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Biomedical subjects

Linda S Williams

Publications and source records attributed to Linda S Williams.

At least 19 recordsLinked to original sources
PubMed2006

Accuracy and yield of ICD-9 codes for identifying children with ischemic stroke.

The medical records of all children at our hospital with International Classification of Diseases 9th revision (ICD-9) codes 342, 433 to 438, or 767 from May 1999 to May 2004 were reviewed to assess whether they had stroke (any type) or, specifically, arterial ischemic stroke (AIS). Code accuracy ranged from 37 to 88%; each code missed more than half of AIS identified by the combined code search. Studies are needed to determine whether other local and national ICD-9 databases have similar limitations.

Brain Ischemia↗
PubMed2006

The impact of poststroke depression on healthcare use by veterans with acute stroke.

BACKGROUND AND PURPOSE: Poststroke depression (PSD) is common among stroke survivors, and it is associated with worse functional outcomes and increased poststroke mortality. Limited information is available about its impact on healthcare use. This study assessed the impact of PSD on healthcare use by veterans with acute stroke. METHODS: In this retrospective, observational national study, 5825 veterans with acute stroke were identified from Veterans Affairs' (VA) inpatient databases. To determine the patients' comprehensive PSD and use status, VA and Medicare fee-for-service inpatient and outpatient as well as VA pharmacy data were used. PSD was established if a patient had an inpatient or outpatient depression diagnosis or if a patient received one of the antidepressants within the VA 12 months postindex stroke. Healthcare use referred to the number of hospital stays, outpatient visits, and cumulative length of inpatient stays under both VA and Medicare fee-for-service programs. Poisson regression was fitted to estimate the impact of PSD on use controlling for sociodemographic, clinical, and disease severity factors. RESULTS: Forty-one percent of the sample had PSD. After adjusting for patient demographic and clinical factors, we found that the patients with stroke with PSD had significantly (P<0.0001) more hospitalizations, outpatient visits, and longer length of stays 12 months poststroke compared with these patients with stroke without PSD. CONCLUSIONS: Patients with PSD had greater 12-month poststroke healthcare use even when controlling for other demographic and clinical variables. Early detection and appropriate management of PSD for veterans with acute stroke may help reduce their poststroke healthcare use.

Acute Disease↗
PubMed2006

How valid are family proxy assessments of stroke patients' health-related quality of life?

BACKGROUND AND PURPOSE: Proxy respondents are often needed to report outcomes in stroke survivors, but they typically systematically rate impairments worse than patients themselves. The magnitude of this difference, the degree of agreement between patients and proxies, and the factors influencing agreement are not well known. METHODS: We compared patient and family proxy health-related quality of life (HRQL) responses in 225 patient-proxy pairs enrolled in a clinical trial for poststroke depression. We used paired t-tests and the intraclass correlation (ICC) statistic to evaluate the agreement between patient and proxy domain scores and the overall Stroke-specific Quality of Life (SS-QOL) score. We used multivariate linear regression to model patient- and proxy-reported SS-QOL scores. RESULTS: Patients were older (63 versus 55 years) and less often female (48% versus 74%) than proxies. Proxies rated all domains of SS-SQOL slightly worse than patients. The Mood, Energy, and Thinking domains had the greatest disparity with mean patient-proxy differences of 0.45, 0.37, and 0.37 points, respectively. The ICC for each domain ranged from 0.30 (role function) to 0.59 (physical function). Proxy overall SS-QOL score was also lower (worse) than patient score (3.7 versus 3.4, P<0.001) with ICC of 0.41. Agreement was higher among patient-proxy pairs with higher patient depression scores and with lower proxy report of caregiving burden. CONCLUSIONS: Proxies systematically report more dysfunction in multiple aspects of HRQL than stroke patients themselves. Agreement between patient and proxy HRQL domain scores is modest at best and is affected by patient depression and proxy perception of burden. These differences may be large enough to impact the outcome assessment in stroke clinical trials.

Affect↗
PubMed2006

Using change in the National Institutes of Health Stroke Scale to measure treatment effect in acute stroke trials.

BACKGROUND AND PURPOSE: Outcome measures in acute stroke trials are being refined. Changes in neurological deficits might be useful outcome measures because they can measure the entire spectrum of deficits. METHODS: We analyzed data from the acute stroke treatment trial Trial of Org 10172 in Acute Stroke Treatment (TOAST). Using logistic regression analysis, we modeled the probability of the TOAST predefined very favorable outcome (VFO; both Glasgow Outcome Scale 1 and modified Barthel Index 19 to 20) at 3 months. Within-subject changes (baseline-3 months) on the National Institutes of Health Stroke Scale (NIHSS) was the main predictor of interest. RESULTS: The baseline median NIHSS for the entire TOAST cohort was 7, and it improved by 4 points (interquartile range 3 to 6) among 603 patient with VFO and by 2 points (interquartile range -1 to 5) among 638 patients without a VFO (P<0.001). The odds for VFO increased by 2.29 (95% CI, 2.06 to 2.54; P<0.001) for each 1-point improvement on the NIHSS. In receiver operating characteristic analysis, final NIHSS < or =2 was a good predictor of VFO, but no single NIHSS change cut point was a good predictor of VFO. CONCLUSIONS: NIHSS change appears to be a useful outcome measure for acute stroke trials and is not fully comparable to dichotomized functional outcomes.

Acute Disease↗
PubMed2006

Cerebral sinovenous thrombosis in the neonate.

BACKGROUND: There are few studies on neonatal cerebral sinovenous thrombosis (SVT). OBJECTIVES: To describe the presentations, treatments, and outcomes of neonatal SVT and to assess infarction as a predictor of outcome. DESIGN: Retrospective chart study. SETTING: A tertiary pediatric hospital in Indianapolis, Ind. Patients Forty-two children with neonatal SVT identified using International Classification of Diseases, Ninth Revision code searches from 1986 through June 2005 and review of neurology clinic records. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Cognitive impairment, motor impairment, and epilepsy at last clinic visit. RESULTS: Gestational or delivery complications or risk factors and comorbid conditions such as dehydration, sepsis, and cardiac defects were common (gestational/delivery factors in 82% [31 of 38 with available maternal data]; comorbid conditions in 62% [26 of the 42]). Twenty-four (57%) presented with seizures. Twenty-five (60%) had infarcts, which were hemorrhagic in 22. Only 27 (64%) of 42 received prothrombotic evaluations; none had persistent deficiencies of protein C, protein S, or antithrombin III. Three (7%) received heparin sodium. All other children received only supportive care. One child died. Outcome data were available for 29 (71%) of the 41 survivors; of these, 23 (79%) had impairment(s). Two were known to be in early intervention, and no further information was available. Of the remaining 27, 16 (59%) had cognitive impairment, 18 (67%) had cerebral palsy, and 11 (41%) had epilepsy. Infarction was associated with the presence of later impairment (P = .03). CONCLUSIONS: The presentation of neonatal SVT is often nonspecific, the diagnosis can be difficult to make, treatment beyond supportive care is rarely used, and outcomes can be severe. Further work is needed to develop standardized guidelines for the evaluation and treatment of neonatal SVT.

Female↗
PubMed2006

Family history is a poor screen for prothrombotic genes in children with stroke.

OBJECTIVE: To evaluate family history of early pathological thrombosis as a screen for genetic prothrombotic risk factors in children with stroke. STUDY DESIGN: A 5-year retrospective review of standardized pediatric stroke clinic evaluations of children with arterial ischemic stroke (AIS) or sinovenous thrombosis (SVT). A family history of early pathological thrombosis was defined as stroke, heart attack, or deep venous thrombosis before 50 years of age or multiple miscarriages in the parents or grandparents of the patient. We evaluated the association between family history and the presence of the Factor V Leiden mutation (FVL) and/or Prothrombin G20210A mutation (PTG) in these children. RESULTS: The study included 68 children. Thirteen (19.1%) had a positive family history of early pathological thrombosis, nine (13.2%) were heterozygous for FVL, and one (1.5%) was heterozygous for PTG. Family history was not associated with the presence of FVL (p = .36) or FVL combined with PTG (p = .40). For FVL, family history had a positive predictive value of 23.1% and a negative predictive value of 89.1%. CONCLUSION: A family history of early thrombosis is not associated with the presence of FVL or PTG in children with stroke. We recommend that all children with stroke receive a prothrombotic workup regardless of family history.

Adolescent↗
PubMed2006

Outcomes of children with infantile spasms after perinatal stroke.

The object of this study was to describe the outcomes of children with infantile spasms resulting from perinatal stroke. We used International Classification of Diseases, Ninth Revision (ICD-9) searches of billing records to identify 110 children with infantile spasms examined at our hospital from 1998 through 2005. Five of the 99 with symptomatic spasms (5%) had perinatal stroke. An additional five children with spasms caused by perinatal stroke were identified from pediatric stroke clinic records. Seven of the 10 children with spasms due to perinatal stroke presented with stroke as neonates. Three initially appeared healthy but were diagnosed with "presumed perinatal stroke" after radiographic imaging for their spasms evaluation. Median age at last follow-up was 6.3 years: 9 (90%) had epilepsy, 8 (80%) manifested cognitive impairment, and all (100%) had cerebral palsy. The three children who had delayed presentation of "presumed perinatal stroke" had better epilepsy and cognitive outcomes than the seven with neonatal presentation (P = 0.03). Perinatal stroke accounts for 5% of symptomatic spasms and results in high rates of chronic disability similar to those observed with other types of symptomatic spasms. However, a subgroup of children with spasms caused by delayed presentation of "presumed perinatal stroke" appears to have better epilepsy and cognitive outcomes.

Adolescent↗
PubMed2006

Perinatal stroke in twins without co-twin demise.

Perinatal stroke in twins without co-twin demise has not been well-described. In this study, the International Classification of Diseases- 9th edition code searches and medical record review were used to identify all children with arterial ischemic stroke examined in a pediatric stroke clinic over a 2-year period. Four of the 35 children (11.4%) with perinatal arterial ischemic stroke were twins; none had co-twin demise. No co-twin had any clinical evidence of perinatal stroke. The most common findings on prothrombotic evaluation were elevated antiphospholipid antibodies (2), elevated lipoprotein a (2), and elevated Factor VIIIc (2). Twin gestation without co-twin demise may be a risk factor for perinatal stroke, and might help explain the higher incidence of cerebral palsy in twins.

Child, Preschool↗
PubMed2005

Perinatal stroke in baby, prothrombotic gene in mom: does this affect maternal health insurance?

BACKGROUND: Maternal prothrombotic disorders may contribute to stroke in the fetus before and during birth. Many of the mothers of children with perinatal stroke have no previous history of pathologic thrombosis. OBJECTIVE: To determine if finding the Factor V Leiden mutation, prothrombin 20210 G-A gene defect, or methylene tetrahydrofolate reductase C677T mutation in an asymptomatic mother of a child with perinatal stroke would affect that mother's ability to obtain health insurance. METHODS: 1) The authors reviewed the literature on genetic prothrombotic risk factors and health insurance. 2) The authors surveyed the 17 largest insurance carriers in Indiana to find if diagnosing genetic prothrombotic risk factors in asymptomatic mothers of children with perinatal stroke would affect the mothers' health insurance status. RESULTS: Three articles on genetic prothrombotic risk factors and insurance were identified. Twelve of 17 insurance companies responded to our survey; three had policies on genetic testing. Most companies refused to provide clear, useful information on their policies regarding these risk factors. CONCLUSIONS: The authors are currently unable to counsel their patients' families on the long-term insurance implications of screening for genetic prothrombotic risk factors. The insurance implications of diagnosing healthy women with genetic prothrombotic risk factors need further study.

Blood Coagulation Disorders↗
PubMed2005

Performance of the PHQ-9 as a screening tool for depression after stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to examine the performance of the Patient Health Questionnaire (PHQ)-9, a 9-item depression scale, as a screening and diagnostic instrument for assessing depression in stroke survivors. METHODS: As part of a randomized treatment trial for poststroke depression (PSD), subjects with and without PSD completed the PHQ-9, a 9-item summed scale, with scores ranging from 0 (no depressive symptoms) to 27 (all symptoms occurring daily). Subjects endorsing 2 or more symptoms of depression were administered the criterion standard Structured Clinical Interview for Depression (SCID). Receiver operating characteristic analysis was used to examine the sensitivity and specificity of the PHQ-9 RESULTS: Of 316 subjects enrolled, 145 met SCID criteria for major depression or other depressive disorder, and 171 were not depressed. PHQ-9 scores discriminated well between subjects with any versus no depressive disorder, with an area under the curve (AUC) of 0.96, as well as between subjects with and without major depression (AUC=0.96). The AUC was similar regardless of patient age, gender, or ethnicity. A PHQ-9 score > or =10 had 91% sensitivity and 89% specificity for major depression, and 78% sensitivity and 96% specificity for any depression diagnosis. CONCLUSIONS: The PHQ-9 performs well as a brief screener for PSD with operating characteristics similar or superior to other depression measures and similar to its characteristics in a primary care population. Moreover, PHQ-9 scores discriminate equally well between those with and without PSD regardless of age, gender, or ethnicity.

Depression↗
PubMed2005

Ethnic disparities in stroke: epidemiology, acute care, and postacute outcomes.

BACKGROUND AND PURPOSE: Evidence for ethnic disparities in stroke incidence, severity, and mortality has continued to mount in recent years. However, the picture for disparities in acute management and rehabilitation remains more ambiguous. The objective of this report is to summarize current evidence from stroke epidemiology and studies focusing on disparities in stroke care and disability, suggesting courses for action. METHODS: A comprehensive search of current literature on ethnic/racial variation in stroke incidence, mortality, and severity, as well as acute and postacute patient care was performed. RESULTS: Recent evidence unambiguously reaffirms a greater burden of disease in stroke, greater mortality, and greater severity of strokes for blacks. Evidence for disparities in acute and postacute care is less conclusive, as is the evidence for disparities among other ethnic groups. Evidence for health disparities in stroke care across settings, regions, and the continuum of care varies considerably. CONCLUSIONS: Minority ethnic groups have higher rates or more severe stroke, but variations in prognosis for clinical outcomes other than mortality remain less certain. There is considerable need for more studies that take into account regional ethnic variations in treatment and outcomes, and for better documentation of stroke outcomes among groups in addition to blacks. Dealing with ethnic disparities in stroke will be served by sustained attention to quality improvement in high-impact areas in stroke care, complemented by initiatives that promote cultural competence.

Aged↗
PubMed2005

Depression and stroke: cause or consequence?

Depression after stroke is common. Although different opinions exist about the definition, diagnosis, and measurement of outcomes related to depression after stroke, there is little debate about the prevalence of depression symptoms and their impact on stroke survivors and their families. Depression after stroke has long been recognized as a common condition with many negative effects in the poststroke period, but more recently depression has also been identified as an independent stroke risk factor. Given that there are at least 500,000 new ischemic strokes yearly in the United States, a conservative estimate is that 150,000 U.S. stroke survivors develop poststroke depression each year. Because effective treatments exist but are likely underutilized for depression, this is an important example of an evidence-practice gap to which increased efforts to improve care should be made. Such efforts would likely improve not only patient symptoms but may also decrease stroke risk, influence stroke functional recovery, decrease mortality, and reduce poststroke health care utilization. This article provides an overview of depression diagnosis in stroke, reviews the epidemiology of poststroke depression and its associated morbidity and mortality, and reviews existing evidence on the treatment and prevention of poststroke depression.

Caregivers↗
PubMed2005

Depression and other mental health diagnoses after stroke increase inpatient and outpatient medical utilization three years poststroke.

OBJECTIVE: Poststroke depression (PSD) has been linked to negative outcomes, including mortality and decreased functioning. However, the effect of PSD and other mental health conditions on inpatient and outpatient healthcare utilization after stroke has not been examined. The primary objective of this study was to evaluate the relationship between PSD and healthcare utilization after stroke. The secondary objective was to evaluate the relationship between other mental health diagnoses and medical utilization after stroke. METHOD: We examined 3 years of poststroke healthcare utilization data in a national cohort of veterans with ischemic stroke. Mental health diagnoses were identified with inpatient International Classification of Diseases, 9th Revision codes. Multivariate analysis of variance was used to compare patient characteristics and multivariate linear regression to model utilization in: 1) patients with PSD, 2) patients diagnosed with other mental health conditions poststroke, and 3) patients with no mental health diagnosis. RESULTS: Of 51,119 veterans identified, 2405 (5%) received a PSD diagnosis and 2257 (4%) received a diagnosis of another mental health condition after their stroke. Patients with PSD had significantly more inpatient hospitalization days and outpatient visits than those without any mental health diagnosis, even after adjusting for the number of mental health clinic visits. Likewise, patients diagnosed with other mental health diagnoses had greater medical utilization than patients without any mental health diagnosis. Both PSD and other mental health diagnoses independently predicted medical utilization. CONCLUSION: Mental health diagnosis after stroke increases inpatient and outpatient healthcare utilization in the first 3 years poststroke. Additional biologic and psychosocial factors should be investigated.

Aged↗
PubMed2004

Measuring gross motor recovery in young children with early brain injury.

Motor outcome measures may be used in both research and clinical practice. Although many motor outcome measures exist, only a small subset are suitable for use in children, and an even smaller subset is suitable for use in children under the age of 5 years who are undergoing rapid motor development. In this article, the issues involved in choosing an outcome measure are reviewed, and four of the most common gross motor outcomes measures used in young children are discussed.

Brain Diseases↗