Relative Risk Of Poor Outcome Research Articles

Endovascular Therapy of Tandem Occlusions: Baseline Characteristics and Outcomes Compared With Intracranial Occlusion

Background Endovascular therapy is highly effective in stroke caused by large vessel occlusion. Guidelines support treatment in case of occlusion of the intracranial internal carotid artery or the first segment of the middle cerebral artery. We aimed to examine baseline characteristics and outcome of patients who underwent endovascular therapy for tandem occlusions. Methods We conducted a retrospective study of patients who underwent endovascular therapy of tandem occlusion or occlusion of intracranial internal carotid artery/first segment of the middle cerebral artery between May 2015 and December 2019. Univariate comparisons of baseline characteristics and outcome (favorable functional outcome 90‐days after treatment and mortality) were performed. We used inverse‐probability‐of‐treatment‐weights to adjust for confounders. Results We compared 167 patients with tandem occlusion and 414 with intracranial occlusions. Patients with tandem occlusion were younger (69 years [interquartile range: 59.25–76] versus 74 [interquartile range: 64–81]; P = 0.0002), male (64.7% versus 51.4%; P = 0.004), more frequently active smokers (42.5% versus 25.6%; P = 0.0001), and less frequently subject to atrial fibrillation (18.6% versus 41.3%; P <0.0001). No significant differences were seen in the rate of 90‐day good outcome (49.1% versus 51.0%; P = 0.68) or mortality (16.8% versus 18.1%; P = 0.70). This was also true after adjustment (relative risk for poor outcome 0.86 [95% CI: 0.72–1.05]). More proximal occlusions resulted in worse outcome in both tandem and intracranial occlusions. Conclusion Patients with tandem occlusion were more frequently younger, male smokers without atrial fibrillation illustrating the different risk factors underlying these strokes. Benefit from treatment was similar between groups, supporting endovascular therapy in tandem occlusions.

Performance of Salamanca refinement of the T3-AJCC8 versus the Brigham and Women's Hospital and Tübingen alternative staging systems for high-risk cutaneous squamous cell carcinoma

The Brigham and Women's Hospital and the Tübingen cutaneous squamous cell carcinoma (SCC) stratification systems propose different criteria from the American Joint Committee on Cancer, eighth edition. Our group identified prognostic subgroups within T3 stage according to the American Joint Committee on Cancer eighth edition's classification, the most common classification for high-risk cutaneous SCCs. To compare the performance and prognostic accuracy of these staging systems in a subset of high-risk cutaneous SCCs. Homogeneity, monotonicity, and McNemar tests for pairwise comparisons were assessed. Distinctiveness and relative risk of poor outcome were calculated by stage. Prognostic accuracy was compared with respect to quality (Akaike and Bayesian information criteria), concordance (Harrell C-index and Gönen and Heller concordance probability estimate), and predictive accuracy (sensitivity, specificity, negative predictive value, positive predictive value, and global accuracy). The Brigham and Women's Hospital and Salamanca systems were more distinctive, homogeneous, and monotonic than the Tübingen system. The Tübingen system was the most specific, whereas the Salamanca and Brigham and Women's Hospital systems were more sensitive. Negative predictive value was high in all 3 systems, but positive predictive value and accuracy were low overall. Alternative staging systems may partially overcome the heterogeneity and low prognostic accuracy of the American Joint Committee on Cancer, eighth edition and enable high-risk cutaneous SCCs to be stratified more reliably, but their prognostic accuracy is still low. Considering the accumulation of risk factors may improve high-risk cutaneous SCC risk stratification.

Dexamethasone in Patients with Spontaneous Intracerebral Hemorrhage: An Updated Meta-Analysis

Background: Spontaneous intracerebral hemorrhage (ICH) is a frequent cerebrovascular disorder and still associated with high mortality and poor clinical outcomes. The purpose of this review was to update a 15-year-old former meta-analysis on randomized clinical trials (RCTs) addressing the question of whether ICH patients treated with dexamethasone have better outcomes than controls. Methods: The electronic databases PubMed, SCOPUS, and Cochrane as well as web platforms on current clinical trials were searched for the years 1970–2020 without constriction on language. Data were extracted and outcomes were pooled for conventional and cumulative meta-analysis using a commercial software program (www.Meta-Analysis.com). Results: Finally, 7 RCTs were identified and analyzed including 248 participants in the dexamethasone groups and 242 in the control groups. Five studies showed a high risk of bias. The overall relative risk (RR) for death was 1.32 (95% confidence interval [CI] 0.99–1.76; p = 0.06) and did not differ significantly between the 2 groups. After exclusion of studies with high risk of bias, the RR for death was 1.37 (95% CI 0.54–3.42; p = 0.51). The RR for poor outcome did not differ significantly between the 2 groups analyzed for all included studies (RR = 0.69; 95% CI 0.47–1; p = 0.05) and after exclusion of studies with high risk of bias (RR = 0.7; 95% CI 0.45–1.08; p = 0.11). The RR for complications did not differ significantly including all studies (RR = 1.29; 95% CI 0.77–2.17; p = 0.34) and after exclusion of studies with high risk of bias (RR = 1.27; 95% CI 0.18–8.89; p = 0.81). The cumulative statistics delivered no other results; however, it pointed out fewer complications over time in the dexamethasone group. Conclusion: Clear evidence of a beneficial or negative effect of dexamethasone is still lacking. Modern RCTs or observational studies with propensity design are necessary to evaluate the efficacy and safety of treatment with dexamethasone in patients with ICH.

Diabetes in tuberculosis patients: An emerging public health concern and the determinants and impact on treatment outcome.

BACKGROUND:Tuberculosis (TB) and diabetes mellitus are still of much public health concern. Screening of TB patients for diabetes will ensure early case detection, better management of diabetes, and better TB treatment outcome. The objective of this study was to determine the prevalence and associated factors of diabetes in TB patients and their impact on treatment outcome of TB.MATERIALS AND METHODS:This was a longitudinal follow-up study of registered TB patients under the Revised National Tuberculosis Control Program in all five TB units of Bhopal district. Participants were contacted and the interview was conducted. The blood sugar of all TB patients was checked, and they were followed up to assess the treatment outcome from October 2014 to September 2017. Data were analyzed using SPSS (version 16.0. Chicago, SPSS Inc.). Logistic regression was done to find the factors for diabetes in TB patients. The Chi-square tests were used to find the difference in treatment outcomes and assess the relative risk for poor outcome in diabetic TB patients.RESULTS:Of total 662 TB patients, 82 (12.39%) were diagnosed as diabetic. Age >50 years, males, higher body mass index, pulmonary TB, patients on Category II treatment, and history of smoking were found to be predictors of diabetes in TB patients. The treatment outcome of TB was more unfavorable (defaulter, failure, and death) in diabetic TB patients (16.17%) than in nondiabetic TB patients (5.8%) (risk ratio = 2.78, 1.469–5.284 confidence interval).CONCLUSION:The high prevalence of diabetes and the unfavorable treatment outcome in diabetic TB patients make screening and management of diabetes at an early-stage crucial for a better outcome in TB patients.

Systemic Inflammatory Response Syndrome (SIRS) Score Independently Predicts Poor Outcome in Isolated Traumatic Brain Injury.

Systemic inflammatory response syndrome (SIRS) is frequently observed after various types of acute cerebral injury and has been linked to clinical deterioration in non-traumatic brain injury (TBI). SIRS scores have also been shown to be predictive of length of stay and mortality in trauma patients. We aimed to determine the prognostic utility of SIRS present at admission in trauma patients with isolated TBI. This was a 5-year retrospective cohort study of adults (≥18years) with isolated TBI admitted to a Level II trauma center. The prognostic value of SIRS, total SIRS scores, and each SIRS criterion was examined by Χ 2 and logistic regression analyses. Of the 330 patients identified, 50 (15.2%) met SIRS criteria. SIRS was significantly associated with poor outcome (P<0.001). Relative risk of poor outcome was 2.7 times higher in patients with a SIRS score of 2 on admission (P=0.007) and increased significantly to 6.5 times in patients with a SIRS score of 3 (P=0.002). Logistic regression demonstrated SIRS and each criterion to be significant independent prognostic factors (SIRS, P=0.030; body temperature, P=0.006; tachypnea, P=0.022, tachycardia P=0.023). SIRS at admission is an independent predictor of poor outcome in isolated TBI patients. These data demonstrate SIRS to be an important clinical tool that may be used in facilitating prognostication, particularly in elderly trauma patients. Future prospective studies aimed at therapeutic interventions to mitigate SIRS in TBI patients are warranted. Prognostic, Level III.

Statistics for clinicians: An introduction to logistic regression.

Statistics for clinicians: An introduction to logistic regression.

Impact of the day-30 screening strategy on the disease presentation and outcome of retinopathy of prematurity. The Indian twin cities retinopathy of prematurity report number 3

Context:Outcomes of various screening strategies in retinopathy of prematurity are not well reported.Aim:To assess the impact of a city-wide, ROP screening strategy, on the disease presentation and treatment outcome.Materials and Methods:A retrospective case-control study from a prospectively collected ROP data-base was analyzed. Cases (group 1a) included ROP babies that were screened directly in neonatal intensive care units, and controls (group 1b) were babies referred directly to the institute from other neonatal centers during the same period. Historical controls (group 2) were ROP cases seen in the years preceding establishment of this ROP program and database. Primary outcome measure was the risk of eyes presenting with stage 4 or worse ROP, and main secondary outcome measure was the final anatomic outcome.Results:Of the 643 cases screened, 322 eyes of 161 babies had ROP. The median age of 7.19 months at presentation for the 46 patients (92 eyes) in group 2 was higher than the median age of 1.29 months for the 115 patients (230 eyes) in group 1. Within the group 1, group 1a had lower median age at presentation than group 1b (0.91 months versus 2.30 months). The relative risk of an eye presenting in the stage 4 and 5 in group 2 was 4.7 times higher (95% confidence interval 3.07 -7.32) than in group 1. Eyes that could be given treatment in group 2 were significantly less (P < 0.0005) than in group 1. The relative risk of poor outcome in group 2 was 3.83 times higher (95% confidence interval 2.75 -5.34) than in group 1. Group 1a eyes had the best outcomes.Conclusion:Early screening before one month of age in neonatal centers detects the disease early where prompt treatment can lead to favorable outcomes. The study provides early results of a model strategy for ROP screening.

INTERACT-2

Blood pressure (BP) lowering after spontaneous intracerebral hemorrhage (ICH) is intuitively attractive as a means to prevent continued bleeding or perihematomal edema. Concerns about potential reduction of cerebral perfusion pressure with concomitant risk of ischemia, particularly among patients with a recalibrated autoregulatory curve as a consequence of chronic hypertension, were largely mitigated by imaging studies that found no significant reduction of cerebral blood flow in the face of pharmacological BP lowering,1–3 and the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT) pilot study.4 The INTERACT investigators have now formally put the concept to test and have shown that if there is a clinical effect of BP lowering, it is fairly muted and smaller than anticipated. Of 2794 patients with spontaneous ICH, the relative risk for poor outcome was 0.94 (0.87–1.002), P =0.063, in the intensive BP-lowering group (to target systolic pressure ≤140 mm Hg) compared with the control guideline group aiming for systolic pressure ≤180 mm Hg. Various permutations of modified Rankin Scale dichotomization were also nonsignificant when adjusted for baseline factors. The Rankin shift analysis using ordinal logistic regression was marginally significant in favor of the intensive BP-lowering group ( P =0.04). Importantly, no differences in mortality and major safety …

Magnesium Sulfate Treatment Improves Outcome in Patients with Subarachnoid Hemorrhage: A Meta-analysis Study

To elucidate the role of magnesium sulfate in patients with subarachnoid hemorrhagic (SAH) brain injury Studies for the meta-analysis were identified from PubMed (1966 to 2009), Embase (1980 to 2009), and two Chinese journals (1989 to 2009). Paper selection was based on randomized controlled trials comparing magnesium sulfate to placebo treatment in patients with SAH. Two independent review authors extracted the data and assessed trial quality. Meta-analysis was performed using the Cochrane Review Manger software. Five trials involving 482 patients were included in the review. Magnesium sulfate reduced the risk of poor outcome and reduced the occurrence of delayed cerebral ischemia. In the treatment groups, relative risk for poor outcome was 0.73 (CI 0.57-0.93) and 0.66 (CI 0.47-0.92) for delayed cerebral ischemia. Case fatality assessment at three to six months did not show statistically significant data (RR 0.88; CI 0.61-1.29). Magnesium sulfate appears to be an effective treatment option in the management of SAH. Further clinical trials are needed before magnesium sulfate can become a routine treatment for SAH.

Enlarged Left Atrium Is a Simple and Strong Predictor of Poor Prognosis in Patients after Myocardial Infarction

Patients after myocardial infarction (MI) differ according to the extend of myocardial damage and prognosis. Diastolic function impairment may have great impact on development of heart failure and outcomes. We evaluated the prognostic value of various echocardiographic measurements in 18-month and 3-year observation after MI. 60 patients after MI (44 male, mean age 60 +/- 11) were examined by transthoracic echocardiography with the assessment of wide spectrum of parameters. Mortality and combined end points (cardiac deaths and heart failure exacerbation) were assessed after 18-month and 3-year observation and groups with and without end points were compared. Optimal cutoff values were estimated by receiver operating characteristic (ROC) analysis and resulting Kaplan-Meier curves were compared. After 18 months, 11 deaths occurred and 20 subjects experienced hospitalization caused by heart failure exacerbation. Although the group with cardiac events showed a greater enlargement of the left ventricle and lower ejection fraction, the highest relative risk of poor outcome (RR = 5.0) was related to the left atrial enlargement above 44 mm. Although restrictive or pseudonormal inflows were connected with 2.1 relative risk of combined end point, all patients with E deceleration time < or = 130 ms experienced heart failure exacerbation or death. Despite tissue Doppler and propagation parameters describing elevated end-diastolic pressure differed between groups with various outcomes in multivariate analysis, only enlarged left atrium was an independent predictor for both combined end point and cardiac death. Further 3-year follow-up solely confirmed the role of above described predictors.

Somatic and Psychologic Predictors of Long-term Unfavorable Outcome After Surgical Intervention

To identify somatic and psychologic predictors of pain, functional limitations, global perceived recovery, and quality of life 6 months after surgical intervention. Recent studies have indicated that chronic pain after surgical intervention is more common than previously assumed. Several demographic and somatic predictors of long-term unfavorable outcome have been identified, but little is known about the contribution of psychologic risk factors. A prospective cohort study, including 625 patients undergoing elective surgery at the University Hospital Maastricht, The Netherlands, was conducted between February and August 2003. Psychologic questionnaires were completed preoperatively and acute postoperative pain was recorded until 4 days after the operation. Six months later, all patients received follow-up questionnaires to assess pain, functional limitations, global perceived recovery, and quality of life. Multivariable logistic regression analyses were used to estimate relative risk of poor outcome in terms of pain, functional limitations, and global recovery. Multivariable linear regression analysis was used to assess associations with quality of life at 6 months. The most important somatic predictors of unfavorable outcome were duration of the operation and high levels of acute postoperative pain. Patients reporting high levels of pain 4 days after the operation and patients undergoing an operation of longer than 3 hours were at risk for increased pain, increased functional limitations, poor global recovery, and reported lower levels of quality of life 6 months after the operation. Psychologic variables that influenced long-term outcome were preoperative fear of surgery and optimism. Fear of the long-term consequences of the operation was associated with more pain, poor global recovery, and worse quality of life 6 months later, whereas optimism was associated with better recovery and higher quality of life. This study was the first to identify the joint contribution of somatic and psychologic factors to chronic pain, functional limitations, and quality of life 6 months after surgical interventions. It replicates previous findings that intense acute postoperative pain is a risk factor for long-term adverse outcome and also identified additional risk factors, namely, long duration of the operation, ASA status, and preoperative fear of surgery.

Enhanced upper respiratory tract airflow and head fanning reduce brain temperature in brain-injured, mechanically ventilated patients: a randomized, crossover, factorial trial

Heat loss from the upper airways and through the skull are physiological mechanisms of brain cooling which have not been fully explored clinically. This randomized, crossover, factorial trial in 12 brain-injured, orally intubated patients investigated the effect of enhanced nasal airflow (high flow unhumidified air with 20 p.p.m. nitric oxide gas) and bilateral head fanning on frontal lobe brain temperature and selective brain cooling. After a 30 min baseline, each patient received the four possible combinations of the interventions--airflow, fanning, both together, no intervention--in randomized order. Each combination was delivered for 30 min and followed by a 30 min washout, the last 5 min of which provided the baseline for the next intervention. The difference in mean brain temperature over the last 5 min of the preceding washout minus the mean over the last 5 min of intervention, was 0.15 degrees C with nasal airflow (P=0.001, 95% CI 0.06-0.23 degrees C) and 0.26 degrees C with head fanning (P<0.001, 95% CI 0.17-0.34 degrees C). The estimate of the combined effect of airflow and fanning on brain temperature was 0.41 degrees C. Selective brain cooling did not occur. Physiologically, this study demonstrates that heat loss through the upper airways and through the skull can reduce parenchymal brain temperature in brain-injured humans and the onset of temperature reduction is rapid. Clinically, in ischaemic stroke, a temperature decrease of 0.27 degrees C may reduce the relative risk of poor outcome by 10-20%. Head fanning may have the potential to achieve a temperature decrease of this order.

Endovascular Coiling Versus Neurosurgical Clipping for Patients With Aneurysmal Subarachnoid Hemorrhage

Endovascular Coiling Versus Neurosurgical Clipping for Patients With Aneurysmal Subarachnoid Hemorrhage

Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage

Patients who have had an aneurysmal subarachnoid haemorrhage (SAH) are at very high risk of rebleeding if the aneurysm is not treated. The standard treatment for several decades has been surgical clipping of the neck of the aneurysm. In recent years, an alternative, the introduction of detachable coils to occlude the aneurysm, has become more common. To compare the effects of endovascular coiling versus neurosurgical clipping in patients with aneurysmal subarachnoid haemorrhage. We searched the Cochrane Stroke Group Trials Register (last searched in February 2005). In addition we searched MEDLINE (1966 to January 2004) and EMBASE (1980 to January 2004), and contacted trialists. We included randomised trials in which endovascular coiling of aneurysms was compared with neurosurgical clipping in patients with SAH who have proven aneurysm. Two authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. We identified three randomised trials: two published and one unpublished. The trials included a total of 2272 patients (range per trial: 20 to 2143 patients). Most of the patients were in good clinical condition and had an aneurysm on the anterior circulation. After one year of follow up, the relative risk (RR) of poor outcome for coiling versus clipping was 0.76 (95% confidence interval (CI) 0.67 to 0.88). The absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome overall, the relative risk for coiling versus clipping was 0.81 (95% CI 0.70 to 0.92) and the absolute risk reduction was 6% (95% CI 2% to 10%). For patients with anterior circulation aneurysm the relative risk of poor outcome was 0.78 (95% CI 0.68 to 0.90) and the absolute risk decrease was 7% (95% CI 3% to 10%). For those with a posterior circulation aneurysm the relative risk was 0.41 (95% CI 0.19 to 0.92) and the absolute decrease in risk 27% (95% CI 6% to 48%). The evidence comes mainly from one large trial. For patients in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation we have firm evidence that, if the aneurysm is considered suitable for both surgical clipping and endovascular treatment, coiling is associated with a better outcome.

Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: a systematic review.

Observational studies suggest that platelet inhibitors reduce the risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage and thereby have a beneficial effect on clinical outcome. Robust evidence, however, is lacking. We performed a systematic meta-analysis to determine whether antiplatelet therapy has a beneficial effect after SAH. We searched Medline and the Cochrane Library to identify all randomized controlled trials of antiplatelet drugs versus control and calculated relative risks with corresponding 95% confidence intervals (CIs) for poor outcome (dependence or death), the occurrence of DCI, and the occurrence of any intracranial hemorrhage. We included 5 trials totaling 699 patients. The overall relative risk for poor outcome was 0.87 (95% CI, 0.65 to 1.17); for the occurrence of DCI (reported in 3 of the 5 studies), 0.65 (95% CI, 0.47 to 0.89); and for the occurrence of intracranial hemorrhage, 1.19 (reported in 4 of the 5 studies) (95% CI, 0.76 to 1.85). Our data indicate that antiplatelet drugs reduce the risk of DCI in patients with subarachnoid hemorrhage. A randomized clinical trial is warranted to assess the effect on overall outcome.

Current treatment strategies and factors influencing outcome in patients with bacterial brain abscess.

We clearly determined the key to managing patients with brain abscess by retrospectively evaluating the factors affecting poor outcome in these patients. This study included 113 patients with brain abscess diagnosed in the CT era. Basic characteristics and therapeutic parameters were estimated as independent predictors of poor outcome by using univariate and multivariate logistic regression analysis. Patients with poor outcomes more frequently had deeply-located abscesses (p < 0.02), IVROBA (intraventricular rupture of brain abscess (p < 0.001) and were in a severely deteriorated neurological state (p < 0.001) than those with good outcomes. Multiple logistic regression analysis predicted that IVROBA (ORs, 24.5; 95% CI, 3.04 to 197.9) and severely deteriorated cases (ORs, 13.7; 95% CI, 2.34 to 80.8) resulting from IVROBA increased the relative risk of poor outcome. Patients with IVROBA more frequently had also deeply-located abscesses (p < 0.005), positively immunocompromised states (p < 0.05) and were in a severely deteriorated condition (p < 0.003) than those without IVROBA. Patients with metastatic abscess had also IVROBA (p < 0.006). Multiple logistic regression analysis anticipated that deeply-located abscess (ORs, 3.90; 95% CI, 1.38 to 11.04), and metastatic abscess (ORs, 12.26; 95% CI, 1.35 to 111.2) increased the relative risk of IVROBA. Patients in an obtunded state and with marked neurological deficit had IVROBA more often than patients in an alert state and/or mild neurological deficit (ORs, 3.23; 95% CI, 1.17 to 8.86, p < 0.03) before treatment. Our findings suggest that IVROBA strongly influences poor outcome in patients with brain abscess. The key to decreasing poor outcomes may be the prevention and management of IVROBA, by evaluating intracranial pressure pathophysiology. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with appropriate intravenous and intrathecial administration of antibiotics.

Auditory and somatosensory evoked potentials in coma following spontaneous cerebral hemorrhage: early prognosis and outcome

The aim of this study was to check the prognostic power of auditory brain-stem responses (ABRs) and somatosensory evoked potentials (SEPs) in coma following spontaneous cerebral hemorrhage. Seventy patients comatose following subarachnoidal or hypertensive hemorrhage were submitted to ABR and SEP recordings during the acute phase of clinical course. Twenty-one patients survived (30%), two remained vegetative (2.9%) and 47 died (68.1%). The Glasgow Coma Score (GCS) was significantly related to the outcome ( P<0.001), but showed a low sensitivity, about 50% of patients with GCS=5–8 died or remained vegetative. ABRs and SEPs showed a much closer correlation with outcome ( P<0.001): their combined use allowed there to be a sensitivity of 96%, a specificity of 90% and a predictive power of 96%; the relative risk of poor outcome in patients with at least one abnormal modality was equal to 223 times the one for patients with normal evoked potentials. Moreover, in surviving patients a significant relationship appeared to exist between abnormalities of SEPs during the acute phase and the severity of disability. Our results confirm the prognostic effectiveness of short latency evoked potentials in cerebral hemorrhage: they are far superior to clinical data, being able to yield a marked decrease of falsely optimistic predictions.

Prediction of Outcome in Patients with Missile Craniocerebral Injuries during the Croatian War

The factors assumed to exert an influence on the outcomes of 176 patients who sustained head injuries through projectiles during the Croatian War were evaluated. The type of projectile, wound age, retained foreign bodies, and patient sex and age had no significant influence on outcome. Patients with a Glasgow Coma Scale score of 3 to 5 had 7.3 times higher relative risk of poor outcome than those with a score of 6 to 15. Patients with penetrating injuries (47%), with a projectile's path traversing both hemispheres (45.5%), and with intracranial hematomas (49%) had significantly poorer outcomes than patients without such lesions. Infections were more common in patients with retained foreign bodies in wounds that were older than 48 hours (43%) and in patients with cerebrospinal fluid fistulas (50%). In assessing the outcomes of missile head injuries in wartime, the Glasgow Coma Scale score, type of head wound, site of skull penetration, endocranial projectile path, intracranial hematomas, and complications, especially infectious, represent reliable predictors of outcome.

Antipyretics in acute ischaemic stroke

An association between rectal temperature and prognosis in ischaemic stroke 1 Hindfelt B The prognostic significance of subfebrility and fever in ischaemic cerebral infarction. Acta Neurol Scand. 1976; 53: 72-79 Crossref PubMed Scopus (132) Google Scholar was reported more than 20 years ago, when Hindfelt described a retrospective study of 110 patients admitted within 24 h of stroke onset. It showed that “subfebrility” (temperature ≥37·5 to ≤38.0°C) and fever during the first days after stroke were predictive of poor outcome. This observation gained little attention until, 18 years later, Castillo and co-workers 2 Castillo J Martinez F Leira R Prieto JM Lema M Noya M Mortality and morbidity of acute cerebral infarction related to temperature and basal analytic parameters. Cerebrovasc Dis. 1994; 4: 56-71 Crossref Scopus (134) Google Scholar also found that a raised body temperature in patients with acute cerebral infarction admitted within 24 h after stroke was associated with significantly worse outcome. Subsequently, investigators from the Copenhagen Stroke Study reported that a raised tympanic membrane temperature (>37.5°C) on admission within 6 h after stroke was associated with increased mortality and disability. 3 Reith J Jrgensen HS Pedersen PM et al. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet. 1996; 347: 422-425 Summary Full Text PDF PubMed Scopus (782) Google Scholar For each 1°Cincrease in body temperature the relative risk of poor outcome rose by 2.2 This effect was independent of initial stroke severity. Last year, Castillo and colleagues further confirmed that raised body temperature at admission was an independent risk factor for progressive neurological deterioration within the first 48 h after stroke. 4 Castillo J Davalos A Noya M Progression of ischaemic stroke and excitotoxic aminoacids. Lancet. 1997; 349: 79-83 Summary Full Text Full Text PDF PubMed Scopus (309) Google Scholar Now, in a review of the evidence that the acutely ischaemic brain is inordinately susceptible to even modest increases of brain temperature, M D Ginsberg and R Busto advise assiduous treatment of hyperthermia in acute stroke. 5 Ginsberg MD Busto R Combating hyperthermia in acute stroke: a significant clinical concern. Stroke. 1988; 29: 529-534 Crossref Scopus (436) Google Scholar Should antipyretics be routine in prehospital emergency management of stroke patients with raised body temperature?

Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome

SummaryBackground In laboratory animals, cerebral ischaemia is worsened by hyperthermia and improved by hypothermia. Whether these observations apply to human beings with stroke is unknown. We therefore examined the relation between body temperature on admission with acute stroke and various indices of stroke severity and outcome.Methods In a prospective and consecutive study 390 stroke patients were admitted to hospital within 6 h after stroke (median 2·4 h). We determined body temperature on admission, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge on the Scandinavian Stroke Scale (SSS). Infarct size was determined by computed tomography. Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors such as age, gender, stroke severity on admission, body temperature, infections, leucocytosis, diabetes, hypertension, atrial fibrillation, ischaemic heart disease, smoking, previous stroke, and comorbidity.Findings Mortality was lower and outcome better in patients with mild hypothermia on admission; both were worse in patients with hyperthermia. Body temperature was independently related to initial stroke severity (p<0·009), infarct size (p<0·0001), mortality (p<0·02), and outcome in survivors (SSS at discharge) (p<0·003). For each 1°C increase in body temperature the relative risk of poor outcome (death or SSS score on discharge <30 points) rose by 2·2 (95% Cl 1·4-3·5) (p<0·002).Interpretation We have shown that, in acute human stroke, an association exists between body temperature and initial stroke severity, infarct size, mortality, and outcome. Only intervention trials of hypothermic treatment can prove whether this relation is causal.