Worse Functional Outcome In Patients Research Articles

Prognostic significance of leukoaraiosis in intracerebral hemorrhage: A meta-analysis

BackgroundPatients with intracerebral hemorrhage (ICH) have high disability and mortality. Leukoaraiosis refers to the diffuse abnormalities of white matter on neuroimaging, which has been suggested to be with poor outcome in patients with ICH. This meta-analysis was performed to summarize the current evidence on the prognostic significance of leukoaraiosis in ICH patients. MethodsDatabases were searched for published studies about leukoaraiosis and prognosis in patients with ICH. Data from eligible studies were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) from each study were combined with DerSimonian–Laird method and random effect model for quantitative analysis. Begg's funnel plot was adopted to assess the publication bias. ResultsA total of nine studies with 4948 patients were finally included in this meta-analysis. Six studies reported functional outcome, two studies reported mortality, and another study reported both functional outcome and mortality. The meta-analysis showed that leukoaraiosis was significantly associated with worse functional outcome in patients with ICH (OR = 1.40, 95%CI 1.17–1.68, P < .001). In addition, leukoaraiosis was also significantly associated with higher mortality in patients with ICH (OR = 1.59, 95%CI 1.21–2.08, P = .001). ConclusionsLeukoaraiosis is significantly associated with both worse functional outcome and higher mortality in patients with ICH. Leukoaraiosis can be a useful imaging marker for predicting outcome in patients with ICH.

The Impact of Lower Back Pain on Functional Outcomes for Ankle Arthritis Treated with Arthroplasty and Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Methods: Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. Results: In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p &lt; 0.04), SF-36 PCS (32.5 vs 28.9 p &lt;0.01), and SF-36 MSC (51.8 vs 47.8 p &lt; 0.01). At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p &lt;0.02) and SF-36 MSC (54.1 vs 51.1 p &lt; 0.001). These results where repeated at the 5 year mark. There was no difference between TAA or AA (p &gt; 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. Conclusion: The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post-operatively, this was not the case for AAS scores.

Abstract WP5: Reperfusion Reduces Brain Edema in Patients With Acute Ischemic Stroke. A MR CLEAN Substudy

Introduction: The main objective of this study was to elucidate the relation between reperfusion and brain edema. The secondary objective was to evaluate if brain edema partially mediated worse outcome in patients without reperfusion, or in patients with delayed reperfusion or a lower ASPECTS. Methods: MR CLEAN was a prospective, randomized, multicenter clinical trial of endovascular treatment (EVT) compared to conventional care. In this exploratory post hoc study, 462 of 500 patients were included. Brain edema was assessed by midline shift (MLS) measured on follow-up CT scans. Reperfusion status was assessed by the modified thrombolysis in cerebral infarction (mTICI) score in the EVT arm. The modified Arterial Occlusive Lesion (mAOL) score was used to evaluate the recanalization status in both arms. The associations between MLS and modified Rankin Scale (mRS), and MLS with reperfusion or recanalization were performed in univariable and multivariable analyses. Mediation analyses were performed to determine whether MLS was partially responsible for worse functional outcome in the groups without reperfusion or recanalization, and in the groups with delayed reperfusion or lower ASPECTS. Results: Reperfusion and recanalization were associated with reduced likelihood of having MLS (acOR 0.26, 95%CI 0.13-0.51, p &lt; 0.001; acOR 0.38, 95%CI 0.24-0.60, p &lt; 0.001 respectively). Accordingly, the presence of MLS was associated with an increased risk of worse 90-day outcome (acOR 3.89, CI 2.71-5.61, p &lt; 0.001). In mediation analysis, MLS was partially responsible for worse mRS scores in patients without reperfusion or recanalization, and in those with delayed reperfusion or lower ASPECTS (MLS changed the logistic regression coefficients by 30.3%, 12.6%, 33.3%, and 64.2%, respectively). Conclusion: Successful reperfusion or recanalization reduces brain edema, reflected by MLS. The presence of MLS mediated part of the worse functional outcomes in patients without reperfusion or in those patients with delayed reperfusion or a lower ASPECTS. This study confirms a pleiotropic benefit of reperfusion that extends beyond the concept of rescuing ischemic brain tissue at risk for infarction.

Active Foot Synovitis in Patients With Rheumatoid Arthritis: Unstable Remission Status, Radiographic Progression, and Worse Functional Outcomes in Patients With Foot Synovitis in Apparent Remission.

To determine whether foot synovitis is associated with adverse radiographic and functional outcomes after 3 years in an inception rheumatoid arthritis (RA) cohort receiving treat-to-target combination disease-modifying antirheumatic drug therapy. Disease activity was assessed in early RA patients (n = 266) using the Disease Activity Score in 28 joints, Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI). Radiographic outcomes were assessed with annual hand and feet radiographs and quality of life with the Short Form 36 (SF-36). The prevalence of remission and foot synovitis was calculated using marginal binomial generalized estimating equations, transition between remission and nonremission states by a multistate Markov model, and changes in radiographic scores by a negative binomial mixed regression log-link model. Population-matched SF-36 data were analyzed by mixed-effects linear regression. Disease activity scores that omit foot joints were modest in their ability to capture foot synovitis. Despite the relative stringency of the SDAI and CDAI for remission, 25-36% of patients in remission had foot synovitis. In patients in remission, foot synovitis predicted transition from remission into relapse by up to 2-fold. The sustainability of remission markedly influenced the progression of erosion scores (P = 0.006). After adjusting for disease activity, foot synovitis was associated with worse SF-36 physical functioning scores (P = 0.025). Disease activity measures that omit foot joints capture foot synovitis poorly. When it is used to define remission, foot synovitis is found in a substantial proportion of patients, which predicts relapse and worse physical function. Foot synovitis influences the sustainability of remission, which in turn markedly influences radiographic progression. Regardless of remission status, persistent foot synovitis should prompt therapy escalation in order to improve long-term outcomes.

Early Postoperative Radiotherapy is Associated with Worse Functional Outcomes in Patients with Prostate Cancer

The effect of time between radical prostatectomy and radiation therapy on postoperative functional outcomes is still unclear in patients with surgically managed prostate cancer. We hypothesized that a shorter time between radical prostatectomy and radiotherapy might be associated with worse functional recovery rates after radical prostatectomy. We retrospectively evaluated 2,190 patients treated with radical prostatectomy and stratified according to radiotherapy schedule (adjuvant radiotherapy, salvage radiotherapy, no radiotherapy). We examined recovery rates for erectile function and urinary function according to adjuvant radiotherapy, salvage radiotherapy and no radiotherapy, and according to time from surgery to radiotherapy. Cox regression analyses were used to evaluate the impact of these predictors on functional outcomes. Median followup was 48 months. The 3-year erectile function recovery rates were 35.0%, 29.0% and 11.6% in patients who received no radiotherapy, salvage radiotherapy and adjuvant radiotherapy, respectively (p <0.001), and differed significantly according to time to radiotherapy (11.7% vs 34.7% for less than 1 year vs 1 year or more, respectively, p <0.001). The 3-year urinary continence recovery rates were 70.7%, 59.0% and 42.2% in patients who received no radiotherapy, salvage radiotherapy and adjuvant radiotherapy, respectively (p <0.001), and differed according to time to radiotherapy (43.5% vs 62.7% for less than 1 year vs 1 year or more, respectively, p <0.001). Cox regression analyses confirmed the negative impact of early radiotherapy on recovery rates for erectile function and urinary continence. Time from radical prostatectomy to radiotherapy has an important role in the recovery of erectile function and urinary continence. Delayed radiotherapy is preferred to improve functional outcomes after surgery.

Association between Admission Serum 25-Hydroxyvitamin D Levels and Functional Outcome of Thrombolyzed Stroke Patients

25-Hydroxyvitamin D (25(OH)D) deficiency is a frequent condition in patients who suffer a stroke, and several studies suggested that it may be associated with a poorer prognosis. The aim of this study was to investigate specifically the association between 25(OH)D levels and functional outcome at 3 months in ischemic stroke patients treated with intravenous thrombolysis. Consecutive ischemic stroke patients who received intravenous thrombolysis were enrolled between 2010 and 2013. Baseline characteristics were collected, and serum concentrations of 25(OH)D were measured within the first 24 hours after admission and were analyzed according to the quartiles of their distribution (<25 nmol/L versus ≥ 25 nmol/L). Multivariable ordinal logistic regression was used to evaluate the association between 25(OH)D and 3-month functional outcome assessed by the modified Rankin score. Three hundred fifty-two patients were included (mean age 68.6 ± 15.8, 50.7% women, mean 25(OH)D level 45 ± 25 nmol/L). The characteristics of the patients only differed with regard to higher premorbid functional impairment in patients with low 25(OH)D. In univariate analysis, the risk of functional impairment in patients with low 25(OH)D levels was greater than that in patients with higher 25(OH)D levels (odds ratio [OR] 2.10, 95% confidence interval [CI]: 1.35-3.27, P = .001). This association was still observed after adjustment for confounding variables (OR 1.70, 95% CI: 1.06-2.71, P = .027). A low serum 25(OH)D level is associated with worse functional outcome in patients with acute ischemic stroke treated with intravenous thrombolysis. Further investigations are required to understand the underlying mechanisms of this association.

Hyperglycemia and Mortality Risk in Patients with Primary Intracerebral Hemorrhage: A Meta-Analysis.

Hyperglycemia may be associated with worse functional outcomes in patients with primary intracerebral hemorrhage. We performed a systematic review and meta-analysis to investigate the relationship between hyperglycemia and mortality risk in patients with primary intracerebral hemorrhage. We searched PubMed and Embase databases for studies investigating the association between hyperglycemia and mortality risk in patients with primary intracerebral hemorrhage. We estimated the pooled relative risk (RR) with its 95% confidence interval (95% CI) to assess the impact of hyperglycemia on mortality risk. Seventeen studies with a total of 6527 primary intracerebral hemorrhage patients were included. Meta-analysis of those studies showed that hyperglycemia significantly increased risk of mortality in patients with primary intracerebral hemorrhage (RR = 2.36, 95% CI 1.79-3.12). Subgroup analysis by time of follow-up showed that hyperglycemia significantly increased risk of short-term mortality (RR = 3.97, 95% CI 2.13-7.43) and long-term mortality (RR = 1.53, 95% CI 1.14-2.05). The RR of mortality for per 1-mmol/L increment in glucose level was 1.14 (95% CI 1.06-1.22). In patients with primary intracerebral hemorrhage, hyperglycemia significantly increases risk of both short-term mortality and long-term mortality.

Leukoaraiosis on Magnetic Resonance Imaging Correlates With Worse Outcomes After Spontaneous Intracerebral Hemorrhage

Leukoaraiosis (LA) is associated with dementia, ischemic stroke, and intracerebral hemorrhage (ICH), but there are few data on how LA might impact outcomes after acute ICH. We tested the hypothesis that the severity of LA on magnetic resonance imaging is related to worse functional outcomes after spontaneous ICH. We prospectively identified patients with spontaneous acute ICH. LA was identified on magnetic resonance imaging and its severity was graded using the Fazekas method to include a score for the deep white matter and periventricular regions. Outcomes were obtained at 14 days, 28 days, and 3 months with the modified Rankin Scale (mRS; a validated scale from 0 [no symptoms] to 6 [dead]) and analyzed with multivariate logistic regression. Higher Fazekas total (periventricular plus deep white matter) score correlated with higher mRS score at 14 days (P=0.02) and 3 months (P=0.02). This relationship was driven by the periventricular score, for which higher score (more severe disease) correlated with higher National Institute of Health Stroke Scale at 14 days (P=0.03), and higher mRS score at 14 days (P<0.001), 28 days (P=0.004), and 3 months (P=0.005). A higher (more severe) Fazekas periventricular score was associated with dependence or death at 3 months (odds ratio, 1.8 per point; 95% confidence interval, 1.02-3.1; P=0.04) after correction for the ICH score. Increased LA is an independent predictor of worse functional outcomes in patients after spontaneous ICH. The pathophysiology associating LA with worse outcomes requires further study. These data may improve prognostication and selection for clinical trials.

Abstract TP296: Leukoaraiosis on MRI Correlates with Worse Outcomes after Intracerebral Hemorrhage

Background: Leukoaraiosis (LA) is associated with aging, dementia, ischemic stroke, and intracerebral hemorrhage (ICH), but there are few data on how LA might impact outcomes after ICH. We tested the hypothesis that the severity of LA on MRI is related to worse functional outcomes after spontaneous ICH. Methods: We prospectively identified patients with spontaneous ICH. LA was identified on MRI and its severity graded using the Fazekas method to include a score for the deep white matter (DWM) and periventricular (PV) regions. Outcomes were obtained at 14 days, 28 days, and 3 months with the modified Rankin Scale (mRS, a validated scale from 0, no symptoms, to 6, dead), analyzed with multivariate ordinal and logistic regression. Results: Higher Fazekas total (PV+DWM) score correlated with higher mRS at 14 days (p=0.02) and 3 months (p=0.02). This relationship was driven by the PV score, for which higher score (more severe disease) correlated with higher NIHSS at 14 days (p=0.03), and higher mRS at 14 days (p&lt;0.001), 28 days (p=0.004), and 3 months (p=0.005). The relationship persisted after correction for the ICH score (OR 1.8 for mRS&gt;3 per point on Fazekas PV, 95% CI 1.02-3.2, p=0.04). Conclusion: Increased severity of LA in PV regions is an independent predictor of worse functional outcomes in patients after spontaneous ICH. The pathophysiology associating LA with worse outcomes requires further study. These data may improve prognostication and selection for clinical trials.

Predictors of Functional Outcome among Stroke Patients in Lima, Peru

Because of the aging population in low- and middle-income countries, cerebrovascular disease is expected to remain a leading cause of death. Little has been published about stroke in Peru. We conducted a retrospective cohort study of hospitalized stroke patients at a referral center hospital in Lima, Peru to explore factors associated with functional outcome among stroke patients. We identified 579 patients hospitalized for ischemic stroke or intracerebral hemorrhage stroke at the National Institute of Neurologic Sciences in Lima, Peru in 2008 and 2009. A favorable outcome was defined as a modified Rankin scale score of ≤ 2 at discharge. The mean age was 63.3 years; 75.6% had ischemic stroke; the average duration of stay was 17.3 days. At hospital discharge, 231 (39.9%) had a favorable outcome. The overall mortality rate was 5.2%. In multivariate models, the likelihood of having a favorable outcome decreased linearly with increasing age (P = .02) and increasing National Institutes of Health Stroke Scale (NIHSS) score (P = .02). Favorable outcome was also associated with male gender (relative risk [RR] 1.2; 95% confidence interval [CI] 1.0-1.5) and divorced status (RR 1.3; 95% CI 1.1-1.7). Patients on Salud Integral de Salud (SIS; public assistance-type insurance; RR 0.7; 95% CI 0.5-1.0) were also less likely to have a favorable outcome. Favorable outcome after stroke was independently associated with younger age, a lower NIHSS score, male gender, being divorced, and not being on SIS insurance. These findings suggest that additional study of worse functional outcomes in patients with SIS insurance be conducted and confirm the importance of risk adjustment for age, stroke severity (according to the NIHSS scale), and other socioeconomic factors in outcomes studies. Future studies should preferentially assess outcome at 30 days and 6 months to provide more reliable comparisons and allow additional study of Peruvian end-of-life decision-making and care.

Active tissue factor and activated factor XI in patients with acute ischemic cerebrovascular events

Elevated factor (F)XI and tissue factor (TF) have been reported to occur in patients with acute ischemic stroke (AIS). We sought to investigate whether circulating activated FXI (FXIa) and TF on admission can predict clinical outcomes in patients with acute cerebrovascular events. In the observational study, we evaluated 205 consecutive patients aged 70 years or less within the first 72 h of acute event, including 140 with AIS and 65 with transient ischemic attack (TIA). Plasma TF and FXIa activity were determined on admission in clotting assays by measuring the response to inhibitory monoclonal antibodies. Active TF and FXIa activity were detected in 58 (28·9%) and 132 (64·4%) patients on admission, respectively. Active TF was detected in 45 of the 136 AIS patients with available TF levels (33·1%) and 13 of the 65 patients with acute TIA (20%; 0·05). Corresponding values for FXIa were 99 of the 140 (70·7%) and 33 of the 65 (50·8%; P= 0·006), respectively. Patients with detectable TF were more frequently women and hypertensive, while subjects with detectable FXIa had more often diabetes and higher levels of fibrinogen, C-reactive protein and interleukin-6 (all P < 0·05). Patients with detectable FXIa but not TF had higher National Institutes of Health Stroke Scale score, higher modified Rankin scale score and lower Barthel Index at discharge (all P < 0·05). Circulating active TF and FXIa occur frequently in acute cerebrovascular ischemic events. Active FXIa in plasma might be useful as a novel risk marker of worse functional outcomes in patients with acute cerebrovascular events.

Optimal oxygenation during and after cardiopulmonary resuscitation

Reversal of tissue hypoxia, particularly in the heart and brain, is a fundamental goal of cardiopulmonary resuscitation. However, a growing body of evidence suggests that hyperoxia, especially after return of spontaneous circulation (ROSC), may worsen outcomes. The purpose of this review is to describe the current evidence supporting the concept of controlled oxygenation during and after cardiac arrest. Animal studies over the last two decades have built a compelling case that arterial hyperoxemia during the first hour after ROSC causes increased oxidative damage, increased neuronal death, and worse neurologic function. However, human data are limited. The only prospective randomized clinical trial comparing different inspired oxygen concentrations in post-cardiac arrest patients was underpowered to detect a difference in survival or neurologic outcome. More recently a retrospective analysis of data from a multicenter registry found that initial arterial hyperoxemia (paO2 ≥ 300 mmHg) was associated with increased mortality and worse functional outcome in patients admitted to the ICU after cardiac arrest. The existing evidence, though limited, has contributed to new guidelines for oxygen therapy in patients resuscitated from cardiac arrest. The benefit of supplemental oxygen during cardiopulmonary resuscitation remains uncertain. However, in patients who achieve ROSC after cardiac arrest, available evidence supports adjusting inspired oxygen content to avoid arterial hyperoxemia while providing adequate arterial oxyhemoglobin saturation. This strategy is likely to be most effective when initiated as soon as possible after ROSC and appears to be most important during the first hour. Definitive clinical trials are needed to determine the ultimate impact on outcome.

Is decompressive craniectomy useless in severe traumatic brain injury?

Recently, a multicenter randomized controlled trial (RCT) by Cooper and colleagues indicated that decompressive craniectomy (DC) may be associated with a worse functional outcome in patients with diffuse traumatic brain injury (TBI), although DC can immediately and constantly reduce intracranial pressure (ICP). As this trial is well planned and of high quality, the unexpected result is meaningful. However, the evidence of the study is insufficient and the effect of DC in severe TBI is still uncertain. Additional multicenter RCTs are necessary to provide class I evidence on the role of DC in the treatment of refractory raised ICP after severe TBI.

Emergency Department Hyperglycemia as a Predictor of Early Mortality and Worse Functional Outcome after Intracerebral Hemorrhage

We have previously reported the association of hyperglycemia and mortality after ischemic stroke. This study attempts to answer the hypothesis, if hyperglycemia at arrival, is associated with early mortality and functional outcome in patients with acute non-traumatic intracerebral hemorrhage (ICH). The study cohort consisted of 237 patients who presented to the ED with ICH and had blood glucose measured on ED presentation. The presence of hyperglycemia on presentation was correlated with outcome measures including volume of hematoma, intraventricular extension of hematoma (IVE), stroke severity, functional outcome at discharge, and date of death. Of the cohort of 237 patients, a total of 47 patients had prior history of Diabetes Mellitus (DM). Median blood glucose at presentation was 140 mg/dl (Inter-quartile range 112-181 mg/dl). DM patients had higher glucose levels on arrival (median 202 mg/dl for DM vs. 132.5 mg/dl for non-DM, P < 0.0001). Higher blood glucose at ED arrival was associated with early mortality in both non-diabetics and diabetics (P < 0.0001). Higher blood glucose was associated with poor functional outcome in non-DM patients(P < 0.0001) but not in DM patients (P = 0.268). In the logistic regression model, after adjustment for stroke severity, hematoma volume, and IVE of hemorrhage, higher initial blood glucose was a significant predictor of death (P = 0.0031); as well as bad outcome in non-DM patients (P = 0.004). Hyperglycemia on presentation in non-diabetic patients is an independent predictor of early mortality and worse functional outcome in patients with intracerebral hemorrhage.

Radiation Therapy After Radical Prostatectomy: Impact on Metastasis and Survival

Although secondary radiation therapy decreases the risk of biochemical progression after radical prostatectomy, its impact on metastasis and survival is less well established. We evaluated the impact of adjuvant and salvage radiotherapy on clinical progression and mortality. A total of 361 patients who received adjuvant radiation were matched based on clinicopathological features to patients who did not receive adjuvant radiation in a 2:1 case-control ratio. Postoperative survival was estimated using the Kaplan-Meier method and compared using the log rank test. A second cohort of 2,657 men who experienced biochemical recurrence after prostatectomy was separately evaluated. Cox proportional hazard regression models were used to analyze the impact of salvage radiotherapy on disease progression and survival. Adjuvant radiotherapy was associated with significantly improved 10-year biochemical recurrence-free survival (63% vs 45%, p <0.001), local recurrence-free survival (97% vs 82%, p <0.001) and a decreased need for late hormone therapy (17% vs 28%, p = 0.002) but did not impact systemic progression and overall survival (p = 0.94 and 0.27, respectively). Of the 2,657 patients who experienced biochemical recurrence after surgery 856 (32.3%) received salvage radiation. On multivariate analysis salvage radiotherapy decreased the risk of local recurrence (HR 0.13, 95% CI 0.06-0.28, p <0.0001) and delayed hormonal therapy (HR 0.81, 95% CI 0.71-0.93, p = 0.003) and systemic progression (HR 0.24, 95% CI 0.13-0.45, p <0.0001) but did not significantly impact mortality (p = 0.48). Adjuvant and salvage radiation provide long-term local control and decrease the need for delayed hormonal therapy but neither improves survival. These results must be weighed against the potential morbidity of postoperative radiation when counseling patients.

Hemodynamics of microvascular dysfunction in patients with anterior wall acute myocardial infarction

This study investigated whether the no-reflow phenomenon in acute myocardial infarction (AMI) is associated with an increase in coronary zero flow pressure (ZFP), a decrease in coronary arterial conductance, or both phenomena. Coronary blood flow velocity and pressure were measured with a Doppler guidewire and a pressure wire, respectively, during vasodilation with adenosine triphosphate after coronary intervention. The data indicate that the no-reflow phenomenon is not necessarily associated with a decrease in coronary arterial conductance but with an increase in ZFP. Greater ZFP is associated with more severe microvascular dysfunction and worse functional outcomes in patients with AMI.