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PubMed1995

Factors influencing users' return home on discharge from a geriatric intermediate care facility in Japan.

OBJECTIVES: To determine the factors that influence users' destinations on discharge from Geriatric Intermediate Care Facilities (GICFs), which were established in Japan in 1987 to help hospitalized older people return home. DESIGN: Retrospective chart review. SETTING: A 94-bed GICF attached to Saku Central Hospital in Japan. SUBJECTS: Charts of all users (N = 437) aged 65 years and older, discharged from the GICF between July 1987 and February 1991, were reviewed. MEASUREMENTS: The independent variables, obtained from users' admission records, were age, sex, place of residence before admission, length of stay, intellectual impairment (assessed by Karasawa's diagnostic criteria for senile dementia), ability to perform activities of daily living (ADLs), and living arrangement of users in the GICF. The dependent variable was destination after discharge from the GICF. MAIN RESULTS: Multiple logistic regression analyses revealed that, compared with users who were able to successfully return home, users with little ability to perform ADLs, male users, and those admitted from other institutions were more likely to be hospitalized. Such analyses also revealed that users who came from institutions, had low ability to perform ADLs, and lived alone were more likely to be institutionalized in nursing homes. CONCLUSIONS: Evaluating a user's physical, mental, and socioeconomic conditions at an early stage of admission to a GICF may allow us to predict whether the user can be successfully discharged to his or her home or will have to remain in the GICF for an extended period.

Activities of Daily Living↗
PubMed1997

Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit.

OBJECTIVES: To compare outcomes (physical functions and discharge destinations) of cognitively impaired and intact older hip fracture patients, and to identify cognitive skills related to functional gains. DESIGN: Prospective longitudinal study of hip fracture patients treated on an acute inpatient rehabilitation service, with evaluation of functional performance and living status determined at admission and discharge. SETTING: A specialized inpatient geriatric rehabilitation program at Wesley Woods Geriatric Hospital, which is affiliated with Emory University School of Medicine. SUBJECTS: Fifty-eight hip fracture patients, 35 with and 23 without cognitive impairment. MEASUREMENTS: Cognitive functioning measured by the Mattis Dementia Rating Scale (MDRS); functional outcome assessed by the Functional Independence Measure (FIM); comparison of pre-fracture with discharge living environments. MAIN RESULTS: Both cognitively impaired and intact hip fracture patients exhibited similar overall FIM motor improvements as well as functional gains in specific FIM areas measuring self-care, sphincter control, and locomotion (e.g., walking). Cognitively intact patients, however, displayed significantly greater gains in mobility (e.g., transfers) at discharge. Cognitively impaired patients who lived in the community were as likely as intact patients to return to the community. Patients who entered the program at a modified dependence level (FIM 3-5) and achieved motor independence at discharge (FIM 6-7) had higher MDRS initiation/ perseveration and memory scores. CONCLUSIONS: Hip fracture patients with cognitive impairments can achieve positive outcomes as defined by functional improvement and discharge destination. Intensive post-fracture rehabilitation in the early phase of recovery may promote functional independence and a return to the community for older patients at risk for nursing home placement. Future research should examine the long-term maintenance of these improvements and explore how rehabilitation interventions can be altered to enhance outcome.

Aged↗
PubMed1994

Specialized Travel Consultation Part I: Travelers' Prior Knowledge.

Studies have shown that more than one third of all travelers to tropical countries experience an illness while abroad. Naiveté about diseases, such as malaria, travelers' diarrhea, cholera, and HIV infections, appears to be the most crucial factor determining travel-related morbidity rates. A study was designed both to evaluate the level of disease-related, pretravel knowledge prior to a specialized travel clinic consultation as well as to correlate the level of knowledge with demographic and travel variables and previous travel experience. Using a self-administered questionnaire, data were collected from 167 clients who attended the Hospital for Tropical Diseases Travel Clinic, London, England, in June 1991. The questionnaire evaluated clients' knowledge and attitudes of travel-related diseases, their prevention and treatment, and the scores were analyzed using the Statistical Analysis System software, Version 5. Predictors for increased knowledge scores were examined by a one-way layout model comparing disease knowledge scores with variables such as sex, age, socioeconomic class, ethnic background, previous travel experience, type and duration of travel, destination, accommodation quality, and health insurance coverage. A step-down regression model was constructed to control for the effects of the many mutually confounding factors. Travelers' diarrhea and malaria risk at destination were acknowledged by more than 85% of the respondents, and 60% of the questions on travelers' diarrhea prevention, compared to 81% of those on malaria prevention, were answered correctly. Significantly, however, only one half of the respondents indicated that they would take appropriate measures concerning diarrhea while abroad. Stepwise regression identified previous travel experience, pretravel advice, traveling for work purposes, and using backpack overland tours as significant predictors of high knowledge. This study points out the necessity of pretravel education and that it should focus not only on malaria but also on other travel-related diseases like travelers' diarrhea. As well, target groups for whom more detailed information should be provided are identified, including inexperienced travelers, those using organized tours and sleeping indoors, those planning to visit friends or relatives, and those who have not received sufficient pretravel health advice.

Journal Article↗
PubMed1994

Recommendations for Prevention of Hepatitis A Based on a Cost-Effectiveness Analysis.

Hepatitis A viral infection poses a substantial risk for travelers from low-endemic countries visiting high-endemic destinations. In this study, the general indications for the optimal prevention of hepatitis A are derived using a cost-effectiveness analysis based on the risk exposure determined by frequency and duration of travel as well as natural immunity. Three possible hepatitis A prevention strategies are compared to no prophylaxis: active immunization; an initial screening for HAV followed by active immunization of susceptible travelers; and passive immunization with immune globulins. Using a number of baseline assumptions, a scenario for travel from low- to high-endemic countries and an average travel duration and frequency rate, threshold values were obtained comparing active versus passive immunization. The study shows that, for travelers not expected to journey more than twice in a 10-year period, passive immunization is the most cost-effective prophylaxis for travel from both very-low or low-to-high endemic areas. For more frequent travel, vaccination is more cost effective, as well as for journeys of 6-months' duration or longer. As well, pretravel screening before vaccination was shown to be worthwhile, except when the probability of natural immunity is low. As the results indicate, the cost effectiveness of a strategy is related to several considerations: the prices of vaccine and screening tests, travel destinations and endemic conditions, frequency and duration of travel, and natural immunity. A decision-tree-based simulation model is helpful in determining the strategy to employ.

Journal Article↗
PubMed1997

Travel Health Advice Provided by In-flight Magazines of International Airlines in Australia.

More than 3 million Australians travel overseas each year, and the most popular destination for these Australian travelers is Asia. Many of the countries in the Asian region are developing, and travelers to such countries may encounter tropical illness or serious injury, particularly diarrheal disease and motor vehicle accidents.1 The latter is the most common preventable cause of death in travelers.2 These problems are in addition to some of the potential problems associated with international flights, such as swelling feet, dehydration, jet lag, and venous thrombosis. There are a number of media through which travelers could receive travel health advice. However, a study of travel agent brochures by Reid et al.3 indicated that about one-third of these carried no travel health advice, with most of those that did carry travel advice providing only general information. Airline magazines also represent a possible source of in-flight and destination-specific travel health advice to which most travelers would have access.

Journal Article↗
PubMedDate not supplied

Imported malaria in Jakarta, Indonesia: passive surveillance of returned travelers and military members postdeployment.

BACKGROUND: Autochthonous malaria does not currently occur in Jakarta, the most populous city in Indonesia. Military, forestry, mining, and tourist activities draw Jakarta residents to distant parts of the archipelago with high rates of malaria. Although malaria is a reportable disease in Jakarta, little has been published. METHODS: We collected demographic and travel information from patients in Jakarta with microscopically confirmed malaria from January 2004 to February 2005, using a standardized data collection form. These results were compared to regional rainfall statistics and transit patterns of Jakarta residents to and from rural areas. RESULTS: Data from 240 patients were collected. Aceh Province was the travel destination most commonly recorded for military members, while Papua and Bangka Island were the most frequently cited by civilians. Plasmodium falciparum accounted for 53% of cases, of which 15% had detectable gametocytemia. The most common admission diagnoses were malaria (39%), febrile illness not otherwise specified (23%), viral hepatitis (19%), and dengue (11%). The median time from admission to microscopic diagnosis was 2 days for civilian patients and 2.5 days for military patients. The highest number of cases occurred in May, July, and December with the nadir in October. CONCLUSIONS: The diagnosis of malaria may be overlooked and therefore delayed, in nonendemic areas such as Jakarta. Travel destinations associated with contracting malaria vary significantly for civilian and military populations. The factors affecting the peak months of importation likely include rainfall, holiday transit, military flight availability, and referral center locations.

Adult↗
PubMedDate not supplied

Ultrasonographic diagnosis of ovine cystic echinococcosis.

The sanitary and economic impact of cystic echinococcosis is serious in those countries where it becomes endemic. Ultrasonography is one technique that may be used to diagnose this disease in endemic areas. In parasitized sheep, hydatid cysts appear sonographically as a round hypoechoic structure. Twenty two sheep destined for slaughter were studied sonographically and imaging findings compared to post-mortem findings. Three sheep with hydatid cysts were identified. Eighty additional sheep not destined for slaughter were also studied. Echinococcus granulosus cysts were detected in three animals. Forty sheep from a non-endemic area had no hepatic cysts. The in vivo sonographic study of sheep provides a useful screening tool for echinococcosis.

Animals↗
PubMedDate not supplied

An evolving continuous quality improvement role for managed care: a behavioral healthcare perspective.

Managed care's initial continuous quality improvement impact may have been comparable to the sentinel, or Hawthorne, effect. Managed behavioral healthcare's CQI role can be compared with that of the clinical navigator. The clinical navigator attempts to develop a consensus with the patient on what is the clinical destination, and must choose a route to travel that is the best approach to reach the destination (i.e., a focused treatment plan). In addition, the clinical navigator tries to find the most efficient mode of travel--or, the least restrictive, least intrusive site of care from where the patient can receive treatment. Essential clinical tasks or expectations in the clinical assessment are also outlined, and the concept of knowledge coupling is introduced to accommodate the unique, individual issues of the patient. The emphasis of managed care today is shifting to further accentuate a CQI, outcomes-based approach.

Efficiency, Organizational↗
PubMed1983

Patterns of innervation of neurones in the inferior mesenteric ganglion of the cat.

The patterns of peripheral and central synaptic input to non-spontaneous, irregular discharging and regular discharging neurones in the inferior mesenteric ganglion of the cat were studied in vitro using intracellular recording techniques. All three types of neurones in rostral and caudal lobes received central synaptic input primarily from L3 and L4 spinal cord segments. Since irregular discharging neurones received synaptic input from intraganglionic regular discharging neurones, some of the central input to irregular discharging neurones may have been relayed through the regular discharging neurones. In the rostral lobes of the ganglion, more than 70% of the non-spontaneous and irregular discharging neurones tested received peripheral synaptic input from the lumbar colonic, intermesenteric and left and right hypogastric nerves. Most of the regular discharging neurones tested received synaptic input from the intermesenteric and lumbar colonic nerves; none of the regular discharging neurones received synaptic input from the hypogastric nerves. Some of the peripheral synaptic input from the lumbar colonic and intermesenteric nerves to irregular discharging neurones may have been relayed through the regular discharging neurones. Axons of non-spontaneous and irregular discharging neurones located in the rostral lobes travelled to the periphery exclusively in the lumbar colonic nerves. Antidromic responses were not observed in regular discharging neurones during stimulation of any of the major peripheral nerve trunks. This suggests these neurones were intraganglionic. In the caudal lobes, irregular discharging neurones received a similar pattern of peripheral synaptic input as did irregular discharging neurones located in the rostral lobes. The majority of irregular discharging neurones in the caudal lobes projected their axons to the periphery through the lumbar colonic nerves. Non-spontaneous neurones in the caudal lobes, in contrast to those located in the rostral lobes, received peripheral synaptic input primarily from the hypogastric nerves. Axons of the majority of non-spontaneous neurones located in the caudal lobes travelled to the periphery through hypogastric nerves. The results suggest that non-spontaneous neurones and irregular discharging neurones in the rostral lobes and the majority of irregular discharging neurones in the caudal lobes transact and integrate neural commands destined for abdominal viscera supplied by the lumbar colonic nerves. Non-spontaneous neurones in the caudal lobes transact and integrate neural commands destined for pelvic viscera supplied by the hypogastric nerves.

Action Potentials↗
PubMed1974

Neurons in rhesus monkey visual cortex: systematic relation between time of origin and eventual disposition.

Autoradiographic evidence after injection of tritiated thymidine indicates that cell position in the laminae of the monkey visual cortex is systematically related to time of cell orgin. The earliest-formed neurons, destined for the deepest stratum, arise at about embryonic day 45, and the last ones, destined for the outermost cell stratum, form at about day 102; cells of intervening layers are generated at intervening times. No neocortical neurons are produced in the last two prenatal months or after birth. Compared to cortical neurons in rodents, those in the monkey arise earlier, and the "inside-out" relation of cell position to time of origin is more rigid.

Animals↗
PubMed1981

Effect of fructose and other carbohydrates on the surface properties, lipoteichoic acid production, and extracellular proteins of Streptococcus mutans Ingbritt grown in continuous culture.

Streptococcus mutans Ingbritt was grown in a chemostat at destined dilution rates in either 0.5% fructose or 0.5% sorbitol and at destined pH values in 0.5% fructose. The yield of cells was affected by the carbohydrate source, as well as by the pH, with the lowest yield being at pH 5.5 in 0.5% fructose. Fructose-grown cells showed greater susceptibility to lysis by a muramidase than the corresponding glucose-grown cells, but there were no marked differences in the lytic susceptibilities of the corresponding cell wall preparations or in the serological reactivities of wall lysates with antiserum to S. mutans Ingbritt. The greatest amounts of cellular lipoteichoic acid were obtained at high dilution rates in both fructose and sorbitol, as well as at high pH values in fructose. The greatest amounts of extracellular lipoteichoic acid were found at low dilution rates, as estimated by rocket immunoelectrophoresis and also by hemagglutination. Three major extracellular protein components were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and the effects of growth conditions on these components were determined. Results for batch-grown cultures showed that there was genotypic variation in the susceptibility of cells to lysis by a muramidase. The enhancement of lipoteichoic acid production by fructose and sorbitol in batch cultures was not identical in representative strains of S. mutans serotype c, nor was the effect of fructose found uniformly in representative strains of the different S. mutans serotypes.

Bacterial Proteins↗
PubMed1993

Signal sequence processing is required for the assembly of LamB trimers in the outer membrane of Escherichia coli.

Proteins destined for either the periplasm or the outer membrane of Escherichia coli are translocated from the cytoplasm by a common mechanism. It is generally assumed that outer membrane proteins, such as LamB (maltoporin or lambda receptor), which are rich in beta-structure, contain additional targeting information that directs proper membrane insertion. During transit to the outer membrane, these proteins may pass, in soluble form, through the periplasm or remain membrane associated and reach their final destination via sites of inner membrane-outer membrane contact (zones of adhesion). We report lamB mutations that slow signal sequence cleavage, delay release of the protein from the inner membrane, and interfere with maltoporin biogenesis. This result is most easily explained by proposing a soluble, periplasmic LamB assembly intermediate. Additionally, we found that such lamB mutations confer several novel phenotypes consistent with an abortive attempt by the cell to target these tethered LamB molecules. These phenotypes may allow isolation of mutants in which the process of outer membrane protein targeting is altered.

Bacterial Outer Membrane Proteins↗
PubMed1994

The regulation of competence transcription factor synthesis constitutes a critical control point in the regulation of competence in Bacillus subtilis.

comK, which encodes the competence transcription factor, is itself transcriptionally activated at the transition from exponential growth to stationary phase in Bacillus subtilis. MecA, a negative regulator of competence, also inhibits comK transcription when overexpressed, and a mecA null mutation results in comK overexpression. Although null mutations in mecA, as well as in another gene, mecB, are known to bypass the requirements for nearly all of the competence regulatory genes, the comK requirement is not suppressed by mecA inactivation. Various competence regulatory genes (comA, srfA, degU, abrB, sin, and spo0A) are shown to be required for the expression of comK. srfA transcription is shown to occur equally in cells destined for competence and those destined not to become competent. In contrast, comK transcription is restricted to the presumptive competent cells. These and other results are combined to describe a regulatory pathway for competence.

Bacillus subtilis↗
PubMed1968

Utilization of exogenous and endogenous ornithine by Neurospora crassa.

Through the use of a mutant deficient in ornithine-delta-transaminase (OTA), it is shown that this enzyme normally has no obligate or even major biosynthetic role in Neurospora. The pathways of ornithine and proline synthesis proceed wholly independently of each other in OTA-less strains. It is probable that OTA functions as an enzyme of arginine catabolism. With mutants affected in OTA, ornithine transcarbamylase, and the synthesis of ornithine, it was demonstrated that exogenous and endogenous ornithine are utilized in different ways. Exogenous ornithine is destined mainly for catabolism, whereas endogenous ornithine is destined mainly for biosynthesis. It is suggested that this distinction depends upon differences in the intracellular location or origin of the two sources of ornithine.

Arginine↗
PubMed2003

Loss of the perforin cytotoxic pathway predisposes mice to experimental cytomegalovirus retinitis.

AIDS-related human cytomegalovirus (HCMV) retinitis continues to be a chronic ophthalmologic problem among human immunodeficiency virus type 1 (HIV-1)-infected patients who do not respond to highly active antiretroviral therapy. Although HCMV retinitis occurs during HIV-1-induced immunosuppression, the precise effector mechanism(s) that fails during the immunopathogenesis of AIDS to allow onset and progression of HCMV retinal disease remains unclear. We therefore performed a series of experiments to explore the relative roles of distinct pathways of lymphocyte-mediated cytotoxicity in either resistance or susceptibility to experimental murine cytomegalovirus (MCMV) retinitis in mice. Whereas mutant C57BL/6 mice deficient in the Fas/FasL cytotoxic pathway (gld mice) were identical to normal C57BL/6 mice and exhibited absolute resistance to retinal necrosis following subretinal MCMV inoculation, knockout C57BL/6 mice deficient in the perforin cytotoxic pathway (PKO mice) were susceptible to MCMV retinitis. Susceptibility of PKO mice to MCMV retinitis correlated with increased ocular MCMV titers when compared with ocular MCMV titers of gld and normal mice. Since mice with retrovirus-induced immunodeficiency syndrome (MAIDS) exhibited a frequency and severity of MCMV retinitis that were equivalent to those observed in PKO mice, we hypothesized that susceptibility to MCMV retinitis during MAIDS correlates with a decrease in the perforin cytotoxic pathway. To test this hypothesis, we developed a quantitative competitive reverse transcription-PCR assay to measure mouse perforin mRNA levels in the splenic T lymphocytes and MCMV-inoculated eyes of normal mice or mice with MAIDS. Perforin mRNA levels in splenic T lymphocytes were significantly decreased during MAIDS, by approximately 100-fold, from perforin mRNA levels in normal mice. Moreover, MCMV-inoculated eyes destined to develop retinitis during MAIDS also showed a significant decrease in perforin mRNA levels from the perforin mRNA levels of MCMV-inoculated eyes of normal mice destined to be resistant to retinitis. As expected, perforin mRNA could not be detected in unmanipulated and uninfected eyes of normal mice. These results provide the first evidence that the perforin cytotoxic pathway is more important than the Fas/FasL cytotoxic pathway in providing resistance to experimental MCMV retinitis and that loss of the perforin cytotoxic pathway predisposes to MCMV retinitis.

Animals↗
PubMed2002

Importance of emergency identification schemes.

BACKGROUND: Millions of people worldwide may have a hidden medical condition that could endanger their life in an emergency. These conditions may include cardiac conditions, severe allergies, or diabetes. Emergency identification schemes such as Medic Alert produce emblems that alert health care professionals to potential problems and can ensure appropriate and prompt treatment. This paper uses mechanical failure of the Björk-Shiley convexo-concave (BSCC) heart valve as an example of a hidden medical condition. These patients have been encouraged to carry information to alert staff in an emergency that they have a BSCC patient in their care and to be alert to the signs and symptoms of acute valve malfunction. OBJECTIVE: To establish awareness and credibility of emergency identification schemes among emergency personnel and to assess if information on specific medical conditions would influence ambulance personnel regarding destination hospitals. METHODS: Questionnaires were sent to senior staff (n=380) of accident and emergency (A&E) departments and operational directors of ambulance headquarters (n=39) throughout the United Kingdom. Hospitals were divided into regional divisions to assess differences in responses across regions. RESULTS: The majority of respondents (99%) had heard of emergency identification schemes and felt that it was important for patients with special conditions to carry some form of identification. Nearly all ambulance respondents (97%) indicated it was routine to search for body worn emblems in contrast with only 71% of A & E staff. However, more than half of ambulance respondents (53.9%) stated information on emblems/cards would not influence their choice of destination hospital. CONCLUSIONS: The importance of how information on pre-existing medical conditions can influence care, is highlighted by the BSCC valve issue, where immediate diagnosis is essential for patient survival. It is vital that all staff routinely search patients for this information and if necessary act upon the information provided.

Emergency Medical Services↗
PubMed2006

Adult patients with Eisenmenger syndrome report flying safely on commercial airlines.

BACKGROUND: Despite fears of compromised oxygen delivery in patients with Eisenmenger syndrome during flight on commercial aircraft, a clinical study has shown no adverse effects, and many patients travel frequently. METHODS: The air travel history over the past decade of 53 patients with Eisenmenger syndrome and 48 acyanotic patients was obtained. Patients listed all flights and destinations, and any major adverse event or symptoms, including, specifically, headache, palpitations, oedema or need for supplemental oxygen. For the patients with Eisenmenger syndrome, a full blood count, 6-minute walk test and p50 of the oxygen-haemoglobin dissociation curve were also obtained. RESULTS: 1157 flights were reported evenly between the two groups. Thirteen patients with Eisenmenger syndrome reported no travel in the past 10 years (vs 4/48 acyanotic patients, p = 0.03), six of whom were told not to fly by healthcare providers. Of those who flew, the number and distance of flights was similar in both groups. No major adverse events were reported. One patient with Eisenmenger syndrome possibly had a transient ischaemic attack and a second patient needed supplemental oxygen when exposed to ambient cigarette smoke in flight. Other symptoms such as headache, palpitations and lower extremity oedema at the travel destination were reported with similar frequency in both groups. Patients with Eisenmenger syndrome had a raised p50 of the oxygen-haemoglobin dissociation curve (mean (SD) 29.4 (2.6) mm Hg vs 27 (3) mm Hg in laboratory controls, p<0.01). CONCLUSIONS: Patients with Eisenmenger syndrome report travelling frequently and safely on commercial airlines. Shifts in the oxygen-haemoglobin dissociation curve are likely to attenuate the effects of low oxygen tension. Patients with Eisenmenger syndrome should, nevertheless, be advised to avoid inactivity and dehydration as usual, but there is no justification for limiting air travel.

Adult↗
PubMed2002

Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study.

OBJECTIVES: The debate on the timing of aneurysm surgery after subarachnoid haemorrhage (SAH) pivots on the balance of the temporal risk for fatal rebleeding versus the risk of surgical morbidity when operating early on an acutely injured brain. By following a strict management protocol for SAH, the hypothesis has been tested that in the modern arena of treatment for aneurysmal SAH the timing of surgery to secure supratentorial aneurysms does not affect surgical outcome. METHODS: Over a 6 year period, patients admitted with a diagnosis of SAH to a regional neurosurgical unit have been prospectively studied. All have been on a management protocol in which early transfer and resuscitation has been followed regardless of age and clinical condition. Angiographic investigation and surgery have been pursued in those who have been able to at least flex to pain. A total of 1168 patients (60.7% female, mean age 54.3) with proved SAH were received on median day 1 (86.4% arrived within 3 days) of the ictus. Of these, 784 (67.1%) showed aneurysms on angiography and were prepared for surgery. Those who received surgery for a supratentorial aneurysm within 21 days of the ictus were included in the final analysis (n=550). Patients with an initial negative angiogram, with posterior circulation aneurysms, or aneurysms treated by endovascular means, with aneurysms requiring emergency surgery for space occupying haematomas, with aneurysms which re-bled before surgery, and those who received very late surgery (after 21 days from ictus) were excluded. Surgical outcomes at hospital discharge and after 6 months were assessed using the Glasgow outcome score (GOS). Discharge destination and duration of stay in a neurosurgical ward were also documented. The influence of the timing of surgery (early group day 1-3 postictus, intermediate group day 4-10, or late group day 11-21) was analysed prospectively. RESULTS: 60.2% of cases fell into the early surgery group, 32.4% into the intermediate group, and 7.5% into the late operated group. Late surgery was due to delays in diagnosis, transfer, and logistic factors, but not clinical decision. The demographic characteristics, site of aneurysm, and clinical condition of the patients at the time of initial medical assessment were balanced in the three surgical timing groups. There was no significant difference in GOS between the surgical timing groups at 6 months (favourable GOS score 4 and 5: 83.2%, 80.5%, and 83.8% respectively; p=0.47, Kruskal-Wallis test). Outcome was favourable in 84% of patients under 65 years, and 70% in those over 65. The discharge destinations (home, referring hospital, nursing home, rehabilitation centre) showed no significant difference between surgical timing groups. There was no significant difference in mean time to discharge after admission to this hospital from the referring hospital (16.2, 16.2, and 14.6 days for early, intermediate, and late groups respectively; p=0.789, Analysis of variance (ANOVA)). As a result, there was reduction in the mean duration of total hospital inpatient stay in favour of the earliest operated patients (mean time 18.1, 22.0, and 28.3 days respectively; p=0.001. ANOVA showed that besides age, the only determinant of surgical outcome and duration of stay was presenting clinical grade (p<0.0005). CONCLUSION: The current management of patients presenting with SAH from anterior circulation aneurysms allows early surgery to be followed safely regardless of age. The only independent variables affecting outcome are age and clinical grade at presentation. The timing of surgery did not significantly affect surgical outcome, promoting a policy for early surgery that avoids the known risks of rebleeding and reduces inpatient stay.

Adolescent↗