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PubMed2006

Outcomes research in hand surgery: where have we been and where should we go?

PURPOSE: The outcomes movement began in response to a national emphasis to control cost and to limit geographic variation in medical services. The impact of the outcomes movement on hand surgery research is unknown. We conducted a systematic review of hand surgery studies to assess the past and current states of outcomes research in this specialty. METHODS: A systematic review of hand surgery outcomes studies was conducted in The Journal of Hand Surgery (American and British volumes) from 1988 to 2004. A Medline search using the 11 Agency for Healthcare Research and Quality categories of outcomes studies was performed. Studies were rated for study design, data endpoints, and level of impact using the Agency for Healthcare Research and Quality-designated impact levels. RESULTS: A total of 2,236 studies were identified, and 1,188 were included in the analysis. Most studies were rated as level 1 impact (N = 1,090, 92%), and a small number of studies were level 4 impact (N = 98, 8%). Thirty-nine percent were prospective and 45% (N = 529) were retrospective descriptive studies. Data gathered in studies included objective clinical measures (N = 672, 57%), quality of life (N = 374, 31%), morbidity (N = 401, 34%), subjective clinical measures (N = 27, 16%), cost (N = 185, 2%), and mortality (N = 11, 1%). CONCLUSIONS: Our systematic review of hand surgery outcomes studies found that much of the research is confined to testing new or existing surgical techniques (level 1 impact). We found a small number of studies that did show improvement in patient outcomes as a result of an intervention (level 4 impact). The future direction of outcomes studies should consider the impact of the research goals to change patient or physician behavior to enhance health parameters. More research on economic analysis needs to be conducted in hand surgery to meet the national goal of containing cost and improving the quality of health care.

Biomedical Research↗
PubMed2006

Determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions.

BACKGROUND: When reporting standards for successful lower extremity revascularization were established, it was assumed that arterial reconstruction, patency, and limb salvage would correlate with the ultimate goal of therapy: improved functional performance. In reality, factors determining improvement of ambulation and maintenance of independent living status after revascularization have been poorly studied. The purpose of this study was to assess the important determinants of functional outcome for patients after intervention for critical limb ischemia. METHODS: The results of 1000 revascularized limbs from 841 patients were studied. Indications were rest pain, 41.1%; ischemic ulceration, 35.6%; gangrene, 23.3%; infrainguinal, 70.9%; aortoiliac, 24.2%; and both, 4.9%. Treatment was by endovascular intervention, 35.5%; open surgery, 61.7%; and both, 2.8%. Patient were mean age of 68 +/- 12 years, and 56.6% were men, 74.7% were white, 54.2% had diabetes mellitus, 67% were smokers, 13.4% had end-stage renal disease and were on dialysis, and 36% had prior vascular surgery. Patients were treated with conventional therapy by fellowship-trained vascular specialists at a single center and were analyzed according to the type of intervention, the arterial level treated, age, race, gender, presentation, the presence of diabetes, smoking history, end-stage renal disease, coronary disease, hypertension, hyperlipidemia, obesity, chronic obstructive pulmonary disease, previous stroke, dementia, prior vascular surgery, preoperative ambulatory status, limb loss <or=1 year of treatment, and independent living status. The technical outcomes of reconstruction patency and limb salvage as well as the functional outcomes of survival, maintenance of ambulation, and independent living status were measured for each variable using Kaplan-Meier life-table analysis, and differences were assessed using the log-rank test. A Cox proportional hazards model was used to assess independent predictors of outcome and obtain adjusted hazard ratios and 95% confidence intervals. RESULTS: At 5 years, 72.4% of the entire cohort had a patent reconstruction and 72.1% had an intact limb. Overall 5-year functional outcomes were 41.9% for survival, 70.6% for maintenance of ambulation, and 81.3% for independent living status. Outcome was not significantly affected by the type of treatment (endovascular or open surgery) or by the level of disease treated (aortoiliac, infrainguinal, or both). The most important independent, statistically significant predictors of particularly poor functional outcome were impaired ambulatory ability at the time of presentation (70% 5-year mortality, hazard ratio, 3.34; 39.5% failure to eventually ambulate, hazard ratio, 2.83; 30% loss of independent living status, hazard ratio, 7.97), and the presence of dementia (73% late mortality, hazard ratio, 1.57; 41.2% failure to eventually ambulate, hazard ratio, 2.20; 46.4% loss of independent living status, hazard ratio, 5.44). These factors were even more predictive than limb amputation alone. CONCLUSION: Functional outcome for patients undergoing intervention for critical limb ischemia is not solely determined by the traditional measures of reconstruction patency and limb salvage, but also by certain intrinsic patient comorbidities at the time of presentation. These findings question the benefit of our current approach to critical limb ischemia in functionally impaired, chronically ill patients--patients who undoubtedly will be more prevalent as our population ages.

Adult↗
PubMed2004

Acoustic neuroma surgical cost and outcome by hospital volume in California.

CONTEXT: Successful outcome of complex surgical techniques depend on the surgical team's level of experience. However, unless benefit is demonstrated in the presence of cost savings, insurance companies are reluctant to approve care from highly experienced hospitals and surgical teams. OBJECTIVE: To determine the relationship between the number of acoustic neuroma surgeries performed at California hospitals with surgical outcome and hospital stay cost. DESIGN: Acoustic neuroma surgery information was extracted from the California hospital discharge database and was grouped according to the number of surgeries performed at each hospital. SETTING: A database review of California hospitals. PATIENTS: Persons (n=1,213) undergoing acoustic neuroma surgery at a California hospital between 1996 and 1998. Main outcome measures Outcome measures included discharge status (routine vs. not routine), medical procedures indicating surgical complications, total cost of hospitalization, and average cost per hospitalization day. Odds ratios were used to compare the hospital volume groups on likelihood of a routine surgical outcome. RESULTS: The frequency of routine surgical outcome increased as hospital acoustic neuroma surgical volume increased, ranging from 68% among patients in the lowest volume group to 97% in the highest hospital volume group. Patients in the highest hospital volume group were 15 times more likely to have a routine surgical outcome than patients in the lowest hospital volume group. Patients in the second highest volume group were 5 times more likely to have a routine surgical outcome than in the lowest volume group. The two highest volume hospital groups had lower total charges and average charges per day than the two lower volume hospital groups. CONCLUSIONS: Acoustic neuroma surgeries at higher volume hospitals had higher frequency of routine discharge, lower frequency of apparent complications, and lower average cost of hospitalization.

California↗
PubMed2006

Symptoms of distress as prospective predictors of pain-related sciatica treatment outcomes.

Prior studies evaluating predictors of pain-related outcomes following treatment for sciatica have been limited by methodological problems, including retrospective study design, use of unvalidated outcome measures, and short-term follow-up periods. Despite these limitations, some reports have suggested that symptoms of psychological distress may predict individual differences in pain treatment-related outcomes (e.g., higher levels of depressive and anxious symptomatology are associated with greater pain and disability after treatment). In this study, we sought to determine whether acute symptoms of depression and anxiety were prospectively associated with treatment outcomes over a 3-year follow-up period in surgically treated and non-surgically treated patients with sciatica. Patients were recruited from the practices of community-based physicians throughout the state of Maine, and underwent in-person baseline assessments, with mailed follow-up questionnaires at 3, 6, 12, 24, and 36 months. Study outcomes included patient-reported symptoms of pain and disability. For each outcome variable, we examined whether baseline mood (i.e., mood assessed prior to the initiation of treatment), as well as mood at the immediately preceding assessment point, prospectively predicted outcomes over 3 years in multivariate repeated-measures analyses. In most analyses, symptoms of depression and anxiety, both at baseline and at the preceding time point, were significant independent predictors of worse pain and function after controlling for relevant covariates. Collectively, elevated distress appears to be a significant risk factor for reduced treatment benefit (i.e., less improvement in pain and disability) over short and medium-term follow-up periods in patients with sciatica. Future research should determine whether the prospective identification and treatment of patients with high levels of distress (a "yellow flag") is associated with improved treatment outcomes.

Adult↗
PubMed2007

Preoperative or postoperative self-efficacy: which is a better predictor of outcome after total hip or knee arthroplasty?

OBJECTIVE: Self-efficacy is considered an important determinant of outcome after total hip or knee arthroplasty. Aim of this study is to evaluate the contributions of preoperative and short-term postoperative self-efficacy in predicting long-term outcome. METHODS: Self-efficacy was determined in 103 total hip and knee arthroplasty patients preoperatively and 6 weeks postoperatively with the Self-Efficacy for Rehabilitation Outcome Scale (SER). The 6-month outcome was assessed with a disease-specific and a generic self-report questionnaire and an objective measure of function (walking speed). Multiple linear regression analyses were used to examine the value of preoperative and short-term postoperative self-efficacy in predicting 6-month outcomes. RESULTS: Preoperative self-efficacy was only a significant predictor of long-term postoperative walking speed, with higher self-efficacy resulting in faster walking speed at the long-term measurement (R(2)=0.47). Short-term postoperative self-efficacy was a significant predictor of the long-term postoperative generic outcome measure (physical functioning: R(2)=0.30; mental health: R(2)=0.53) and of walking speed (R(2)=0.66), with higher self-efficacy resulting in a better long-term outcome. CONCLUSION: Short-term postoperative self-efficacy seems a better predictor of long-term outcome after total hip or knee arthroplasty than preoperative self-efficacy. PRACTICE IMPLICATIONS: Interventions should focus on enhancing short-term postoperative rather than preoperative self-efficacy.

Activities of Daily Living↗
PubMed2006

Incidence of cross-border emergency care and outcomes of cardiopulmonary resuscitation in a unique European region.

BACKGROUND: Emergency medical service (EMS) systems in Europe have developed differently due to legal, educational and organisational aspects. The aim of the present study was to compare cardiopulmonary resuscitation (CPR) outcomes and characteristics in three differently organised and staffed EMS systems in close vicinity. METHODS: We analysed the charts of patients treated in the EMS systems of the cities of Aachen (Germany), Heerlen (The Netherlands) and Eupen (Belgium), retrospectively. Main outcome measures were the rate of return of spontaneous circulation (ROSC), hospital discharge and cerebral performance after 1 year. Furthermore, factors influencing neurological outcome and the incidence of cross-border emergency assistance were assessed. RESULTS: Of 852 patients found unresponsive with no palpable pulse and/or the absence of breathing, CPR was performed in 322 patients. The overall rate of ROSC was 44.1 and 13.7% of patients were discharged alive. A good neurological outcome was observed in 95.5% of survivors. The rate of ventricular fibrillation was significantly higher (46.9% versus 21.9 and 21.2%, p < 0.05) and the total amount of epinephrine given during CPR significantly lower (4.5+/-5.2 mg versus 9.8+/-10.8 and 8.4+/-6.2 mg, p < 0.05) in the Dutch system. No significant differences in outcome variables were observed between the systems. Neurological outcome was favourable when the arrest was witnessed, occurred in a public place, the initial rhythm was shockable, a low total amount of adrenaline (epinephrine) was given and the call-response interval was short. In 1.2% of the cases cross-border emergency care was provided. CONCLUSIONS: Despite medical and organisational discrepancies, outcomes of CPR in three neighbouring EMS systems are comparable. Neurological outcome is influenced by demographical, organisational and medical factors. Cross-border emergency assistance for CPR is almost undetectable and needs improvement.

Belgium↗
PubMed2005

Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia.

BACKGROUND: Prospective outcome studies based on a community sample of mostly neuroleptic naive cases of schizophrenia are uncommon. OBJECTIVES: To describe short-term symptomatic and functional outcomes of schizophrenia, and potential predictors of outcome. METHODS: After a baseline assessment, 63 incident and 208 prevalent cases of schizophrenia were followed by a yearly clinical assessment for an average of 2.5 (range 1-4) years. Scores of negative symptoms and positive symptoms were used as indicators of symptomatic outcomes. SF-36 scores of physical and social functioning, and role limitation due to mental health problems were used as indicators of functional outcomes. Several variables were evaluated as potential predictors of outcome in random coefficient models. RESULTS: Functioning and other measures of health related quality of life were significantly diminished in cases as compared to the general population of the area at baseline and follow up. Of the socio-demographic and clinical factors evaluated, only lower negative and positive symptom scores were significantly associated with improvements in functioning. The level of functioning observed in cases from Butajira was lower than that reported for cases from developed countries. CONCLUSIONS: Our findings are not in accord with other outcome studies that have reported better functional outcome for cases of schizophrenia from developing countries.

Adolescent↗
PubMedDate not supplied

Anterior cervical discectomy and fusion with implantable titanium cage: initial impressions, patient outcomes and comparison to fusion with allograft.

BACKGROUND CONTEXT: The use of metal cage prosthetic devices in anterior cervical discectomy with fusion (ACDF) has increased rapidly. One of these devices is the titanium Rabea cage (Signus, Alzenau, Germany) [correction]. There are no peer-reviewed objective reports on the use of these cages in cervical discectomy. PURPOSE: The authors present preliminary outcomes data on the Rabea cage. This study is intended to provide adjunct data for surgeons who are using or are considering the use of these devices. STUDY DESIGN/SETTING: Patients in a private practice were studied prospectively as part of a long-term assessment of outcomes using several surgical procedures. Data were collated and analyzed by an independent researcher. PATIENT SAMPLE: Rabea cages were used in consecutive candidates (n=37) for ACDF. The results using Rabea cages were compared with two prospectively studied control groups, one historical (n=66) and one concurrent (n=28), both groups using ACDF with bone allograft and no instrumentation. OUTCOME MEASURES: Success at 6 months after surgery was determined using six major patient-reported outcome measures, including visual analog scales (VAS) for arm and neck pain, the Oswestry pain and disability scale, four-part (excellent-through-poor) scales for measurement of return to activities of daily living or to work and satisfaction with the results of surgery. Perioperative complications, number of vertebral levels fused, and worker's compensation and smoking status were also compared among the study groups. Fusion and subsidence were evaluated for the Rabea cage group. METHODS: Criteria for inclusion consisted of consecutive patients who presented with unremitting radicular arm pain, with or without neck pain, and/or a neurological deficit that correlated with appropriate level and side neural compression on magnetic resonance imaging or computed tomography. Questionnaire follow-up was at 6 months after surgery with 100% compliance. RESULTS: A total of 50 cages were implanted in the 37 patients. At 6-month follow-up, 78% of patients reported successful arm pain relief (VAS scores below 5). Patient satisfaction was successful in 78% of the cases. Other success rates included neck pain relief in 73% and Oswestry pain and disability scale in 70%. There was a median improvement in the Oswestry scores of 28 points (61% change). Worker's compensation patients fared dramatically worse than did the noncompensation patients in all outcome measurements. Combining all three study groups resulted in significantly worse outcomes for multilevel than for single-level procedures and for smokers compared with nonsmokers, but low case numbers precluded conclusive analysis for the Rabea group alone. In the Rabea group there were two complications, neither cage related, whereas none were reported for the ACDF controls. Rabea group fusion rates were 84% at 3 months and 95% at 6 months, but the clinical relevance of this radiological evidence when metal prostheses are used is questionable. The outcomes results were clinically and statistically indistinguishable from those of our control groups and were similar to published studies using other titanium cages. CONCLUSIONS: This is the first prospective, independently conducted report on Rabea cages. Results of the short-term (6 months) follow-up did not differ from outcomes results in our patients who have undergone ACDF with bone allograft. Although this is a preliminary assessment, the Rabea cage may represent an alternative to bone dowels and hip graft. As is the case for other allografts, artificial or bone, the main advantage is elimination of donor site complications, and the disadvantages include difficulty in radiographic assessment of fusion and potential for cage subsidence.

Activities of Daily Living↗
PubMedDate not supplied

Smoking status and psychosocioeconomic outcomes of functional restoration in patients with chronic spinal disability.

BACKGROUND CONTEXT: Studies have revealed smoking to have a negative impact on spinal surgery. It is assumed that this is the result of the negative impact of nicotine on revascularization of damaged tissue. However, there is a paucity of research on the role of smoking with regard to nonsurgical rehabilitation, but there exists a clear bias for believing that smoking is strongly associated with poor socioeconomic and psychosocial outcome. PURPOSE: This study was designed to examine the relationship between smoking and outcomes in a chronically disabled work-related spinal disorder (CDWRSD) cohort undergoing functional restoration. STUDY DESIGN: A prospective comparison cohort study investigating the effects of smoking status on functional restoration treatment outcomes. PATIENT SAMPLE: A cohort of 1,141 consecutive CDWRSD patients were divided into four groups: Group A, patients who did not smoke (n=710); Group B, patients who smoked less than one cigarette pack/day (n=157); Group C, patients who smoked 1.0 to 1.9 packs/day (n=218); Group D, patients who smoked 2.0 or more packs/day (n=56). OUTCOME MEASURES: Before the start of functional restoration, and upon its completion, patients received a standard psychosocial assessment battery and were assessed on a variety of physical factors. A structured clinical interview examining socioeconomic outcomes was conducted 1 year after the program. METHODS: Patients underwent an intensive functional restoration chronic pain management rehabilitation program consisting of quantitatively directed exercise progression and a multimodal disability management program for CDWRSD. The program consisted of four phases, the most significant of which involved a 3-week full-day intensive phase after preparatory preprogram phases and before a work transition phase. RESULTS: Analysis revealed that the percent of males increased as the smoking level increased (Group A=51.8% vs Group D=73.2%; p<.001). Also, as smoking increased, the level of education significantly decreased. In addition, as smoking level increased, the percent of patients completing the rehabilitation program decreased (from 86.3% to 75%; p=.03). No significant differences in 1-year posttreatment socioeconomic outcomes of work status, health utilization, recurrent injury or case closure were related to smoking except work retention, which decreased with more smoking (85 to 71%, p<.05). Surprisingly, the physical cumulative score at posttreatment increased as smoking frequency increased (p<.01). This finding indicates that those who smoked more performed at a higher level on physical measures. Those who smoked more frequently before treatment also appeared more depressed (p<.001), but after treatment, these differences disappeared. Self-reported pain intensity differed only after treatment, and posttreatment disability ratings showed a significant linear trend. CONCLUSIONS: Contrary to popular belief, CDWRSD patients who smoke do not differ significantly in socioeconomic or psychosocial outcomes relative to those who do not. Although this study does indicate that those who smoke more evidence lower rehabilitation completion rates, those who completed the program had identical 1-year posttreatment outcomes of socioeconomic importance except in retraining work at year end as those who did not smoke. Smokers had slightly higher posttreatment self-reported pain and disability ratings mixed and limited. Overall, there is evidence for the widely held belief that smoking negatively affects tertiary rehabilitation.

Adult↗
PubMed2005

Clinical factors affecting the outcome of arthrocentesis and hydraulic distension of the temporomandibular joint.

OBJECTIVE: Significant psychosocial distress and substantial cost are associated with the diagnosis and management of chronic temporomandibular joint (TMJ) pain conditions. Successful intervention based on identified risk factors has potential functional and financial benefits. Arthrocentesis and hydraulic distension of the TMJ has been described as an effective modality in the treatment of patients demonstrating clinical findings consistent with the diagnosis of disc displacement without reduction. The purpose of this study was to investigate whether clinical variables such as age, gender, time since pain onset (TSO), visual analog scale (VAS) pain level, and mandibular range of motion (ROM) may predict treatment outcomes of arthrocentesis and hydraulic distension of the TMJ. STUDY DESIGN: The study comprised 64 consecutive patients presenting with TMJ pain, who were diagnosed with a unilateral clinical TMJ disorder of "TMJ pain associated with an internal derangement (ID) type III (disc displacement without reduction)." TMJ pain level of function and mandibular range of motion were assessed initially and then compared with the respective 2-month follow-up findings after arthrocentesis and hydraulic distension. Outcome criteria of success included an absence of signs and symptoms characteristic of a diagnosis of ID type III. A multiple logistic regression analysis of pretreatment data was used to compute the odds ratio for variables of age, gender, TSO, VAS pain level, and ROM for successful outcomes (n = 34) vs nonsuccessful (n = 30) outcomes. RESULTS: At 2-months follow-up, clinical evaluation showed a significant reduction in TMJ pain during function (P < .001), a significant reduction in clinical diagnoses of TMJ disorders (P < .001), and a significant increase in mandibular range of motion (P < .001). For the outcome criteria of "absence of ID type III," there was a significant difference between the clinical outcome groups for the variables of age (P = .029) and VAS pain level (P < .001). Significant increase in benefit of a successful outcome occurred with an age of < or = 25 years (11.8 odds ratio; P = .044), a VAS pain level of > 75 mm (6.5 odds ratio; P = .026), and an ROM of < 25 mm (6.9 odds ratio; P = .029). CONCLUSION: Clinical variables predicted TMJ "ID type III and pain" patients who went on to show successful treatment outcomes of arthrocentesis and hydraulic distension. Predictive modeling may provide clinicians with the opportunity to identify "at-benefit" patients early and initiate specific treatments.

Adolescent↗
PubMed1998

Assessment of uterine arterial notching as a screening test for adverse pregnancy outcome.

OBJECTIVE: The objective of the study was to evaluate the screening potential of routine uterine arterial Doppler ultrasonography as a predictor of adverse pregnancy outcome. STUDY DESIGN: All women (n = 6579) with singleton pregnancies undergoing a fetal anomaly scan at 18 to 20 weeks' gestation between January 1, 1994, and December 31, 1995, at Ninewells Hospital and Medical School were screened for the presence of uterine arterial notching. Women who had evidence of bilateral notching were rescanned at 22 to 24 weeks' gestation. Outcome measures included proteinuric hypertension, premature separation of the placenta, and birth weight z score. RESULTS: The sensitivity and positive predictive value of uterine arterial notching as a predictor of adverse pregnancy outcomes was low. For all types of notching and disease, outcome sensitivity was never higher than 44% and positive predictive value was never higher than 27%. In contrast, the relative risk of adverse pregnancy outcome in the presence of uterine arterial notching was uniformly high for all disease outcomes (range of relative risk 3.5-30.7). Significant obstetric morbidity was seen in 57% of women with bilateral notches at 18 to 20 weeks' gestation and 72% of women with persistent bilateral notches. CONCLUSIONS: As a screening test for adverse pregnancy outcomes, detection of uterine arterial notching is poor. Nevertheless, the presence of bilateral uterine arterial notching is associated with a significantly increased risk of adverse pregnancy outcome. In units performing routine anomaly screening, the addition of maternal uterine arterial Doppler ultrasonography may help to discriminate this small group of women at high risk.

Adolescent↗
PubMed2004

Outcomes after spinal cord injury: comparisons as a function of gender and race and ethnicity.

OBJECTIVE: To identify gender and racial and ethnic differences in subjective well-being (SWB), participation, and general health ratings in participants with spinal cord injury (SCI). DESIGN: A multisite, cross-sectional study that used stratified sampling to identify and maximize participation among groups of people traditionally underrepresented in SCI research. SETTING: Four Model Spinal Cord Injury Systems participated in the data collection. The primary site was a large southeastern specialty hospital; the other 3 were in the western and mountain regions of the United States. PARTICIPANTS: A total of 512 participants, 475 of whom were included in the analysis. This group included relatively equal portions of whites, African Americans, American Indians, and Hispanics. Approximately 40% of the sample was women. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary outcome measures included 2 measures of SWB (Life Situation Questionnaire-Revised, Older Adult Health and Mood Questionnaire), 1 measure of participation (Craig Handicap Assessment and Reporting Technique), and several items from the Behavioral Risk Factor Surveillance System. RESULTS: The majority of racial and ethnic differences in SWB related to specific life areas (eg, economics, employment), rather than more global outcomes (eg, engagement, health), with whites generally reporting the best outcomes, followed by African Americans. American Indians, and whites generally reported the highest participation scores, whereas limited differences were noted between the racial and ethnic groups on health indicators. Women reported lower satisfaction with health, more poor mental health days, and lower SWB related to home life, but higher SWB related to interpersonal relations. CONCLUSIONS: There are racial and ethnic differences in outcomes after SCI focused primarily on subjective outcomes in areas in which racial and ethnic minorities have traditionally been disadvantaged. The results of this study direct rehabilitation professionals to the outcomes that need to be targeted for intervention to eliminate inequities in outcomes for all persons with SCI.

Adult↗
PubMed2003

Initial magnetic resonance imaging volumetric brain measurements and outcome in schizophrenia: a prospective longitudinal study with 5-year follow-up.

BACKGROUND: Several demographic and phenomenological variables have been identified as predictors of outcome in schizophrenia. Far fewer studies have examined the relationships between brain morphology assessed at illness onset and subsequent outcome, and their results have been contradictory. METHODS: The relationships between magnetic resonance imaging (MRI) regional brain volumes at illness onset and outcome five years later were studied in 123 schizophrenia patients using regression and correlation analysis. Outcome measures included psychosocial functioning, weeks per year receiving inpatient treatment, and persistence of severe psychotic, disorganized and negative symptoms. RESULTS: Temporal lobe tissue volume at onset was predictive of outcome. Smaller temporal lobe gray matter volume (both left and right) was associated with persistence of hallucinations during follow-up. There were no significant associations between hallucinations and temporal white matter, or between delusions and temporal white or gray matter volumes. None of the other volumetric brain measures were predictive of outcome. CONCLUSIONS: The association between initial temporal lobe gray matter volume and subsequent persistent hallucinations may help identify individuals who are at higher risk for poor outcome and help guide their treatment planning. However, regional brain volumes assessed near illness onset, in general, do not appear to be indicative of subsequent outcome in schizophrenia.

Age of Onset↗
PubMed1998

Electrocorticography and outcome in frontal lobe epilepsy.

The prognostic significance of epileptiform activity (EA) recorded at electrocorticography (ECOG) was examined in a group of 60 consecutive non-tumoral patients with intractable frontal lobe epilepsy (FLE). Pre-excision EA was documented as absent, focal (one gyrus), regional (two gyri), lobar (3 gyri) or multilobar (frontal + temporal gyri). Post-excision EA was documented as absent, restricted to the resection border, or recorded distant to the resection border, and was quantitated by spike frequency. Pre-excision EA from < or = 2 gyri and absence of post-resection EA correlated with Class I or II (Engel classification) outcome while pre-excision EA from > or = 3 gyri and persistent post-resection EA, especially distant to the resection border, correlated with Class III or IV outcome (P < 0.001). A significant correlation between poorer outcomes and increased abundance of distant post-resection EA was observed (P < 0.001). EA restricted to the resection border was not significantly correlated with outcome. Presence of a circumscribed lesion correlated with Class I outcome (P < 0.01) and absence of pathological abnormality correlated with Class IV outcome (P < 0.05). Neither side nor extent of surgical excision correlated with outcome. EA recorded at ECOG is of prognostic significance in FLE. A lobar or multilobar distribution of pre-excision EA and persistent post-excision EA distant to the resection border, especially when abundant, are highly unfavorable prognostic indicators. In contrast, a restricted distribution of pre-excision EA and absence of post-resection EA both herald a favorable outcome.

Adolescent↗
PubMed1994

Success rate of modified Pereyra bladder neck suspension determined by outcomes analysis.

The reported success rates of the modified Pereyra bladder neck suspension vary from 51 to 90%. Retrospective chart review studies have reported cure rates of 77 to 90%. In contrast, a questionnaire based outcomes analysis, using a strict definition of cure, reported 51% of the patients to be cured of stress urinary incontinence after modified Pereyra bladder neck suspension. We conducted a questionnaire based outcomes analysis of the modified Pereyra bladder neck suspension at our institution. The objectives of the study were to determine the success rates of this procedure using strict criteria in an outcomes analysis format, assess the overall satisfaction of patients postoperatively and identify historical factors that may be predictive of outcome. Between September 1988 and December 1991, 151 patients underwent a modified Pereyra bladder neck suspension for urodynamically documented genuine stress urinary incontinence. Mean patient age was 56 years (range 19 to 82 years) and mean followup was 25 months (range 9 to 45). All patients had type 2 incontinence (anatomical) based on history (severity of symptoms), physical examination, and fluoroscopic assessment of the bladder neck and urethra. Preoperative pad use, and irritative and obstructive symptoms were retrospectively assessed, and a preoperative Stamey incontinence score was assigned. A standardized questionnaire was used to compare preoperative and postoperative voiding symptoms, perception of urinary control and satisfaction with the decision to undergo an operation. Followup telephone calls were made by a trained registered nurse not associated with the original procedure. Postoperative pad use also was quantified and a postoperative Stamey score was assigned. A total of 106 patients (70%) returned the questionnaires. Cure was strictly defined as no urine leakage under any circumstance. While 78% of the patients required no to minimal protection postoperatively, 50 (47%) reported cure of the stress urinary incontinence, 68 (64%) reported subjective improvement, 27 (26%) were the same and 11 (10%) were subjectively worse after modified Pereyra bladder neck suspension. Of the patients 77% were satisfied with the decision to undergo the operation. Patients subjectively worse were significantly older than those subjectively improved (66 versus 54 years, p = 0.05). Postoperative failures had significantly higher obstructive and irritative symptom scores. Questionnaire based outcomes analysis has consistently demonstrated success rates less than those reported in retrospective chart review studies. Outcomes analysis, based on patient assessment of satisfaction, may more accurately reflect the expected surgical outcome after a modified Pereyra bladder neck suspension. We emphasize the need for standardized questionnaires and outcomes analysis to evaluate patient satisfaction with surgery designed to improve quality of life.

Adolescent↗
PubMed2001

Prediction of adverse outcomes by common definitions of hypertension in pregnancy.

OBJECTIVE: To examine the ability of five common definitions of hypertension in pregnancy to predict adverse maternal and perinatal outcomes. METHODS: We studied 9133 singleton nulliparous pregnancies with early prenatal care from the Collaborative Perinatal Project, a large cohort study conducted between 1959 and 1965. Definitions from five different groups were evaluated. Severe maternal and perinatal morbidity and mortality were used as the outcome measurements. Sensitivity, specificity, and positive predictive value for outcomes were compared across various definitions. RESULTS: Blood pressure alone had very poor discriminatory power to predict adverse outcomes. Positive predictive values of adverse outcomes by the diagnosis of preeclampsia were 18-20% based on antepartum and intrapartum blood pressures and 22-36% based on antepartum blood pressure only. Mild hypertension occurring for the first time in labor and isolated mild systolic hypertension were not associated with adverse outcomes. Similarly, an increase in diastolic blood pressure of 15 mmHg that did not achieve an absolute value of 90 mmHg did not predict adverse outcome. CONCLUSION: Neither blood pressure nor blood pressure and proteinuria are accurate predictors of severe adverse maternal and perinatal outcomes. Mild hypertension occurring for the first time in labor and isolated mild systolic hypertension should not be considered indicators for hypertensive disorders in pregnancy in a research definition.

Adolescent↗
PubMed2003

The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary.

BACKGROUND: This study explores the volume-outcome relationship for gastric bypass surgery for obesity to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated fewer adverse outcomes. METHODS: The Pennsylvania state discharge database was used to identify 4685 cases of gastric bypass surgery for obesity between 1999 and 2001. Statistical modeling analyses were used to determine whether mortality or adverse outcome rate was significantly related to hospital and surgeon volume; the data were controlled for risk factors such as age, gender, comorbidities, and others. RESULTS: There were 28 deaths (0.6%) and 813 adverse outcomes (17.4%). There was a significant risk-adjusted relationship between surgeon volume and adverse outcome, and the same trend was observed for deaths. Surgeons who performed fewer than 10 procedures per year had a 28% risk of adverse outcome and a 5% risk of death, compared with 14% (P<.05) and 0.3% (P=.06), respectively, for high-volume surgeons. Hospital volume did not reach significance, but there was a striking interaction between surgeon and hospital volume; surgeons who performed 10 to 50 cases per year operating in low-volume hospitals had a 55% risk of adverse outcome (P<.01). CONCLUSION: Risk-adjusted in-hospital adverse outcome is significantly lower when gastric bypass is performed by higher-volume surgeons.

Adolescent↗
PubMed1997

Association of apolipoprotein E polymorphism with outcome after head injury.

BACKGROUND: Variation in outcome after head injury is not fully explained by known prognostic features. Polymorphism of the apolipoprotein E gene (APOE) influences neuropathological findings in patients who die from head injuries. More people who die from head injuries than non-head-injured controls have deposits of amyloid beta-protein in the cerebral cortex, with amyloid beta-protein deposits present predominantly in patients with the APOE epsilon4 allele. We report a prospective clinical study to test the hypothesis that patients with APOE epsilon4 have a worse clinical outcome 6 months after head injury than those without APOE epsilon4. METHODS: We studied a prospectively recruited series of patients admitted after a head injury to a neurosurgical unit (n=93). Assessment of severity of the initial injury was by means of the Glasgow Coma Score (GCS). Outcome 6 months after injury was assessed by means of the Glasgow Outcome Scale. APOE genotypes were determined from blood samples by standard methods. FINDINGS: Detailed information on outcome was available for 89 patients. 17 (57%) of 30 patients with APOE epsilon4 had an unfavourable outcome (dead, vegetative state, or severe disability) compared with 16 (27%) of the 59 patients without APOE epsilon4 (p=0.006). The association remained significant when adjustment was made to control for age, GCS, and computed tomography scan findings (p=0.024). INTERPRETATION: Our findings show a significant genetic association of APOE polymorphism with outcome after head injury supporting the hypothesis of a genetically determined influence. Patients with APOE epsilon4 are more than twice as likely as those without APOE epsilon4 to have an unfavourable outcome 6 months after head injury. Further studies are under way to confirm and further evaluate this association.

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