic stroke and have a potential to assist clinicians.

Plasma gelsolin levels and outcomes after aneurysmal subarachnoid hemorrhage

IntroductionLower gelsolin levels have been associated with the severity and poor outcome of critical illness. Nevertheless, their link with clinical outcomes of aneurysmal subarachnoid hemorrhage is unknown. Therefore, we aimed to investigate the relationship between plasma gelsolin levels and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage.MethodsA total of 262 consecutive patients and 150 healthy subjects were included. Plasma gelsolin levels were measured by enzyme-linked immunosorbent assay. Mortality and poor long-term outcome (Glasgow Outcome Scale score of 1-3) at 6 months were recorded.ResultsPlasma gelsolin levels on admission were substantially lower in patients than in healthy controls (66.9 (26.4) mg/L vs. 126.4 (35.4) mg/L, P < 0.001), and negatively associated with World Federation of Neurological Surgeons score (r = -0.554, P < 0.001) and Fisher score (r = -0.538, P < 0.001), and identified as an independent predictor of poor functional outcome (odds ratio, 0.957; 95% confidence interval (CI), 0.933-0.983; P = 0.001) and death (odds ratio, 0.953; 95% CI, 0.917-0.990; P = 0.003) after 6 months. The areas under the ROC curve of gelsolin for functional outcome and mortality were similar to those of World Federation of Neurological Surgeons score and Fisher score (all P > 0.05). Gelsolin improved the predictive values of World Federation of Neurological Surgeons score and Fisher score for functional outcome (both P < 0.05), but not for mortality (both P > 0.05).ConclusionsGelsolin levels are a useful, complementary tool to predict functional outcome and mortality 6 months after aneurysmal subarachnoid hemorrhage.

The Impact of Left Ventricular Hypertrophy and Diastolic Dysfunction on Outcome in Intracerebral Hemorrhage Patients

BackgroundThe objective of this study was to determine the prevalence of LVH and DD in patients presenting with supratentorial deep ICH and to determine if the presence of LVH or DD was an independent predictor of initial ICH volume, hematoma expansion, or poor outcome.MethodsA cross-sectional study was performed on ICH patients who presented from 7/2008 to 12/2010. Cases were excluded if ICH was traumatic, lobar, infratentorial, secondary to elevated international normalized ratio, suspicious for underlying structural malformation, or where surgical evacuation was performed. Logistic and linear regressions were used to assess the ability of LVH to predict ICH imaging characteristics and patient outcomes.ResultsAfter adjusting for use of hemostatic agents, LVH was not a significant independent predictor of initial ICH volume (P = 0.344) or 33% volume expansion (P = 0.378). After adjusting for age, infectious complications, and use of hemostatic agents, LVH was not a significant independent predictor of poor functional outcome (P = 0.778). Similar results were seen for DD.ConclusionIn our sample, patients with deep ICH and LVH were more likely to develop IVH, but LVH was not a significant independent predictor of initial ICH volume, hematoma expansion, or poor short-term outcome.

Relationship between plasma high mobility group box-1 protein levels and clinical outcomes of aneurysmal subarachnoid hemorrhage

BackgroundHigh-mobility group box 1 (HMGB1), originally described as a nuclear protein that binds to and modifies DNA, is now regarded as a central mediator of inflammation by acting as a cytokine. However, the association of HMGB1 in the peripheral blood with disease outcome and cerebrovasospasm has not been examined in patients with aneurysmal subarachnoid hemorrhage.MethodsIn this study, 303 consecutive patients were included. Upon admission, plasma HMGB1 levels were measured by ELISA. The end points were mortality after 1 year, in-hospital mortality, cerebrovasospasm and poor functional outcome (Glasgow Outcome Scale score of 1 to 3) after 1 year.ResultsUpon admission, the plasma HMGB1 level in patients was statistically significantly higher than that in healthy controls. A multivariate analysis showed that the plasma HMGB1 level was an independent predictor of poor functional outcome and mortality after 1 year, in-hospital mortality and cerebrovasospasm. A receiver operating characteristic curve showed that plasma HMGB1 level on admission statistically significantly predicted poor functional outcome and mortality after 1 year, in-hospital mortality and cerebrovasospasm of patients. The area under the curve of the HMGB1 concentration was similar to those of World Federation of Neurological Surgeons (WFNS) score and modified Fisher score for the prediction of poor functional outcome and mortality after 1 year, and in-hospital mortality, but not for the prediction of cerebrovasospasm. In a combined logistic-regression model, HMGB1 improved the area under the curve of WFNS score and modified Fisher score for the prediction of poor functional outcome after 1 year, but not for the prediction of mortality after 1 year, in-hospital mortality, or cerebrovasospasm.ConclusionsHMGB1 level is a useful, complementary tool to predict functional outcome and mortality after aneurysmal subarachnoid hemorrhage. However, HMGB1 determination does not add to the accuracy of prediction of the clinical outcomes.

Low ankle-brachial index is an independent predictor of poor functional outcome in acute cerebral infarction

ObjectiveThe ankle-brachial blood pressure index (ABI) is an established clinical test for assessment of peripheral arterial disease and an indicator of generalized atherosclerosis. We investigated whether low ABI is associated with long-term functional outcome in patients with acute cerebral infarction. MethodsWe included 775 patients with acute cerebral infarction who were admitted within 7 days from stroke onset and had completed an ABI measurement during admission. Poor functional outcome was defined as a modified Rankin Scale of more than 2 at three months from stroke onset. The association between low ABI and poor functional outcome was analyzed using logistic regression analysis. ResultsA low ABI (<0.9) was present in 10.1% of patients. At three months from stroke onset, 16.9% of patients showed poor functional outcome (mRS > 2). After adjusting for conventional cardiovascular risk factors and the presence of cerebral atherosclerosis, a low ABI was independently associated with poor functional outcome (odds ratio 2.523, 95% CI 1.330–4.785, p = 0.005). ConclusionsThe presence of a low ABI was associated with an increased risk of poor functional outcome in patients with acute cerebral infarction. Screening for low ABI among stroke patients may be necessary to identify individuals at increased risk of poor functional outcome. Proper and individualized treatment for patients with a low ABI may improve long-term functional outcome following acute cerebral infarction.

Functional survival after acute care for severe head injury at a designated trauma center in Hong Kong

Severe head injury is known to be a major cause of early mortalities and morbidities. Patients' long-term outcome after acute care, however, has not been widely studied. We aim to review the outcome of severely head-injured patients after discharge from acute care at a designated trauma center in Hong Kong. This is a retrospective study of prospectively collected data of patients admitted with severe head injuries between 2004 and 2008. Patients' functional status post-discharge was assessed using the Extended Glasgow Outcome Score (GOSE). Of a total of 1565 trauma patients, 116 had severe head injuries and 41 of them survived acute hospital care. Upon the last follow-up, 23 (56.1%) of the acute-care survivors had improvements in their GOSE, six (11.8%) experienced deteriorations, and 12 (23.5%) did not exhibit any change. The greatest improvement was observed in patients with GOSE of 5 and 6 upon discharge, but two of the 16 patients with GOSE 2 or 3 also had a good recovery. On logistic regression analysis, old age and prolonged acute hospital stay were found to be independent predictors of poor functional outcome after a mean follow-up duration of 42 months. Multidisciplinary neurorehabilitation service is an important component of comprehensive trauma care. Despite significant early mortalities, a proportion of severely head-injured patients who survive acute care may achieve good long-term functional recovery.

Persistence of Hyperdense Middle Cerebral Artery Sign on Follow-Up CT Scan after Intravenous Thrombolysis Is Associated with Poor Outcome

Background: The rates and extent of recovery in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV-tPA) remain highly variable. Hyperdense middle cerebral artery sign (HMCAS) on pretreatment unenhanced computerized tomography (CT) of the brain represents the presence of thrombus, often associated with severe neurological deficits and poor clinical outcome at 3 months. However, HMCAS is reliable only in AIS patients managed conservatively. In patients treated with systemic thrombolysis, HMCAS may disappear (representing clot dissolution) or persist (persisting clot) on the follow-up CT scan of the brain. We aimed at evaluating whether disappearance or the persistence of HMCAS on follow-up CT scan of the brain can predict the final outcome at 3 months. Methods: Data from consecutive AIS patients treated with IV-tPA, in a standardized protocol, from January 2007 to March 2010 were included in the prospective thrombolysis registry at our tertiary care center. For this evaluation, posterior circulation stroke was excluded. HMCAS was assessed on admission as well as follow-up CT by 2 independent stroke neurologists, blinded to the patient data or outcomes. Functional outcomes assessed by the modified Rankin Scale (mRS) at 3 months were dichotomized as good (mRS score 0–1) and poor (mRS score 2–6). The data were analyzed for the early predictors of poor functional outcome with SPSS version 19 for Windows. Results: Of the total of 2,238 patients admitted during the study period, 226 (11%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age of the patients was 65 years (range 19–92), 63% were males and they had a median National Institutes of Health Stroke Scale (NIHSS) score of 16 points (range 4–32). HMCAS was observed on admission CT scan in 109 (48.2%) patients and persisted on follow-up CT in 52 (47.7%) of them. Overall, 108 (47.8%) patients achieved poor functional outcome at 3 months. Admission NIHSS score (OR per 1-point increase = 1.241; 95% CI = 1.151–1.337, p < 0.0005), lesser change in NIHSS score at 24 h (OR per 1-point reduction = 0.730; 95% CI = 0.666–0.800, p < 0.0005) and persistence of HMCAS on follow-up CT scan (OR = 3.352; 95% CI = 1.991–11.333, p = 0.039) were associated with poor outcome at 3 months. Conclusion: Persistence of HMCAS on the follow-up CT scan of the brain in acute ischemic stroke patients treated with IV-tPA can be used as an early predictor of poor functional outcome.

Functional, cognitive and psychological outcomes, and recurrent vascular events in Pakistani stroke survivors: a cross sectional study

BackgroundThere is little direct data describing the outcomes and recurrent vascular morbidity and mortality of stroke survivors from low and middle income countries like Pakistan. This study describes functional, cognitive and vascular morbidity and mortality of Pakistani stroke survivors discharged from a dedicated stroke center within a nonprofit tertiary care hospital based in a multiethnic city with a population of more than 20 million.MethodsPatients with stroke, aged > 18 years, discharged alive from a tertiary care centre were contacted via telephone and a cross sectional study was conducted. All the discharges were contacted. Patients or their legal surrogate were interviewed regarding functional, cognitive and psychological outcomes and recurrent vascular events using standardized, pretested and translated scales. A verbal autopsy was carried out for patients who had died after discharge. Stroke subtype and risk factors data was collected from the medical records. Subdural hemorrhages, traumatic ICH, subarachnoid hemorrhage, iatrogenic stroke within hospital and all other diagnoses that presented like stroke but were subsequently found not to have stroke were also excluded. Composites were created for functional outcome variable and depression. Data were analyzed using logistic regression.Results309 subjects were interviewed at a median of 5.5 months post discharge. 12.3% of the patients had died, mostly from recurrent vascular events or stroke complications. Poor functional outcome defined as Modified Rankin Score (mRS) of > 2 and a Barthel Index (BI) score of < 90 was seen in 51%. Older age (Adj-OR-2.1, p = 0.01), moderate to severe dementia (Adj-OR-19.1, p < 0.001), Diabetes (Adj-OR-2.1, p = 0.02) and multiple post stroke complications (Adj-OR-3.6, p = 0.02) were independent predictors of poor functional outcome. Cognitive outcomes were poor in 42% and predictors of moderate to severe dementia were depression (Adj-OR-6.86, p < 0.001), multiple post stroke complications (Adj-OR-4.58, p = 0.01), presence of bed sores (Adj-OR-17.13, p = 0.01) and history of atrial fibrillation (Adj-OR-5.12, p < 0.001).ConclusionsPakistani stroke survivors have poor outcomes in the community, mostly from preventable complications. Despite advanced disability, the principal caretakers were family rarely supported by health care personnel, highlighting the need to develop robust home care support for caregivers in these challenging resource poor settings.

Abstract 3267: Persistence of Hyperdense Middle Cerebral Artery Sign on Follow-up CT Scan is Associated with Poor Outcome in Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Background- Early identification of reliable predictors of functional outcomes is important for planning rehabilitation strategies in patients with acute ischemic stroke (AIS). Hyperdense middle cerebral artery sign (HMCAS) on unenhanced computerized tomography (CT) of the brain represents presence of thrombus, often associated with poor outcome at 3-months. In thrombolyzed cases, HMCAS may disappear or persist on the follow-up CT scan. We evaluated whether persistence of HMCAS on follow-up CT predicts functional outcome at 3-months. Methods- Consecutive AIS patients treated with intravenous thrombolysis between 2007 and 2010 were included. HMCAS was assessed on admission as well as follow-up CT by 2 independent readers, blinded to patient data and outcomes. Data were analyzed for early predictors of poor functional outcome at 3months (modified Rankin scale 2-6points). Results- Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age of the IV-TPA treated patients was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). HMCAS was observed on admission CT scan in 109 (48.2%) patients and persisted on follow-up CT in 52 (47.7%) of them. Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. Older age (OR 1.024;95%CI0.999-1.048), admission NIHSS score (OR1.08;95%CI 1.03-1.14,p=0.002) and HMCAS on follow-up CT scan (OR 10.25;95%CI 4.05-25.99,p &lt;0.0001) were associated with poor outcome at 3-months. Conclusion- Persistence of HMCAS on the follow up CT scan in AIS patients receiving intravenous thrombolysis is an early predictor of poor functional outcome at 3-months.

Abstract 99: Impact of Acute Perihematomal Edema on Long Term Outcomes Following Primary Intracerebral Hemorrhage

Introduction: The impact of acute perihematomal edema (PHE) as an independent predictor of clinical outcomes following an intracerebral hemorrhage (ICH) has been controversial. To date, some studies have reported that PHE is associated with poorer outcomes, while others have found an association with good outcomes. The goals of the current analysis were to 1) identify predictors of acute PHE, and 2) determine impact of PHE on clinical outcomes in a predominantly African American hypertensive ICH population. Methods: Subjects with spontaneous non-traumatic ICH who were prospectively enrolled in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project were included in the analysis. Baseline MRIs were performed in subjects at median of 2 days from onset. Hematoma volume as well as PHE were calculated from GRE and FLAIR sequences, respectively, employing a semiautomated volumetric analysis. PHE volume was expressed as a percent of the hematoma volume (PHEv/ICHv x 100). Outcome measures included year 1 NIHSS score using a log-linear model and dichotomized (0-2 vs. 3-6) modified Rankin Scale (mRS) using a logistic regression model. Results: A total of 140 subjects were included in the analysis. Mean age was 59, 58% were male, 75% were black, and 85% had a history of hypertension. Baseline NIHSS score was mean 9 (median 6), mean ICH volume was 25 cc (range 0.5-136 cc), and mean relative PHE percent was 115% (range 0-559%). Independent predictors of PHE on multivariate analysis included ICH volume (p=0.004) and antiplatelet use on admission (p=0.02). At the year 1 timepoint, there was no significant association between the severity of PHE percent and good or poor outcome based on dichotomized mRS (p=0.67); however there was a modest trend towards an association between increased edema and lower NIHSS scores (p=0.15). Conclusions: In this large MRI-based cohort of patients with primary ICH, acute perihematomal edema measured on FLAIR sequences was not an independent predictor of poor functional outcome at year 1 employing the mRS. However, there was a modest trend towards an association between increased relative edema volume and lower year 1 NIHSS scores, which may suggest a protective effect of edema on outcome. Further studies in a larger cohort are needed to clarify the impact of both acute and peak perihematomal edema on outcome following primary ICH.

Abstract 3286: Persistently Reduced Venous Drainage After Intravenous Thrombolysis is Associated With Poor outcome in Acute Anterior Circulation Ischemic Stroke

Background- Significant numbers of acute ischemic stroke (AIS) patients recover with timely-administered intravenous tissue plasminogen activator (IV-TPA). However, rates and extent of recovery remain variable. Considering scarce and costly resources, early identification of reliable predictors for functional outcomes is important for planning rehabilitation strategies. We hypothesized that venous drainage would be impaired on the side of cerebral hypoperfusion due to acute occlusion of internal carotid or middle cerebral artery. The 2 internal cerebral veins (ICV) drain the deep parts of hemispheres and run backward to form great cerebral vein. Since ICVs are consistently seen on CT angiography (CTA), parallel and run very close to each other, even minor asymmetry in their filling can be easily diagnosed. ICV asymmetry in pre-TPA CTA can change in patients achieving arterial recanalization, rendering it less useful for predicting the long-term outcomes. Thus, we aimed at evaluating whether the presence of ICV asymmetry on follow-up CTA can predict the final outcome. Methods- Data from consecutive AIS patients treated with IV-TPA, in a standardized protocol, from Jan2007 to March2010 were included in a prospective registry at our tertiary center. In this study, we excluded posterior circulation strokes. Significant proportion AIS patients undergo CTA on day 2 after IV-TPA to assess the status of arterial patency. ICV asymmetry was assessed by 2 independent stroke neurologists/ neuroradiologists, blinded to patient data or outcomes. Functional outcomes were assessed by modified Rankin Scale (mRS) at 3-months, dichotomized as good outcome (mRS 0-1) and poor outcome (mRS 2-6). Data were analyzed for the early predictors of function outcome. Results- Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). Hypertension was the commonest vascular risk factor in 144 (76%) while 63 (33%) patients suffered from atrial fibrillation (AF). Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. ICV asymmetry could be assessed only in 103 (45.5%) patients on their follow up CTA films. Admission NIHSS score (OR1.08;95%CI 1.001-1.157,p=0.048) and ICV asymmetry on follow-up CT scan (OR 23.9;95%CI 5.15-63.99,p &lt;0.0001) were associated with poor outcome at 3-months. Conclusion- Presence of the asymmetry of internal cerebral veins on the follow up CT angiography in acute ischemic stroke patients treated with IV-TPA can be used as an early predictor of poor functional outcome.

Primary hip replacement: First year results and predictive factors of poor outcome

ObjectiveTo evaluate the results of total hip arthroplasty in patients with osteoarthritis and to identify predictors of poor functional outcome. Materials and methodsA prospective observational study in patients operated on in 2006 with total hip arthroplasty in 4 hospitals in Guipúzcoa, followed up for 1 year. Outcome variables: pain, physical function, complications, mortality, quality of life by WOMAC and SF-12 (at 0, 3, 6 and 12 months) and “Poor functional outcome” at one year (last quartile of the WOMAC in function area). Logistic regression was performed to examine predictors of poor functional outcome. ResultsA total of 166 patients were followed up. The incidence of systemic and local complications was 6.3% and 14.5%, respectively, 4.3% readmissions and no deaths related to surgery. Close to 40 points improvement in pain, stiffness and WOMAC functional limitation was mainly in the first 3 months after surgery. A similar trend was seen, but lower in the physical and mental component of the SF12 (12 and 8 points, respectively). The previous score on the WOMAC function area and the physical component of SF-12, and the existence of any complications, are predictors of poor functional recovery. DiscussionThe improvement experienced after the surgery is already very important before the third month. The functional status and physical status before surgery and possible complications of surgery are significant determinants of the results.

Recovery after spinal cord infarcts

To investigate the long-term outcome of patients with spinal cord infarct (SCI) and identify prognostic predictors. We reviewed 115 patients with SCI treated between 1990 and 2007. Severity of impairment was defined using the American Spinal Injury Association (ASIA) scoring. Functional outcome endpoints were ambulatory status, need for bladder catheterization, and pain. Mean age was 64 years; 72 (62.6%) patients were men. A total of 45% of infarcts were perioperative (69% aortic surgeries). A total of 68% reached maximal deficit within 1 hour (mean = 5 hours). Impairment at nadir was ASIA A 23%, B 26%, C 14%, and D 37%. A total of 75/93 (81%) patients studied with MRI had cord signal abnormality. At nadir, 81% required wheelchair, 86% required catheterization, and 32% had pain. At last follow-up (mean = 3 years), 23% had died. Among survivors, 42% required a wheelchair, 54% required catheterization, and 29% had pain upon last follow-up. Of 74 patients using a wheelchair at hospital dismissal, 41% were walking by final follow-up. Of 83 patients catheterized at dismissal, 33% were catheter-free at last follow-up. Older age (p < 0.0001), increased severity of impairment at nadir (p = 0.02), and peripheral vascular disease (p = 0.003) were independent risk factors for mortality. Severe impairment (ASIA A/B) at nadir predicted wheelchair use (p < 0.0001) and bladder catheterization (p < 0.0001) at last follow-up. Gradual improvement in not uncommon after spinal cord infarction and it may continue long after hospital dismissal. While severe impairment at nadir is the strongest predictor of poor functional outcome, meaningful recovery is also possible in a substantial minority of these patients.

Artroplastia primaria de cadera: resultados en el primer año y factores predictores de mala evolución

ObjectiveTo evaluate the results of total hip arthroplasty in patients with osteoarthritis and to identify predictors of poor functional outcome. Material and methodsA prospective observational study in patients operated on in 2006 with total hip arthroplasty in 4 hospitals in Guipúzcoa, followed up for 1 year. Outcome variables: pain, physical function, complications, mortality, quality of life by WOMAC and SF-12 (at 0, 3, 6 and 12 months) and «Poor functional outcome» at one year (last quartile of the WOMAC in function area). Logistic regression was performed to examine predictors of poor functional outcome. ResultsA total of 166 patients were followed up. The incidence of systemic and local complications was 6.3% and 14.5%, respectively, 4.3% readmissions and no deaths related to surgery. Close to 40 points improvement in pain, stiffness and WOMAC functional limitation, mainly in the first 3 months after surgery. A similar trend was seen, but lower in the physical and mental component of the SF12 (12 and 8 points, respectively). The previous score on the WOMAC function area and the physical component of SF-12, and the existence of any complications, are predictors of poor functional recovery. DiscussionThe improvement experienced after the surgery is already very important before the third month. The functional and physical status before surgery and possible complications of surgery are significant determinants of the results.

Functional outcome in older adults with joint pain and comorbidity: design of a prospective cohort study

BackgroundJoint pain is a highly prevalent condition in the older population. Only a minority of the older adults consult the general practitioner for joint pain, and during consultation joint pain is often poorly recognized and treated, especially when other co-existing chronic conditions are involved. Therefore, older adults with joint pain and comorbidity may have a higher risk of poor functional outcome and decreased quality of life (QoL), and possibly need more attention in primary care. The main purpose of the study is to explore functioning in older adults with joint pain and comorbidity, in terms of mobility, functional independence and participation and to identify possible predictors of poor functional outcome. The study will also identify predictors of decreased QoL. The results will be used to develop prediction models for the early identification of subgroups at high risk of poor functional outcome and decreased QoL. This may contribute to better targeting of treatment and to more effective health care in this population.Methods/DesignThe study has been designed as a prospective cohort study, with measurements at baseline and after 6, 12 and 18 months. For the recruitment of 450 patients, 25 general practices will be approached. Patients are eligible for participation if they are 65 years or older, have at least two chronic conditions and report joint pain on most days. Data will be collected using various methods (i.e. questionnaires, physical tests, patient interviews and focus groups). We will measure different aspects of functioning (e.g. mobility, functional independence and participation) and QoL. Other measurements concern possible predictors of functioning and QoL (e.g. pain, co-existing chronic conditions, markers for frailty, physical performance, psychological factors, environmental factors and individual factors). Furthermore, health care utilization, health care needs and the meaning and impact of joint pain will be investigated from an older person's perspective.DiscussionIn this paper, we describe the protocol of a prospective cohort study in Dutch older adults with joint pain and comorbidity and discuss the potential strengths and limitations of the study.

Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

After aneurysmal subarachnoid hemorrhage (SAH), patients with clipped aneurysms have a higher incidence of neurocognitive deficits and seizures compared with patients with coiled aneurysms. It remains unknown if patients with clipped aneurysms also have a higher incidence of other in-hospital complications. We used data from the Registry of the Canadian Stroke Network on consecutive patients admitted to hospital with aneurysmal SAH. Patients who died within 2 days after admission were excluded. Baseline characteristics, incidence of various in-hospital complications within 30 days after admission, length of stay, poor functional outcome (modified Rankin Scale score at discharge of ≥3), and mortality were compared between patients with clipped versus coiled aneurysms. Of the 931 patients, 548 (59%) were clipped and 383 (41%) coiled. Baseline characteristics were similar. Compared with patients with coiled aneurysms, patients with clipped aneurysms had a higher incidence of in-hospital complications (37.2% versus 24.5% of patients; P<0.0001), poor functional outcome at discharge (69.4% versus 51.4%; P<0.0001), mortality (at discharge: 14.6% versus 9.1%; P=0.01), and a longer length of stay (17 [interquartile range, 11 to 29] versus 13 [interquartile range, 7 to 22] days; P<0.0001). Higher incidences were observed for urinary tract infection (P=0.02), pneumonia (P=0.01), cardiac/respiratory arrest (P=0.007), seizure (P=0.01), and decubitus ulcer (P=0.02). Urinary tract infection, pneumonia, cardiac/respiratory arrest, and seizure were independent predictors of poor functional outcome. Patients with clipped aneurysms have a higher incidence of in-hospital complications than patients with coiled aneurysms, which attributes to a higher risk of poor functional outcome and death and an increased length of stay.

Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis

Background and aimLittle is known about the relationship between neurocognitive performance and functional outcome before the onset of frank psychosis. This longitudinal study aimed to investigate neurocognitive predictors of poor functional outcome in a group identified as ultra-high risk (UHR) for psychosis between two and 13years prior. MethodIndividuals (N=230) identified as UHR for psychosis at the PACE Clinic in Melbourne completed assessment of psychopathology, functioning and neurocognition at baseline and follow-up. The mean length of follow-up was 7.26years (SD 3.05). ResultsForty-one individuals with the poorest functional outcome were identified. Only 48.8% of this group had transitioned to psychosis. Poor functional outcome was associated with reduced performance at baseline in the specific neurocognitive domains of verbal learning and memory, processing speed and attention, and verbal fluency, but not global cognitive impairment. Reduced performance on a verbal story recall task, in combination with higher negative symptoms at baseline, was the best predictor of later poor outcome. Baseline positive psychotic symptoms and GAF scores were not associated with later poor outcome. DiscussionTo date, this is the longest follow-up study of an UHR sample. Poor functional outcome was associated with specific neurocognitive decrements, regardless of transition to psychosis. The detection of individuals with poor functioning at follow-up, against a background of previously identified risk factors for psychotic disorder, may yield a valid group in which to study biomarkers and treatment of schizophrenia.

Effect of warfarin withdrawal on thrombolytic treatment in patients with ischaemic stroke

Abruptly discontinuing warfarin may induce a rebound prothrombotic state. Thrombolytic agents may also paradoxically induce prothrombotic conditions, which include platelet activation and thrombin generation. Therefore, prothrombotic states may be enhanced by withdrawing warfarin in patients under thrombolytic treatment. This study was aimed to determine whether patients with warfarin withdrawal have different clinical outcomes from those without warfarin use after thrombolytic treatment. A total of 148 consecutive patients with atrial fibrillation who were not on anticoagulants at admission and who received thrombolysis were included in this study. We compared the outcomes between a warfarin withdrawal group and a no-warfarin group. Fourteen patients (9.5%) were included in the warfarin withdrawal group. Although baseline National Institute of Health Stroke Scale (NIHSS) scores, recanalization rates, and hemorrhage frequencies did not differ between the groups, the warfarin withdrawal group showed poorer outcomes. Increased NIHSS scores during the first 7days were more frequent in the warfarin withdrawal group (57.1% vs. 26.9%, P=0.029). The median percent improvement in NIHSS scores at 24h after thrombolysis was also lower in the warfarin withdrawal group. After adjusting for covariates, warfarin withdrawal was a strong predictor of poor functional outcome at 3months (modified Rankin score≥3) (odds ratio, 17.067, 95% CI 2.703-107.748). Discontinuing warfarin was associated with early neurologic deterioration and poor long-term outcomes after thrombolytic treatment.

Detection of copeptin in peripheral blood of patients with aneurysmal subarachnoid hemorrhage

IntroductionCopeptin has been proposed as a prognostic marker in acute illness. This study investigated the ability of copeptin to predict the disease outcome and cerebrovasospasm in the patients with aneurysmal subarachnoid hemorrhage.MethodsIn this retrospective study, 303 consecutive patients were included. Upon admission, plasma copeptin levels were measured by enzyme-linked immunosorbent assay. The end points were mortality after 1 year, in-hospital mortality, cerebrovasospasm and poor functional outcome (Glasgow Outcome Scale score of 1-3) after 1 year.ResultsUpon admission, plasma copeptin level in patients was statistically significantly higher than that in healthy controls. A multivariate analysis showed that plasma copeptin level was an independent predictor of poor functional outcome and mortality after 1 year, in-hospital mortality and cerebrovasospasm. A receiver operating characteristic curve showed that plasma copeptin level on admission predicted poor functional outcome and mortality after 1 year, in-hospital mortality and cerebrovasospasm of patients statistically significantly. The area under curve of the copeptin concentration was similar to those of World Federation of Neurological Surgeons (WFNS) score and modified Fisher score for the prediction of poor functional outcome and mortality after 1 year, and in-hospital mortality, but not for the prediction of cerebrovasospasm. In a combined logistic-regression model, copeptin improved the area under curve of WFNS score and modified Fisher score for the prediction of poor functional outcome after 1 year, but not for the prediction of mortality after 1 year, in-hospital mortality, and cerebrovasospasm.ConclusionsCopeptin level is a useful, complementary tool to predict functional outcome and mortality after aneurysmal subarachnoid hemorrhage.