Simple Clinical Measures Research Articles

Predictors of Mortality in Home‐Dwelling Patients with Cardiovascular Disease Aged 75 and Older

To compare the predictive value of biomarkers commonly measured in older patients with cardiovascular disease (CVD) with an indicator of cognitive function. Prospective cohort study. Helsinki, Finland. Three hundred ninety-eight home-dwelling older persons (261 women, mean age 80) with stable CVD and without a diagnosis of clinical dementia. Simple laboratory and clinical measurements (including the Mini Mental State Examination (MMSE, maximum score 30 points) and New York Heart Association (NYHA) classification) were used to predict mortality. A MMSE score between 18 and 24 points was considered to indicate cognitive impairment. At baseline, median MMSE score was 27 (interquartile range 25-28), with 59 individuals having a score below 24 points. During a mean follow-up of 6.0 years, 129 participants died. In the fully adjusted Cox proportional hazards model, low MMSE score was the strongest predictor of mortality, with a relative hazard of 2.38 (95% confidence interval=1.52-3.74; P<.001). Of the various clinical and laboratory variables, only creatinine, C-reactive protein, and history of congestive heart failure were significant independent predictors, whereas conventional risk factors were not. Only a few clinical variables independently predicted 6-year mortality in older home-living patients with CVD. The strongest predictor was impaired cognitive function assessed using MMSE.

Issues in the design of new clinical trials for rheumatoid arthritis therapeutics

Rheumatoid arthritis (RA) is a chronic, heterogeneous disease, for which there has traditionally been few reliable prognostic indicators or simple clinical outcome measures with which to adequately assess disease status or clinical improvement. These challenges have hindered the assessment of new therapeutic agents. Investigators in rheumatology have, therefore, attempted over the past two decades to develop new approaches and scoring systems to facilitate the study and development of therapies. As a result of these efforts, the efficacy of almost all new agents tested in clinical trials are now assessed with widely accepted scoring systems that measure improvement in three important areas. First, changes in patient signs and symptoms are measured via composite indices of both clinical and laboratory parameters. Second, the progression of structural damage is assessed by radiographic imaging. Finally, long-term improvement in patient function is measured via patient-reported outcomes. These changes to clinical trial design have been adopted by health authorities around the world. Further challenges, however, must be overcome in order for progress to continue.

Symptomatic hyperlactataemia in adults on antiretroviral therapy: a single-centre experience.

There are limited data on symptomatic hyperlactataemia caused by antiretroviral therapy (ART) in resource-limited settings. We assessed individuals who developed symptomatic hyperlactataemia on ART in an outpatient clinic in South Africa. A retrospective record review was performed on patients attending the clinic from January 2004 to December 2005. Thirty-five patients, all on stavudine-containing regimens, developed symptomatic hyperlactataemia. The incidence in this population was 20.5 cases per 1 000 person-years of ART with an associated mortality of 21%. The major risk factor was being female (risk ratio (RR) 3.27). Significant clinical symptoms preceding symptomatic hyperlactataemia include nonspecific gastrointestinal symptoms, weight loss, and development of symptomatic neuropathy. The incidence of symptomatic hyperlactataemia in our population was high. Simple clinical measures, such as neuropathy symptoms and monitoring of weight, may alert the clinician to impending symptomatic hyperlactataemia. Early diagnosis expedites safe outpatient care and switching of ART regimens without interruption, in many cases.

Riesgo cardiovascular en sujetos con alta probabilidad de síndrome metabólico y resistencia a la insulina. Estudio DESIRE

The metabolic syndrome is an association of closely related alterations. The main objective of this study is to know the frequency of the metabolic syndrome and insulin resistance, and their role as cardiovascular risk indicators in an adult population assigned to Primary Care centers in Spain. Subjects > or = 45 years with basal glycemia > or = 90 mg/dl and abdominal circumference > or = 94 cm (men) or > or = 80 cm (women). ATP III modified-criteria were used for the metabolic syndrome and HOMA index > 3.29 was used for insulin resistance. Cardiovascular risk was estimated by the Framingham and SCORE models. A total of 2,341 subjects (62 +/- 10 years; 44.6% males) were included. Frequency of metabolic syndrome and insulin resistance was 54.6% (52.5; 56.8) and 56.6% (54.5; 58.7) respectively. Metabolic syndrome was associated to a higher cardiovascular risk score with both Framingham (16 [15; 16] vs 11 [11; 12] p < 0.0001) and SCORE (2.7 [2.4; 3] vs 2.4 [2.1; 2.8]; p = 0.006) models. The results were similar for the presence of insulin resistance. Metabolic syndrome and insulin resistance are cardiovascular risk predictors. Early identification of metabolic syndrome by the use of simple clinical measures (basal glycemia and waist circumference) would make the intervention on the different disorders of metabolic syndrome possible.

Diabetes and urinary incontinence – prevalence data from Norway

Few large epidemiological studies have investigated whether diabetes might increase the risk for, or cause greater severity of, urinary incontinence. The aim of the present study was to investigate the association between diabetes and urinary incontinence, including the possible influence of diabetes on the severity of incontinence. The study was a cross-sectional, population-based, study from the county of Nord-Trøndelag, Norway, from 1995 to 1997. Data were collected by means of questionnaires, simple clinical measurements, and some blood tests. A total of 21,057 women, 20 years or older, answered the questions on both diabetes and incontinence, and 685 women were identified with diabetes. The prevalence of incontinence among women with diabetes was 39% compared to 26% in women without diabetes. The women with diabetes had more urge and mixed incontinence. The associations between diabetes and urge incontinence (OR: 1.49; 95% CI: 1.03-2.16), mixed incontinence (OR: 1.32; 95% CI: 1.05-1.67), and severe incontinence (OR: 1.54; 95% CI: 1.21-1.96) were still significant after adjusting for age, body mass index, parity and smoking. We found a strong association between diabetes and urinary incontinence, especially for urge incontinence and severe degree of incontinence.

Metabolic Syndrome: A Multiplex Cardiovascular Risk Factor

The metabolic syndrome (MetS) is a multiplex risk factor for cardiovascular disease. The syndrome develops through interplay of obesity and metabolic susceptibility. This article addresses whether the MetS construct has clinical utility. POSITION: The National Cholesterol Education Program and other organizations have proposed that the MetS can be recognized clinically by a clustering of simple clinical measures including waist circumferences, blood pressure, triglycerides, high-density lipoproteins, and glucose. People with this clustering have most or all of the components of the MetS. Identifying the MetS has several advantages. It discovers persons who are at increased risk for cardiovascular disease. A diagnosis focuses more clinical attention on the underlying causes, notably obesity and other lifestyle factors; it thereby reinforces the utility of lifestyle changes in clinical practice. A diagnosis further informs physicians on choice and intensity of drug therapy for elevated cholesterol, aspirin prophylaxis, and blood pressure and glucose control. The introduction of the MetS has led to a large number of epidemiological, metabolic, and genetic studies that have heightened our understanding of the condition's prevalence and pathogenesis. It has been a stimulus to the development of new drugs or drug combinations that will modify multiple risk factors simultaneously. This author holds that the MetS counts as a multiplex cardiovascular risk factor that is clinically useful and will lead to advances in diagnosis and treatment of an important cause of cardiovascular disease.

Association between auditory and visual symptoms of unilateral spatial neglect

Unilateral spatial neglect due to right brain damage (RBD) can occur in several different sensory modalities in the same patient. Previous studies of the association between auditory and visual neglect have yielded conflicting outcomes. Most such studies have compared performance on relatively simple clinical measures of visual neglect, such as target cancellation, with that on more sophisticated measures of auditory perception. This is problematic because such tasks are typically not matched for the cognitive processes they exercise. We overcame this limitation by using equivalent visual and auditory versions of extinction and temporal-order judgment (TOJ) tasks. RBD patients demonstrated lateralized deficits on both visual and auditory tasks when compared with same-aged, healthy controls. Critically, a significant association between the severity of visual and auditory deficits was apparent on the TOJ task but not the extinction task, suggesting that even when task demands are matched across modalities, dissociations between visual and auditory neglect can be apparent. Across the auditory tasks, patients showed more pronounced deficits for verbal stimuli than for non-verbal stimuli. These findings have implications for recent models proposed to explain the role of spatial attention in multimodal perception.

Simple Pediatric AIDS Severity Score (PASS)

A multidimensional pediatric AIDS severity score (PASS) has been developed for severity adjustment and as a predictive model for mortality in a pediatric HIV-infected population. While the prognostic value of PASS is relevant in the US setting, there is a need to develop a simpler model of PASS for use in resource-limited settings where CD4% values and HIV RNA levels may not be available to assess prognosis and guide treatment decisions. A Simple PASS model was developed including baseline weight percentile, WHO stage, symptoms, a general health rating, total lymphocyte count, packed-cell volume, and albumin measures from 1178 perinatally HIV-infected children enrolled into a prospective cohort study (PACTG 219). This prognostic model was then validated among 952 perinatally HIV-infected children enrolled in other PACTG research studies at the same sites. Survival estimates and Hazard Ratios (HR) were obtained using the Kaplan-Meier method and proportional hazards models, respectively. The predictive ability of the models was determined using Harrell's "C" statistic. Of the clinical measures and assays considered in this study, weight percentile, WHO stage, symptomatology, general health rating, total lymphocyte count, packed-cell volume, and albumin were found to be predictive of mortality. The simple PASS model including only the simple clinical measures and assays was found to be predictive of mortality (C statistic = 0.852). Its discriminative ability for mortality was comparable to a model consisting of the Simple PASS plus CD4% (C statistic = 0.871). The Simple PASS scoring system provides a reasonable alternative to CD4% values and HIV viral-load levels to assess prognosis and guide decisions about antiretroviral therapy initiation in resource-limited settings.

RELATIONSHIP BETWEEN CLINICAL MEASURES OF PARETIC LOWER EXTREMITY MOTOR CONTROL AT 1 MONTH AND GAIT SPEED AT 6 MONTHS POST STROKE

Purpose/Hypothesis: Gait speed is a simple but highly reliable and responsive measure of walking disability that has been recommended as an outcome measure in stroke rehabilitation. Gait speed may depend critically on motor control of the paretic lower extremity (LE) during both stance and swing phases. The purposes of this project were to 1) determine relationships between simple clinical measures of paretic LE stance and swing phase control, tested at 1 month post stroke, and gait speed at 6 months post stroke and 2) compare month 1 measures of stance phase and swing phase control with respect to degree of association with walking outcome. Number of Subjects: Thirty-three subjects (18 men, 15 women; mean age = 58.7 ± 17.3 years) with a diagnosis of a single, unilateral stroke participated in the study. All subjects had significant LE motor impairment as indicated by a baseline Fugl-Meyer Lower Extremity Motor Scale (FM) score 28. Materials/Methods: Subjects were tested at monthly intervals from 1 to 6 months post stroke as part of a larger study. Measures of paretic LE motor control included the Step Test (ST), the Upright Motor Control test (UMCT), and the FM. The ST performed with the non-paretic leg stepping (ST-NP) and the extension component of the UMCT (UMCT-E) required paretic LE extensor muscle activation (stance control), while the ST performed with the paretic leg stepping (ST-P) and the flexion component of the UMCT (UMCT-F) required paretic LE flexor muscle activation (swing control). The FM required both extensor and flexor muscle control and also included reflexes and coordination. Gait speed was calculated from performance of the 10-m walk test at the subject's “usual, comfortable” pace. Statistical analyses included Pearson correlations with Bonferroni adjustment for multiple comparisons and stepwise regression analysis. Significance level was set at p <; .05. Results: With the exception of UMCT-E, all month 1 measures of paretic LE motor control were significantly associated with month 6 GS (r = .67–.85). Associations were somewhat stronger for measures of swing as compared to stance phase control. The association between month 1 ST-NP and ST-P scores was very strong (r = .91), whereas that between UMCT-E and UMCT-F scores was more moderate (r =.68). Younger age, higher ST-P scores, and higher FM scores at 1 month post stroke were associated with faster GS at 6 months post stroke (adjusted R2 = .74, p <;.001), with ST-P scores accounting for >; 70% of the variance. Conclusions: The degree of paretic LE motor control present at 1 month post stroke relates to gait speed at 6 months post stroke. Measures of both stance and swing phase control relate to walking outcome, with the ability to activate paretic LE flexors as needed for swing phase making a somewhat greater contribution. Clinical Relevance: An understanding of how early paretic LE motor control contributes to later walking outcome provides a basis for optimization of assessment and intervention strategies following mild to moderate stroke.

The Evaluation of Patellofemoral Pain in the Clinic

Static measures taken in the clinic are commonly used to infer the cause and treatment of patients with patellofemoral pain (PFP). Functional joint loading parameters taken from a three-dimensional gait analysis also provide useful data to investigate potential mechanisms of lower limb injury, although this takes time, expertise, and expensive equipment. It would be useful for a clinician to assess dynamic joint loading from some simple measures taken in the clinic. Particular focus is given to the hip muscles due to their ability to control femoral rotation and valgus posture at the knee. PURPOSE: To determine if routine clinical measures predict dynamic joint loading response during gait in patients with PFP. METHODS: Gait analysis data and clinical measurements were obtained from 24 subjects with PFP (10 males, 14 females). Subjects walked at a self-selected pace and data were averaged across five trials. Three dimensional kinematics and kinetics were determined using an 8-camera motion analysis system, Bertec force plate, and a standard lower limb marker set. The following parameters were obtained; peak hip adduction moment, hip adduction angle, knee adduction moment, and knee flexion moment. An experienced clinician then took the following clinical measures for each subject; Q-angle, absolute hip abduction strength, hip internal rotation range of motion, iliotibial band tightness, and thigh circumference. A Pearson correlation coefficient was used to compare individual gait variables with clinical measures. A multiple linear regression was also used to determine the ability of the clinical measures to predict the gait variables. RESULTS: Decreased hip abductor strength was associated with decreased hip adductor moments. (R2 = 0.196, p = 0.03). Increased Q-angle was associated with increased peak hip adduction angle (R2 = 0.309, p = 0.005). Agreater ratio of hip internal/ external rotation (IE ratio) was associated with increased hip adduction moments during gait (R2 = 0.179, p = 0.04). Multiple regression using factors hip abductor strength, hip IE ratio, and Q-angle improved the predictions of peak hip adduction moment to 37%. The Q angle and absolute hip abductor strength combined to predict 30% of the knee peak adduction moment. CONCLUSION: In the evaluation of PFP, Q-angle, hip strength, and hip IE ratio were simple clinical measures that were predictive of relevant lower extremity moments and angles during active gait. Supported by Veterans Affairs Rehabilitation R&D (#A2592R), NIH (EB005790-01), and Stanford Regenerative Medicine (1R-90DK071508).

Issue Highlights

HomeCirculationVol. 111, No. 19Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published17 May 2005https://doi.org/10.1161/circ.111.19.2413Circulation. 2005;111:2413POSTINFARCTION GENE THERAPY AGAINST TRANSFORMING GROWTH FACTOR-β SIGNAL MODULATES INFARCT TISSUE DYNAMICS AND ATTENUATES LEFT VENTRICULAR REMODELING AND HEART FAILURE, by Okada et al.REGENERATION OF INFARCTED MYOCARDIUM BY INTRAMYOCARDIAL IMPLANTATION OF EX VIVO TRANSFORMING GROWTH FACTOR-β–PREPROGRAMMED BONE MARROW STEM CELLS, by Li et al.The clinical benefit of limiting ventricular remodeling after myocardial infarction is clear, though the pharmacological tools we have available are only moderately successful. Future therapies targeting the underlying biology of the remodeling process appear promising, although as 2 articles in this week’s Circulation illustrate, ‘the devil is in the details.’ Tissue growth factor β (TGF β) promotes fibroblast proliferation and scar formation, and a study by Okada et al suggests that blocking its action in the heart will improve outcome after infarction. On the other hand, Li et al demonstrate that the same growth factor has a beneficial effect on bone marrow stem cells, improving their ability to differentiate into myocytes and repair the wounded heart. Careful evaluation of these and other biologically based therapeutic strategies have the potential to lead us to the next era in management of the postinfarction patient. See pp 2430 and 2438.LOWER SERUM SODIUM IS ASSOCIATED WITH INCREASED SHORT-TERM MORTALITY IN HOSPITALIZED PATIENTS WITH WORSENING HEART FAILURE: RESULTS FROM THE OUTCOMES OF A PROSPECTIVE TRIAL OF INTRAVENOUS MILRINONE FOR EXACERBATIONS OF CHRONIC HEART FAILURE (OPTIME-CHF) STUDY, by Klein et al.Hyponatremia was identified years ago as a powerful predictor of an unfavorable prognosis in patients with heart failure, originally in patients with severe reduction in serum sodium. In this issue of Circulation, a retrospective analysis of 949 patients admitted to hospital with decompensated heart failure in the OPTIME-CHF trial by Klein and colleagues demonstrates that even modest degrees of reduction in serum sodium were associated with a significantly elevated risk of unfavorable outcomes, including number of days in hospital within 60 days of randomization, as well as in-hospital and 60-day mortality. Moreover, the results were seen in the setting of substantial use of angiotensin-converting enzyme inhibition or angiotensin receptor blockers. These data suggest that a simple clinical measurement can identify a group with very high short-term risk among patients admitted to hospital with heart failure in the contemporary treatment era. See p 2454.LONG-TERM RESULTS OF MITRAL VALVE REPAIR IN ACTIVE ENDOCARDITIS, by Zegdi et al.Mitral valve endocarditis requiring surgical therapy can be treated by valve replacement or mitral valve repair. A variety of repair techniques can be used to reconstruct the valve tissue and remove the site of active infection. In their article, Dr Alain Carpentier’s group in Paris reported having 37 patients undergo a mitral valve repair for active endocarditis. During a 5-year period, these repair patients represented 75% of the total mitral valve operations performed for active endocarditis, demonstrating a high degree of repair feasibility. The operative mortality was low (3%), and the 10-year survival rate was 96%, with 92% having trivial to no mitral regurgitation on echocardiography. Freedom from mitral valve reoperation at 10 years was 91%, and recurrence of endocarditis was 3%. These excellent results should allow clinicians to consider mitral valve repairs as an alternative to replacement for mitral valve endocarditis. See p 2532.Visit www.circ.ahajournals.org:Cardiology Patient PageHomocysteine and MTHFR Mutations: Relation to Thrombosis and Coronary Artery Disease. See p e289.Images in Cardiovascular MedicineContinuous Cardiac Magnetic Resonance Imaging During Untreated Ventricular Fibrillation. See p e294.Download figureDownload PowerPointST-Segment Elevation Due to Hyperkalemia. See p e295.CorrespondenceSee p e297. Previous Back to top Next FiguresReferencesRelatedDetails May 17, 2005Vol 111, Issue 19 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.111.19.2413 Originally publishedMay 17, 2005 PDF download Advertisement

Comparison of thoracic kyphosis and postural stiffness in younger and older women

Background context An increase in thoracic kyphosis and postural stiffness is commonly associated with aging and many pathological conditions. Simple clinical measurements are needed to estimate the relative degree of postural stiffness to determine whether clinical interventions, such as exercise, are beneficial. Purpose To compare the amount of kyphosis and postural stiffness in the thoracic spine of younger and older women. Study design/setting Experimental design conducted at a large health science center in southeastern Texas. Patient sample Fifty-one healthy adult women, 25 between the ages of 21 and 51 years and 26 aged 66 to 88 years. Outcome measures Index of kyphosis (IK) measured with a surveyor's flexicurve. Differences, percent change and ratios between IK measures taken in the relaxed and maximally erect positions were used to estimate postural stiffness. Methods Subjects were measured while standing in their usual relaxed posture and again in their maximally erect posture by three different raters. IK measures were calculated by each rater and averaged for further data analysis. Independent t tests were used to compare the two age groups at the .05 alpha level. Results Significant differences were found in both the relaxed (p = .018) and erect (p<.001) IK measures of younger and older women. The differences, percent change and ratio between the two IK measures were also significantly different in that the younger women demonstrated a greater degree of active reduction of their kyphosis (in the erect posture) than older women. Conclusions Age-related differences in thoracic kyphosis and postural stiffness were documented between younger and older women by means of repeated flexicurve measurements performed in both a relaxed and a maximally erect position.

Establishing the reliability of mobility milestones as an outcome measure for stroke

Baer GD, Smith MT, Rowe PJ, Masterton L. Establishing the reliability of mobility milestones as an outcome measure for stroke. Arch Phys Med Rehabil 2003;84:977–81. Objective:To establish intrarater, interrater, and test-retest reliability of a standardized measure of mobility, “mobility milestones,” incorporating sitting balance, standing balance, and walking ability. Design:Repeated-measures reliability study by using video data of patients with stroke. Setting:Physiotherapy and rehabilitation departments in Scotland. Participants:Forty physiotherapists recruited from within the Lothian region: 20 senior physiotherapists with at least 3 years of experience working with neurologic patients and 20 staff grade physiotherapists with less than 12 months of experience working with neurologic patients. Intervention:Videotape comprising 40 clips (36 original clips, 4 repeated clips) of stroke patients of differing levels of ability attempting the mobility milestones was produced. After a short training session in the interpretation and application of the mobility milestones, each physiotherapist viewed the tape separately and scored whether the milestone had been achieved or not. This was repeated at a separate test session 2 weeks later. Main Outcome Measure:Score for each mobility milestone. Results:Kappa statistics were used to determine interrater reliability and showed good (.61–.80) to very good (.81–1.0) reliability for 3 of 4 milestones. Intraclass correlation coefficients (ICCs) were used to determine intrarater reliability of the 4 repeated clips and showed 75% of all subjects had high (ICC2,1=.91–1.0) reliability. The ICC2,1 for test-retest reliability showed a similar pattern, with 70% of subjects showing good (.81–.90) or high (.91–1.0) reliability. Conclusions:The mobility milestones showed favorable levels of reliability when used by experienced or novice physiotherapists. The milestones can be adopted as a simple clinical outcome measure for use with stroke. Further research is required to establish reliability levels when the measure is used by different rehabilitation professionals.

The relationship between the 'metabolic score' and sub-clinical atherosclerosis detected with electron beam computed tomography.

This study examines the contribution of the metabolic syndrome, as defined by National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), to sub-clinical atherosclerosis and the cardiovascular risk assessment in an asymptomatic screening population. We studied 1000 consecutive, asymptomatic, apparently healthy men and women aged 40-45 years, enrolled into a prospective cardiovascular risk assessment study. The 'metabolic score' (MS) was calculated as the sum of the five metabolic syndrome risk factors defined per NCEP III. The metabolic syndrome was defined as a metabolic score >/=3. Coronary artery calcification (CAC) on electron beam computed tomography (EBCT) was used to measure sub-clinical atherosclerosis. The prevalence of the metabolic syndrome was 8.9% (89/999), and was associated with significantly higher fasting serum insulin levels and significantly lower activity indices. Participants with the metabolic syndrome were more likely to have a positive CAC score 24.7% (24 of 89) compared to those without 16.5% (159 of 910, P<0.05.) After controlling for serum low-density lipoprotein, the metabolic score and the metabolic syndrome remained a significant independent predictor of sub-clinical atherosclerosis. The 'metabolic score' is a simple clinical measurement that directly and independently relates to the likelihood of premature sub-clinical calcified atherosclerosis in an asymptomatic screening population.

Contemporary preoperative parameters predict cancer-free survival after radical prostatectomy: a tool to facilitate treatment decisions

Prostate specific antigen (PSA) screening has heralded stage migration in prostate cancer toward cancers that may be readily eliminated by primary intervention. We sought to identify contemporary, preprostatectomy measures of cancer severity useful and significant for predicting postprostatectomy, recurrence-free survival. The association of baseline variables clinical variables (age, clinical stage, serum PSA, and race) and prostate biopsy parameters (Gleason score, presence of perineural invasion, number of biopsy cores with cancer, and the greatest percentage of a biopsy core occupied by cancer — GPC) with recurrence-free survival was evaluated by multivariate Cox proportional hazards regression among consecutive patients that underwent radical prostatectomy as primary therapy between 1994 and 2002. Tables were generated depicting expected 5-year recurrence-free survival after prostatectomy. From 1414 patients, 183 developed biochemical recurrence, 8 died from prostate cancer, and 31 died of all causes. Multivariable Cox regression found that clinical stage, PSA, Gleason score, and the greatest percentage of a biopsy core involved by cancer (GPC), were each significant determinants of post-prostatectomy, PSA recurrence-free survival ( P < 0.05 for each). Gleason score and GPC were also significantly associated with clinical recurrence-free survival and cancer death, whereas other biopsy parameters and PSA were not. The amount of cancer in a biopsy core is a significant predictor of recurrence-free survival after prostatectomy, and is a simple clinical measure that complements baseline PSA, and Gleason score in predicting outcome. Tabulated 5-year PSA-free survival outcomes, stratified by these preoperative parameters, provide a basis for preoperative counseling of patients regarding postprostatectomy cancer control expectations.

Caries Protocol Compliance Issues

Any caries control or caries protocol program must consider compliance as a measure of success. Lower bacterial counts on saliva tests and lower defs and DMFS scores suggest that some change has occurred. However, compliance with a caries risk protocol is about more than simple and convenient clinical outcome measures. We tend to think of compliance as an individual activity, but all influences on an individual need to be considered. Change may be from external influences rather than from the individual or even from providers interacting with an individual or community. Few studies have directly addressed caries risk protocol. The paradigm change described in this manuscript suggests six key global areas--beneficiary education, health provider network education, community and state agencies, legislative commitment, access to care, and research--as significant factors to be considered in compliance. An outline of the major areas and subheadings for a global caries protocol compliance paradigm are presented.

Recognising severe pneumonia with simple clinical and biochemical measurements

Community-acquired pneumonia (CAP) is the most common reason for acute admission to hospital and the fourth most common cause of death in the UK. It is important to identify patients with severe pneumonia and the worst prognosis. We conducted this study to validate a rule designed to do this devised in New Zealand. CAP was defined by evidence of new shadowing on the chest X-ray and clinical features of pneumonia. A standardised proforma was completed documenting clinical features and investigation results. Severe pneumonia was identified by two or more of the following: confusion; respiratory rate ≥30/min; diastolic blood pressure ≤60 mmHg; urea >7 mmol/l. One hundred patients (mean age 58.8 years) were included; 32 satisfied the rule. Seven died, all of whom satisfied the rule. Ten patients received intensive care including six who died. Of 11 patients who died and/or received intensive care, nine satisfied the rule. The sensitivity and specificity of the rule for predicting death and/or intensive care were 82% and 73% respectively.

Alterations in reaching after stroke and their relation to movement direction and impairment severity

Kamper DG, McKenna-Cole AN, Kahn LE, Reinkensmeyer DJ. Alterations in reaching after stroke and their relation to movement direction and impairment severity. Arch Phys Med Rehabil 2002;83:702-7. Objectives: To examine the effects of stroke severity and target location on reaching (1) to identify regions in space that are difficult to reach, (2) to determine whether specific alterations in reaching are associated with particular clinical impairment levels, and (3) to characterize relationships between reaching alterations. Design: Participants reached toward a screen of 75 targets spanning an approximate range from ±90° side to side and from waist to head. Setting: Rehabilitation research center. Participants: Sixteen chronic stroke patients with a wide range in residual arm function and 4 control subjects. Interventions: Not applicable. Main Outcome Measures: Chedoke-McMaster Stroke Arm Assessment, distance, velocity, smoothness, straightness, and direction of the hand path during each reach. Hand position trajectories were recorded with an electromagnetic sensor. Results: Reaches performed with the impaired arms showed significant degradation in all performance measures. Although only modestly dependent on the target location, these features correlated strongly with impairment level, as well as with each other. Reaching distance showed the strongest correlations with the other parameters. Conclusions: Stroke alters a broad array of features of reaching, yet largely the same degree of movement control is preserved across a range of target locations. The only consistently problematic task is to reach far out from the torso, independent of the movement direction. Thus, active range of motion (AROM), rather than control over a specific subset of movement directions, is a logical focus for therapy. In addition, measuring AROM is a simple clinical measure that yields much information. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Sublingual Capnography: A Clinical Validation Study

ObjectiveTo compare sublingual Pco2 (Pslco2) measurements with gastric intramucosal Pco2 (Pimco2) as well as with the traditional indexes of tissue oxygenation in hemodynamically unstable ICU patients. DesignA prospective, validation study. SettingThe medical and coronary ICUs of a community teaching hospital. PatientsConsecutive patients with severe sepsis, septic shock, or cardiogenic shock requiring pulmonary artery catheterization for hemodynamic management. InterventionsDuring the first 24 h of ICU admission, the Pslco2, Pimco2, and blood lactate concentrations as well conventional hemodynamic and oxygenation parameters were recorded every 4 to 6 h. The Pslco2-Paco2 and Pimco2-Paco2 differences were used as indexes of tissue dysoxia. These variables were correlated with each other as well as with the traditional markers of tissue oxygenation. ResultsSeventy-six data sets were obtained on 22 patients. Fifteen patients had severe sepsis/septic shock, and 7 patients did not have sepsis. A patient with ischemic bowel who had a large Pimco2-Pslco2 difference (60.2 mm Hg) was excluded. The initial Pslco2 and Pimco2 measurements were 43.5 ± 10.4 mm Hg and 42.8 ± 10.9 mm Hg, respectively (correlation coefficient [r] of 0.86; p < 0.001). The mean Pslco2 and Pimco2 for the entire data set were 48.0 ± 13.4 mm Hg and 46.1 ± 12.3 mm Hg, respectively (r = 0.78; p < 0.001). Ten patients died. The initial Pslco2-Paco2 difference was 9.2 ± 5.0 mm Hg in the survivors and 17.8 ± 11.5 mm Hg in the nonsurvivors (p = 0.04). The initial Pimco2-Paco2 difference was 8.4 ± 4.8 mm Hg in the survivors and 16.1 ± 13.7 mm Hg in the nonsurvivors (p = 0.08, not significant). The initial Pslco2-Paco2 difference correlated with the initial mixed venous-arterial CO2 gradient (r = 0.66; p = 0.001), but correlated poorly with the initial blood lactate concentration (r = 0.38), mixed venous Po2 (r = 0.05), and systemic oxygen delivery (r = − 0.39). ConclusionIn this study, sublingual capnometry yielded measurements that correlated well with those of gastric tonometry. Pslco2 may serve as a technically simple and noninvasive clinical measurement of tissue dysoxia in critically ill and injured patients.

Predicting physical therapy visits needed to achieve minimal functional goals after arthroscopic knee surgery.

Retrospective, cross-sectional regression modeling. To predict physical therapy visits following arthroscopic knee surgery. The number of physical therapy visits required to achieve a set of specific minimal-level goals (full knee extension, straight leg raise, normalized gait pattern, bicycle pedaling, and independent home exercises) that are related to decreased complication rates has not previously been modeled. A multiple regression model to predict postoperative physical therapy visits was developed using subject demographics and 2 simple clinical measures, degree of straight leg raise lag and total range of motion. All data were collected from 148 patient charts. Model validity was examined by the predicted residual sum of squares technique and a second independent sample of 157 charts. Diagnosis group, surgery group, and range of motion were the significant variables predicting visits in the final model (R2 = 0.384). Results of model validation analyses using predicted residual sum of squares technique (R2 = 0.346) and the second set of data (R2 = 0.282) were satisfactory. Analysis of residuals (difference of observed and predicted visits) showed prediction of the number of physical therapy visits within 3 visits for approximately 75% of the cases in both sets of data. Using the model to predict physical therapy visits following arthroscopic knee surgery was more accurate than using diagnosis alone, except for lateral retinacular release. This study demonstrates how regression models could be used to explain variance in physical therapy visits for a given set of minimal functional goals.