Unfavorable Recovery Research Articles

Bell’s Palsy in Children

To investigate the correlation between electroneurography (ENoG) findings and the prognosis of Bell's palsy in children compared with adults. Twenty-two children and 92 adults with Bell's palsy who underwent ENoG between 8 days and 4 weeks from the onset of symptoms were retrospectively enrolled. The time to maximal recovery and rate of favorable recovery (House-Brackmann grade I or II) was assessed. Children (C) and adults (A) were further subdivided into low (<10%) or high (≧10%) subgroups according to their ENoG values (affected versus unaffected side) at initial evaluation. The numbers in each subgroup were as follows: C-low (n = 8), A-low (n = 21), C-high (n = 14), and A-high (n = 71). Of the 22 children assessed, 2 of the 4 patients who showed a total loss of evoked potentials on the affected side (0% ENoG value) exhibited an unfavorable recovery. The remaining 20 patients achieved a favorable recovery eventually. Patients in group C-low reached a maximal recovery of facial movement significantly later than those in group C-high (p < 0.001). Time to maximal recovery of facial movement in group A-low was later than that in group C-low, although the difference was not statistically significant (p = 0.15). The patients in group A-high reached a maximal recovery significantly later than those in group C-high (p < 0.05). Bell's palsy seems to recover earlier in children than adults when matched for severity. The presence of an identifiable response in ENoG, irrespective of its amplitude, may indicate a favorable recovery of facial movement in children.

Clinicoradiological Profile and Serum Lipid Levels of Intracerebral Hemorrhage in Prior Statin Users

We aimed to evaluate whether serum lipid levels can influence the clinicoradiological recovery of intracerebral hemorrhage (ICH) in prior statin users. Medical records were reviewed retrospectively in 381 ICH patients (253 men and 128 women). Cardiovascular disease (CVD) risk factors, blood pressure at admission and the first in-hospital day, admission and 30-day scores of National Institute Health Stroke Scale (NIHSS) and modified Rankin scale (mRS), hematoma volume (HV), serum lipid levels were compared between prior statin users and non-users. Statins were pretreated in 56 patients (31 men and 25 women). Statin users were older age, and had higher frequencies of dyslipidemia, diabetes mellitus, atrial fibrillation, prior stroke history and large HV compared to non-users. Serum levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) were significantly decreased in the statin group compared to the non-statin group. There were no statistical differences in the other CVD risk factors, functional scores and other serum lipid levels between the two groups. HV was correlated inversely with serum levels of TC and LDL-C in both groups. Multiple logistic regression analysis showed that serum TC levels ≤150 mg/dL were associated with statin use [Odds ratio (OR)=5.5, 95% confidence interval (CI)=1.55-19.58], worsening of NIHSS score (OR=1.4, 95% CI=1.21-1.63) and HV (OR=1.1, 95% CI=1.07-1.13) in ICH patients. A significant association was found between worsening of NIHSS score (OR=2.0, 95% CI=1.32-3.12) and worsening of mRS score (OR=3.3, 95% CI=1.33-8.00), HV (OR=1.3, 95% CI=1.01-1.76), and serum TC levels ≤150 mg/dL in statin users. Prior statin users with serum TC levels ≤150 mg/dL had worsening of outcome and HV. Excessive lowering of serum TC levels due to statin pretreatment may cause unfavorable clinicoradiological recovery of ICH. Physicians should monitor serum lipid levels carefully in statin users.

Changes in perceived stress and recovery in overreached young elite soccer players

The aim of this study was to prospectively monitor sport-specific performance and assess the stress-recovery balance in overreached (OR) soccer players and controls. During two competitive seasons, 94 players participated in the study. The stress-recovery balance (RESTQ-Sport) and sport-specific performance (Interval Shuttle Run Test) were assessed monthly. Seven players with performance decrement of at least a month were classified as OR. Stress and recovery measures were assessed between groups (OR vs healthy players) and at different times within the OR group. An unfavorable total recovery score appeared 2 months before diagnosis when compared with the reference values of the healthy group established at the start of the season (P=0.009) and also over the two seasons (P=0.028). The scales Emotional Stress (P=0.044), Physical Recovery (P=0.009), General Well-being (P=0.001) and Sleep Quality (P=0.045) were sensitive to OR compared with the average of the healthy group over the two seasons. Finally, Fatigue and Being in Shape demonstrated the largest changes in stress and recovery within the OR players (effect size=1.14 and 1.50). The longitudinal monitoring of performance and changes in stress and recovery may be useful for the detection of OR in its earliest stage. The information obtained from these tests can be used to optimize individual training and recovery programs.

Activation of protein C and hemodynamic recovery after coronary artery bypass surgery

Activated protein C is a physiologic anticoagulant that is activated by thrombin and upregulated during coronary artery bypass grafting. We studied the balance between thrombin generation and activated protein C levels during coronary artery bypass grafting and hypothesized that protein C activation during reperfusion is associated with hemodynamic recovery or postoperative myocardial damage. One hundred patients undergoing elective on-pump coronary artery bypass grafting were prospectively studied. Activated protein C, protein C, prothrombin fragment F1+2 (a marker of thrombin generation), and D-dimer (a marker of fibrinolysis) levels were measured preoperatively and at 7 time points during cardiopulmonary bypass and reperfusion and postoperatively. Hemodynamic parameters were measured serially. Cardiac biomarkers (mass of the Mb fraction of creatine kinase and troponin T) were measured postoperatively. Reperfusion induced a significant increase in thrombin generation. Activated protein C levels peaked after heparin neutralization, when they increased more than 3-fold. Activated protein C levels correlated with F1+2 and D-dimer levels during cardiopulmonary bypass and reperfusion. Even though this correlation peaked during early reperfusion (r = 0.55, P < .001), the ratio of activated protein C to F1+2 decreased during surgical intervention and early reperfusion by 70% from the preoperative level, indicating a marked delay in protein C activation in relation to thrombin generation. Patients in the highest quintile of activated protein C levels during this period had a higher postoperative cardiac index (mean, 3.1 vs 2.5 L x min(-1) x m(-2); P < .05) and lower systemic vascular resistance (mean, 2137 vs 2429 dyne x s x cm(-5) x m(-2); P < .05). Conversely, levels of preoperative activated protein C and activated protein C measured after heparin neutralization were associated with unfavorable hemodynamic recovery postoperatively. Activated protein C or protein C levels were not associated with increased postoperative cardiac biomarkers. Reperfusion caused significant thrombin generation that was followed by activation of protein C. The balance of activated protein C with thrombin is associated dynamically with postoperative hemodynamic recovery.

Nerve root distribution of deltoid and biceps brachii muscle in cervical spondylotic myelopathy: a potential risk factor for postoperative shoulder muscle weakness after posterior decompression

To investigate the nerve root distribution of deltoid and biceps brachii muscle, compound muscle action potentials (CMAPs) were recorded intraoperatively following nerve root stimulation in cervical spondylotic myelopathy. A total of 19 upper limbs in 12 patients aged 55-72 years (mean, 65.5 years) with cervical spondylotic myelopathy were examined. CMAPs were recorded from deltoid and biceps brachii muscle following C5 and C6 root stimulation. Although both C5 and C6 roots were innervated for deltoid and biceps brachii muscle in all subjects, the amplitude ratio of CMAPs (C5/C6) differed individually depending on the symptomatic intervertebral levels of the spinal cord. The C5 root predominantly innervated both deltoid and biceps brachii in patients with symptomatic cord lesions at the C4-C5 intervertebral level compared to patients with symptomatic cord lesions at the C5-C6 intervertebral level. Although no patients sustained postoperative radiculopathy in our study, severe weakness and unfavorable recovery are expected when the C5 root in patients with C4-C5 myelopathy is damaged. From the electrophysiological aspect, C4-C5 cord lesions are likely to be a potential risk factor for postoperative shoulder muscle weakness in patients with compressive cervical myelopathy.

Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome.

Moderate elevation of brain temperature, when present during or after ischemia, may markedly worsen the resulting injury. To evaluate the impact of body temperature on neurologic outcome after successful cardiopulmonary resuscitation. In patients who experienced a witnessed cardiac arrest of presumed cardiac cause, the temperature was recorded on admission to the emergency department and after 2, 4, 6, 12, 18, 24, 36, and 48 hours. The lowest temperature within 4 hours and the highest temperature during the first 48 hours after restoration of spontaneous circulation were recorded and correlated to the best-achieved cerebral performance categories' score within 6 months. Over 43 months, of 698 patients, 151 were included. The median age was 60 years (interquartile range, 53-69 years); the estimated median no-flow duration was 5 minutes (interquartile range, 0-10 minutes), and the estimated median low-flow duration was 14.5 minutes (interquartile range, 3-25 minutes). Forty-two patients (28%) underwent bystander-administered basic life support. Within 6 months, 74 patients (49%) had a favorable functional neurologic recovery, and a total of 86 patients (57%) survived until 6 months after the event. The temperature on admission showed no statistically significant difference (P =.39). Patients with a favorable neurologic recovery showed a higher lowest temperature within 4 hours (35.8 degrees C [35.0 degrees C-36.1 degrees C] vs 35.2 degrees C [34.5 degrees C-35.7 degrees C]; P =.002) and a lower highest temperature during the first 48 hours after restoration of spontaneous circulation (37.7 degrees C [36.9 degrees C-38.6 degrees C] vs 38.3 degrees C [37.8 degrees C-38.9 degrees C]; P<.001) (data are given as the median [interquartile range]). For each degree Celsius higher than 37 degrees C, the risk of an unfavorable neurologic recovery increases, with an odds ratio of 2.26 (95% confidence interval, 1.24-4.12). Hyperthermia is a potential factor for an unfavorable functional neurologic recovery after successful cardiopulmonary resuscitation.

Relative Potencies of Ropivacaine and Bupivacaine

Staff Anesthesiologist Virginia Mason Medical CenterSeattle, WashingtonClinical Associate Professor of AnesthesiologyUniversity of Washington School of MedicineSeattle, Washington 98111anessl@vmmc.orgIn Reply:—Thank you for allowing us to respond to Dr. Wildsmith’s concerns regarding our article in the April 1999 issue of ANESTHESIOLOGY. 1His first comment refers to our explanation of potency, which he defines as the “degree of effect of a drug to its dose.” We studied several “effects” of the two drugs, including height of block, intensity of block (defined as tolerance to transcutaneous electrical stimulation [TES]), and duration of sensory and motor block. A comparison of potencies can be found in the data listed in our table 3, which gives the characteristics of the two spinal anesthetic drugs. For example, 4 mg bupivacaine produces tolerance to TES at T10 and T12 dermatomes, but 4 mg ropivacaine does not (duration not a consideration). Although the strictest definition of potency may be found by testing an isolated nerve in a controlled laboratory setting, to the clinician, who deals with “intact subjects,” duration is an important measure of potency.His concern regarding our use of volunteers (which included one of the authors [S. B. M.] and her spouse) should be allayed not only by our Institutional Review Board approval, but by full disclosure to the volunteers that although ropivacaine is not approved at this time for intrathecal use, its safety has been studied in case of inadvertent intrathecal injection of an epidural test dose. 2,3We chose to use volunteers for two reasons: (1) asking patients to receive an anesthetic in doses not yet proven to produce surgical anesthesia is unethical; and (2) our crossover method of control is unsuitable for patients who require only one anesthetic.The association of back pain and ropivacaine in our study was not statistically significant (as stated, P = 0.098), but the trend is concerning. Our conclusion was that “the possibility of side effects… warrants further investigation.” We apologize if the study design was not clearly stated, but the order of drug injection was randomized as well. In our interpretation of the results, we commented that there was no association whether ropivacaine was given first or second and, in addition, that all three doses were represented.Finally, Dr. Wildsmith suggested that our figure 1, which depicted block height to pin prick, was encouraging evidence that ropivacaine may be a suitable spinal drug for outpatients. However, sensory block to pinprick does not equal surgical anesthesia. Our results regarding TES, which was designed to simulate surgical incision, were far from encouraging. 4Again, referring to our table 3, the 12-mg dose of ropivacaine produced tolerance to TES at the ankle for 48 ± 40 min versus 153 ± 54 min for 12 mg bupivacaine or 46 ± 30 min for 8 mg bupivacaine. Ropivacaine 8 mg did not produce any tolerance to TES. This data coupled with its unfavorable recovery profile brought us to the conclusion that ropivacaine is unlikely to offer an advantage over presently available drugs such as bupivacaine. Other researchers have also come to a similar conclusion for patients undergoing outpatient surgery. 5

Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery.

To determine the prognostic factors of the functional outcome of patients surgically treated for acute epidural hematomas. Two hundred patients who consecutively underwent neurosurgery for acute epidural hematomas over the past 9-year period were studied. Clinical characteristics, radiologic findings, and the time intervals with regard to treatment course were investigated to determine the interactions between all these factors and functional outcome. Functional outcome showed a significant correlation with preoperative consciousness state, Glasgow Coma Scale score, pupillary sizes, and motor posturing (chi2 test, p < 0.05). Functional outcome correlated with the period of brain herniation, the length of time of the operation, as well as the period of hospitalization (chi2 test, p < 0.05), but not with the length of time of craniotomy decompression relative to the length of time from the injury until admission. The radiologic findings of the associated brain injury, the size and the density of the clot, the degree of the brain shift, and the obliteration of the basal cisterns significantly correlated with functional outcome (chi2 test, p < 0.05), whereas no significance was attributable to skull fracture. Multivariate analysis indicated that the following four factors independently correlated with functional outcome: (1) associated brain injury, (2) best motor response, (3) hematoma volume, and (4) period of hospitalization (chi2 test, p < 0.05). A combination of the four factors led to the prediction of the functional outcome with 91% accuracy (1.5 % falsely pessimistic predictions and 7.5 % falsely optimistic prediction) and 82.1% at over 90% confidence level. These four parameters correlated significantly with preoperative neurologic deterioration (chi2 test, p < 0.05). This study identifies the risk factors involved in the functional outcome of patients who underwent surgical treatment for acute epidural hematomas. Our results indicate that associated brain injury plus best motor response are the optimal set of two prognostic indicants, with 87% correct predictions and 70.1% at over a 90% confidence level. Prevention of in-hospital neurologic deterioration would improve the patients' functional outcome with a resultant unfavorable recovery rate ranging from 11.5% to 17%.

The association between blood lactate concentration on admission, duration of cardiac arrest, and functional neurological recovery in patients resuscitated from ventricular fibrillation.

To assess the association between arterial lactate concentration on admission and the duration of human ventricular fibrillation cardiac arrest, and to what degree the arterial lactate concentration on admission is an early predictor of functional neurological recovery in human cardiac arrest survivors. Cohort study. Arterial lactate concentrations and out-of-hospital data concerning cardiac arrest and cardiopulmonary resuscitation were collected retrospectively according to a standardized protocol. Functional neurological recovery was assessed prospectively at regular intervals for 6 months. Emergency department of an urban tertiary care hospital. A total of 167 primary survivors of witnessed out-of-hospital ventricular fibrillation cardiac arrest. The association between arterial lactate concentration on admission, the duration of cardiac arrest, and functional neurological recovery was assessed. Further, we assessed whether admission concentrations of arterial lactate and duration of cardiac arrest can predict unfavorable functional neurological recovery. Functional neurological recovery was measured in cerebral performance categories (CPC). No or minimal functional impairment (CPC 1 and 2) was defined as favorable outcome; the remaining categories (CPC 3, 4 and 5) were defined as unfavorable functional neurological recovery. In 167 patients, a weak association between total duration of cardiac arrest and admission levels of lactate (r = 0.49, P < 0.001) could be shown. With increasing admission concentrations of arterial lactate functional neurological recovery was more likely to be unfavorable (OR 1.15 per mmol/l increase, 95% CI 1.04-1.27). Nevertheless, only at very high levels of lactate (16.3 mmol/l) could unfavorable neurological recovery be detected with 100% specificity, yielding a very low sensitivity of 16%. The arterial admission lactate concentration after out-of-hospital ventricular fibrillation cardiac arrest is a weak measure of the duration of ischemia. High admission lactate levels are associated with severe neurological impairment. However, this parameter has poor prognostic value for individual estimation of the severity of subsequent functional neurological impairment.

Urodynamic findings with disc protrusion

The medical literature on functional bladder problems with disc protrusion is reviewed. The majority of reports concern central lumbar disc protrusion, the main effect of which is bladder hypofunction, with variable degrees of urinary retention. The lack of bladder training in the pre-intermittent catheterization era probably explains the unfavorable bladder recovery reported by past authors. According to the author's experience, intermittent self-catheterization permits the patient to obtain a balanced bladder condition in most cases. Also, upper urinary tract conditions remain good, and close follow-up is mandatory.

Relation of prognosis of peripheral facial nerve palsy to the period between onset of illness and date of denervation.

The presence or absence of the denervation is one of the important factors to determine the prognosis of peripheral facial nerve palsy and it is generally accepted that the denervation becomes apparent within 2 weeks from the onset of illness. In the present study, 62 cases with denervation in which nerve excitability test (NET) was possible within 1 week from the onset of illness were selected for analysis. Although 47 cases exhibited the denervation within 2 weeks, it was first detected after 2 weeks in other 15. Although the prognosis was far better in the latter group, 2 cases exhibited the unfavorable recovery. These results indicate the importance of NET even 2 weeks after the onset of illness.