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PubMed2002

Executive dysfunction and clinical outcome in chronic alcoholics.

BACKGROUND: The purpose of this study was to investigate which of 12 neuropsychological tests predict alcoholic patients' alcohol-specific and/or alcoholic-nonspecific outcome. Our hypothesis was that the ecologically valid neuropsychological tests that measure executive function are better predictors of alcoholics' functional outcome. METHODS: We administered 12 neuropsychological tests to chronic alcoholics. Included in the tests were tasks of Reaction Time, Symbol Digit Modalities, Figure Position, Digit Span, Block Design, Trail Making, and six subtests of a battery called the Behavioral Assessment of the Dysexecutive Syndrome (BADS). Previous investigators have suggested that the BADS has ecological validity. Twenty-two male alcoholics were compared with 15 nonalcoholic control subjects on these neuropsychological measures 7 weeks after detoxification. Two functional outcome indices, i.e., resumption of drinking and occupation, were evaluated 18 months after discharge. RESULTS: The total profile score and the score on three of the six subtests of the BADS were lower in alcoholics than in nonalcoholic controls. Alcoholics' performance on the BADS predicted alcohol-nonspecific outcome (occupation) but not alcohol-specific (drinking) outcome. In contrast, other neuropsychological tests did not predict either of the two outcome indices. CONCLUSIONS: The BADS total profile score is related to alcohol-nonspecific outcome but not to alcohol-specific outcome.

Alcoholism↗

PubMed2005

First-trimester intrauterine hematoma and outcome of pregnancy.

OBJECTIVE: To evaluate the outcome of pregnancies complicated by first-trimester intrauterine hematoma. METHODS: An analysis was performed on 248 cases. The pregnancy outcome was correlated with hematoma volume, gestational age (weeks), and maternal age (years). RESULTS: One hundred eighty-two cases were eligible for the study. Clinical complications occurred in 38.5% of the cases (adverse outcome group). Spontaneous abortion (14.3%), fetal growth restriction (7.7%), and preterm delivery (6.6%) were the most frequent clinical conditions observed. Considering the hematoma variables in adverse and favorable outcome groups, we found a significant difference only for gestational age at diagnosis. The median gestational age was significantly lower (P < .02) in the adverse outcome group (7.27, I and III quartiles 6.22-8.78) than in the favorable outcome cases (8.62, I and III quartiles 6.70-9.98). Among clinical conditions, the median gestational age was significantly lower (P = .02) in pregnancies complicated by spontaneous abortion (6.60, I and III quartiles 5.95-8.36) than in cases not ending in a miscarriage (8.50, I and III quartiles 6.70-9.91). The overall risk of adverse outcome was 2.4 times higher when the hematoma was diagnosed before 9 weeks (odds ratio 2.37, 95% confidence interval 1.20-4.70). In particular, intrauterine hematoma observed before 9 weeks significantly increases the risk of spontaneous abortion (odds ratio 14.79, 95% confidence interval 1.95-112.09) CONCLUSION: Intrauterine hematoma can affect the outcome of pregnancy. The risk of spontaneous abortion is related to gestational age and is significantly increased if diagnosed before 9 weeks. LEVEL OF EVIDENCE: III.

Abortion, Spontaneous↗

PubMed2005

Birth outcomes in obese women after laparoscopic adjustable gastric banding.

OBJECTIVE: This prospective study sought to examine the outcomes of 79 consecutive first pregnancies (> 20 weeks of gestation) in women following laparoscopic adjustable gastric banding (LAGB) for severe obesity. METHODS: The 79 women are from a cohort of 1,382 consecutive patients. The prospectively collected data from 79 first pregnancies has been compared with these patients' previous penultimate pregnancies (n= 40), obstetric histories from matched severely obese subjects (n = 79), and community outcomes. RESULTS: The mean maternal weight gain was 9.6 +/- 9.0 kg, compared with 14.4 +/- 9.7 kg for the 40 penultimate pregnancies of women in this group (P < .001). There was no difference in birth weights: 3,397 g compared with 3,350 g for preband pregnancies, and these were consistent with normal community birth weights. The incidence of pregnancy-induced hypertension (10%) and gestational diabetes (6.3%) were comparable with community levels (12% and 5.5%) and lower than the obese cohort (38% and 19%) and these patients' penultimate pregnancies (45% and 15%). Monitoring and, if necessary, band adjustments during pregnancy provided more favorable maternal weight outcomes (P = .027). Neonatal outcomes, including stillbirths, preterm deliveries, low birth weight, and high birth weight, were consistent with community values. One woman developed anemia during pregnancy. CONCLUSION: Pregnancy outcomes after LAGB are consistent with general community outcomes rather than outcomes from severely obese women. The adjustability of the LAGB assists in achieving these outcomes. Adjustability is appealing because it allows adaptation to the altered requirements of pregnancy. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed2006

Cesarean delivery on maternal request: maternal and neonatal outcomes.

OBJECTIVE: To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery. DATA SOURCES: We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria. METHODS OF STUDY SELECTION: We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery. TABULATION, INTEGRATION, AND RESULTS: We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency. CONCLUSION: The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.

Cesarean Section↗

PubMed2003

Association between funding source and study outcome in orthopaedic research.

The current report tests the hypotheses that commercial funding, country of origin, and presence of a coinvestigator with training in statistics are related to the likelihood of a published orthopaedic study arriving at a positive conclusion. All articles from the Journal of Bone and Joint Surgery (American), the Journal of Arthroplasty, and the American Journal of Sports Medicine published in 1 year were reviewed. The blinded review process classified each article as to study design and outcome (positive or negative), according to previously published definitions. Commercial funding was significantly associated with a positive outcome; 78.9% of commercially funded studies concluded with a positive outcome, compared with 63.3% of nonfunded studies. The presence of a statistician or epidemiologist as a coinvestigator, and the place of origin of the study were not associated with outcome. Only 21% of published studies were prospective, 3.5% were randomized, and 10.5% stated an experimental hypothesis; these factors were not associated with study outcome. Published studies that received funding from commercial parties were significantly more likely to report a positive outcome than studies that received no such funding. This does not imply the presence of a corrupting or causative influence of industry sponsorship on research outcomes; additional research is needed to determine whether such nonscientific factors actually affect study outcome or likelihood of publication.

Authorship↗

PubMed2005

Outcome instruments for patellofemoral arthroplasty.

Although there are numerous patient outcome instruments available, the most reliable and valid instruments for evaluating patient outcomes after patellofemoral arthroplasty have not been identified. In this article, we review and evaluate the psychometric properties and practical considerations of administering general health instruments (Medical Outcomes Study (MOS) Short Form-36 and Short Form-12), knee scales (Knee Society Clinical Rating System, Knee Outcome Survey, International Knee Documentation Committee form, Knee Injury and Osteoarthritis Outcome Score) and a disease specific scale (Western Ontario and McMaster Universities Osteoarthritis Index) for patellofemoral arthroplasty outcome assessment. Based on our review of the literature, we recommend the Short Form-36 and Knee Injury and Osteoarthritis Outcome Score for evaluation of patellofemoral arthroplasty outcomes and provide recommendations for implementation of these instruments in a clinical setting.

Arthroplasty, Replacement, Knee↗

PubMed2004

Protein S-100b for individual prediction of functional outcome in spinal epidural empyema.

STUDY DESIGN: A study correlating protein S-100b serum levels with postoperative functional outcome in patients with spinal cord compression resulting from epidural empyema. OBJECTIVES: To evaluate the potential value of protein S-100b for prediction of individual functional outcome in medullary lesions resulting from spinal epidural empyema. SUMMARY OF BACKGROUND DATA: Despite modern medical advances, a reliable individual prediction of functional outcome in case of spinal epidural empyema is still not possible. METHODS: Forming two outcome groups, clinical outcome following surgery was considered to be favorable in case of neurologic improvement with preservation or retrieval of walking ability, whereas nonimprovement without restoration of gait function was regarded to be unfavorable. Venous blood samples for protein S-100b were taken from all patients immediately after admission and regularly after operative decompression. Initial levels of S-100b were correlated with preoperative degree and duration of paresis, and the individual time course of S-100b measurements was correlated with clinical outcome. RESULTS: The initial level of protein S-100b is not correlated with preoperative degree and duration of paresis or with functional outcome. The individual time course of S-100b measurements, however, is different in both outcome groups. Levels of protein S-100b that were either always normal or that were initially increased but normalized rapidly within 3 days were invariably associated with retrieval of gait function, whereas none of those patients recovered in whom increased levels of S-100b persisted beyond the third postoperative day (P < 0.003). CONCLUSIONS: Protein S-100b might be a promising serum marker with prognostic significance in the event of spinal cord compression resulting from epidural empyema.

Adult↗

PubMed2005

Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study.

STUDY DESIGN: A prospective observational cohort study. OBJECTIVE: To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically. SUMMARY OF BACKGROUND DATA: The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments. METHODS: Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years. RESULTS: Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment. CONCLUSIONS: Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

Aged↗

PubMed2005

The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back pain who are not receiving workers' compensation.

STUDY DESIGN: A prospective, interventional case series design. OBJECTIVES: To determine the degree to which preintervention measures of anticipated pain and fear avoidance beliefs predict outcome after intervention for patients with delayed recovery from low back pain (LBP) for which they are not receiving workers' compensation. SUMMARY OF BACKGROUND DATA: Anticipated pain and fear avoidance beliefs have been suggested as important factors for the classification and treatment of patients with LBP. However, the degree to which they are associated with outcome after intervention is uncertain. METHODS: There were 42 subjects with activity limiting LBP for more than 2 months enrolled in an exercise based, physical therapy program. A multidimensional test battery was completed before and after a 10-week program of lumbar extensor muscle strengthening. Correlational analyses, independent t tests, and validity indexes were used to determine relationships of preintervention measures of anticipated pain and the fear avoidance beliefs to clinically meaningful improvements in the Roland-Morris score. Intention-to-treat strategies were used to account for study dropouts. RESULTS: A total of 36 subjects completed the 10-week intervention. The lack of clinically meaningful outcome, as determined by a failure-to-report a minimum of 16% decrease in the Roland-Morris score, was associated with high preintervention scores on the physical activity subscale of the Fear Avoidance Beliefs Questionnaire (FABQP). Subjects with a preintervention score > or =29 on the FABQP had a likelihood ratio of 3.78 (95% confidence interval [CI] 2.4-5.16) for an increased probability of negative outcome after initial testing when compared to those subjects with low (<20) scores. The sensitivity and specificity of low scores to predict clinically meaningful outcomes compared to those with high scores were moderate (sensitivity = 0.87 and specificity 0.77); however, the likelihood ratio was inconclusive. Anticipated pain was significantly correlated with but was higher than the reported pain during activity both before and after intervention but not predictive of outcome. CONCLUSIONS: In a sample of people from a Middle Eastern culture undergoing exercise intervention for LBP for which they are not receiving workers' compensation, the preintervention physical activity subscale of the FABQ is predictive of negative outcome when the observed scores are > or =29. Despite significant improvements in all variables after intervention, anticipated pain remained significantly higher than reported pain during physical performance testing but did not predict outcome.

Adult↗

PubMed2005

Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging.

OBJECTIVE: Diagnostic selective nerve root injection (SNI) results were analyzed in 101 patients who underwent lumbar or cervical decompression for radiculopathy and compared to surgical outcome 1 year postoperatively. A comparison of surgical outcomes was also examined between magnetic resonance imaging (MRI) and SNI results. RESULTS: Of the 101 patients, 91 (90%) had positive and 10 had negative SNI results at the level operated. Ninety-one percent of the patients with a positive SNI had good surgical outcomes, whereas 60% of the patients with a negative SNI had good outcomes. Of the patients with a positive MRI result, 87% had good surgical outcomes, whereas a similar percentage of the patients with a negative MRI (85%) had good surgical outcomes. When findings between SNI and MRI differed (n = 20), surgery at a level consistent with the SNI was more strongly associated with a good surgical outcome. Of the patients with a poor surgical outcome, surgery was most often performed at a level inconsistent with the SNI finding. CONCLUSIONS: Our study found that a diagnostic SNI can safely and accurately discern the presence or absence of cervical or lumbar radiculopathy. The diagnostic SNI can persuade surgeons from operating on an initially suspicious, but incorrect, level of radiculopathy. In cases where MRI findings are equivocal, multilevel, and/or do not agree with the patient's symptoms, the result of a negative diagnostic SNI (ie, lack of presence of radiculopathy) becomes superior in predicting the absence of an offending lesion.

Anesthetics, Local↗

PubMed2006

From evidence to clinical practice: effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest.

OBJECTIVES: Therapeutic hypothermia has been recommended for postcardiac arrest coma due to ventricular fibrillation. However, no studies have evaluated whether therapeutic hypothermia could be effectively implemented in intensive care practice and whether it would improve the outcome of all comatose patients with cardiac arrest, including those with shock or with cardiac arrest due to nonventricular fibrillation rhythms. DESIGN: Retrospective study. SETTING: Fourteen-bed medical intensive care unit in a university hospital. PATIENTS: Patients were 109 comatose patients with out-of-hospital cardiac arrest due to ventricular fibrillation and nonventricular fibrillation rhythms (asystole/pulseless electrical activity). INTERVENTIONS: We analyzed 55 consecutive patients (June 2002 to December 2004) treated with therapeutic hypothermia (to a central target temperature of 33 degrees C, using external cooling). Fifty-four consecutive patients (June 1999 to May 2002) treated with standard resuscitation served as controls. Efficacy, safety, and outcome at hospital discharge were assessed. Good outcome was defined as Glasgow-Pittsburgh Cerebral Performance category 1 or 2. MEASUREMENTS AND MAIN RESULTS: In patients treated with therapeutic hypothermia, the median time to reach the target temperature was 5 hrs, with a progressive reduction over the 18 months of data collection. Therapeutic hypothermia had a major positive impact on the outcome of patients with cardiac arrest due to ventricular fibrillation (good outcome in 24 of 43 patients [55.8%] of the therapeutic hypothermia group vs. 11 of 43 patients [25.6%] of the standard resuscitation group, p = .004). The benefit of therapeutic hypothermia was also maintained in patients with shock (good outcome in five of 17 patients of the therapeutic hypothermia group vs. zero of 14 of the standard resuscitation group, p = .027). The outcome after cardiac arrest due to nonventricular fibrillation rhythms was poor and did not differ significantly between the two groups. Therapeutic hypothermia was of particular benefit in patients with short duration of cardiac arrest (<30 mins). CONCLUSIONS: Therapeutic hypothermia for the treatment of postcardiac arrest coma can be successfully implemented in intensive care practice with a major benefit on patient outcome, which appeared to be related to the type and the duration of initial cardiac arrest and seemed maintained in patients with shock.

Coma↗

PubMed2005

The impact of provider volume on outcomes from urological cancer therapy.

PURPOSE: Growing evidence suggests an association between higher hospital and surgeon volumes, and better outcomes after high risk surgical procedures. We reviewed the literature on volume and outcomes, specifically in urological cancer therapy. MATERIALS AND METHODS: We searched the literature from 1966 to 2004 using MEDLINE with the keywords outcomes, urology, neoplasms, volume, hospital volume, surgeon volume, prostatectomy, cystectomy, nephrectomy, prostate cancer, bladder cancer, kidney cancer and testis cancer. Relevant articles were reviewed and results were compared for each urological cancer. RESULTS: Several studies demonstrated that higher hospital volume is associated with better outcomes for all urological cancer surgeries. We found that long-term morbidity associated with radical prostatectomy is significantly associated with individual surgeon volume. There were variations in outcome even among high volume surgeons, suggesting that surgical technique can independently impact outcome. Hospitals with a high volume of cystectomies and nephrectomies had decreased overall mortality rates compared with low volume hospitals. Patients undergoing retroperitoneal lymph node dissection for metastatic germ cell tumor had statistically significantly improved survival when treated at larger oncology centers. CONCLUSIONS: Evidence that high volume hospitals have better outcomes is increasing for urological cancer surgeries. Whether volume affects quality or better clinicians and services attract more patients can be debated. Centralizing health care will have major health policy implications, ie high volume hospitals may be overwhelmed and low volume hospitals may be at a disadvantage. An alternative would be to attempt to improve outcomes at low volume hospitals by identifying drivers of high quality care at high volume hospitals and transferring some of these characteristics.

Clinical Competence↗

PubMed2004

Testing a new theory of patient satisfaction with treatment outcome.

OBJECTIVES: Theories of patient satisfaction with treatment outcome have not been developed and tested in healthcare settings. The objectives of this study were to test a new theory linking patient satisfaction and embodiment (body--self unity) and examine it in relation to other competing theories. DESIGN: We conducted a prospective cohort study. SETTING: This study was conducted at a tertiary care hospital. PATIENTS: We studied 122 individuals undergoing elective hand surgery. METHODS: Satisfaction with treatment outcome approximately 4 months after surgery was examined against the following factors (representing 7 theories of satisfaction): 1) overall clinical outcome, 2) patients' a priori self-selected important clinical outcomes, 3) foresight expectations, 4) hindsight expectations, 5) psychologic state, 6) psychologic state in those with poor outcomes, and 7) embodiment. ANALYSIS: Seven hypotheses were tested first using univariate analyses and then multivariable regression analysis. RESULTS: Satisfaction with treatment outcome was significantly associated with embodiment. Three confounders--the extent to which surgery successfully addressed patients' most important reason for surgery, hindsight expectations, and workers' compensation--were also significant. The final model explained 84% of the variance in a multidimensional measure of satisfaction with treatment outcome. CONCLUSION: This research suggests that satisfaction with treatment outcome could be facilitated by developing strategies to improve body--self unity, and eliciting and addressing the patient's most important reason for undergoing treatment.

Adolescent↗

PubMed2003

Measuring outcomes in aesthetic surgery: a comprehensive review of the literature.

Outcomes research examines the end results of medical interventions, taking into account patients' experiences, preferences, and values. The purpose of assessing outcomes is to provide evidence on which to base clinical decisions. The assessment of outcomes in aesthetic surgery is especially pertinent because patient satisfaction is the predominant factor in determining success. In cosmetic surgery, various scales have been used to assess outcomes. Unfortunately, none of these methods has achieved widespread use. The adoption of broadly accepted, relevant scales to measure outcomes would be advantageous, because this would allow the comparison of techniques, quantification of positive effects, and identification of patients unlikely to benefit from surgery. The purpose of this study was to critically review the present literature to identify the appropriate instruments to assess outcomes in aesthetic surgery. After a comprehensive review of aesthetic surgery outcome instruments, the authors identified body-image and quality-of-life measures to be of the greatest value in determining aesthetic surgery outcomes. These conclusions were based on a critical evaluation of the feasibility, validity, reliability, and sensitivity to change of these measures. The Multidimensional Body-States Relations Questionnaire (MBSRQ), a psychological assessment of body image, was selected as a potential candidate for further study. Two additional body-image assessment instruments, the Facial Appearance Sorting Test (FAST) and the Breast Chest Ratings Scale (BCRS), may be useful in the assessment of rhinoplasty and breast surgery, respectively. The Derriford Scale (DAS59), an instrument that assesses appearance-related quality of life, was also selected. In addition, the authors recommend the use of a generic, utility-based quality-of-life instrument, such as the Health Utilities Index (HUI) or the EuroQol (EQ-5D).

Body Image↗

PubMed2004

The impact of major trauma: quality-of-life outcomes are worse in women than in men, independent of mechanism and injury severity.

BACKGROUND: The importance of gender differences in quality of life and psychologic morbidity after major trauma is a newly recognized focus of trauma outcomes research. The Trauma Recovery Project is a large, prospective, epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL), and psychologic sequelae such as depression and early symptoms of acute stress reaction (SASR). The specific objectives of the present report are to examine gender differences in QoL outcomes and the early incidence of combined depression and SASR after injury, controlling for injury severity, specific body area injured, and mechanism. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay greater than 24 hours. QoL outcome after trauma was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Depression was assessed using the Center for Epidemiologic Studies scale. SASR was assessed using the Impact of Events scale. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. RESULTS: Women (n = 313) were significantly more likely to have poor QoL outcomes at follow-up than men (n = 735) (women vs. men: 12-month follow-up odds ratio [OR] = 2.2, p < 0.001; 18-month follow-up OR = 2.0, p < 0.001). Quality of Well-being scores at each of the 6-, 12-, and 18-month follow-up time points were markedly and significantly lower in women compared with men, independent of injury severity, serious and moderate injury status, lower extremity injury, intentional or unintentional injury type, and blunt or penetrating injury. Women were also significantly more likely to develop early combined depression and SASR at discharge (OR = 1.7, p < 0.01) and to have continuous depression throughout the 18-month follow-up period (OR = 2.3, p < 0.001). CONCLUSION: These analyses provide further important and more detailed evidence that women are at risk of worse QoL outcomes and early psychologic morbidity after major trauma than men, independent of mechanism and injury severity. A better understanding of the impact of major trauma in men and women will be an important component of efforts to improve trauma care and long-term outcome in mature trauma systems.

Adult↗

PubMed2004

The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial.

OBJECTIVE: Elderly patients (aged 60 years and older) have been demonstrated to have an increased mortality after isolated traumatic brain injury (TBI); however, the prognosis of those patients surviving their hospitalization is unknown. We hypothesized that surviving elderly patients would also have decreased functional outcome, and this study examined the functional outcome of patients with isolated TBI at discharge and at 6 months posthospitalization. METHODS: This was a multicenter prospective study of all patients with isolated moderate to severe TBI defined as Head Abbreviated Injury Scale score of 3 with an Abbreviated Injury Scale score in any other body area of 1. Patients surviving to discharge gave their consent and were enrolled. Data collected included demographics, Glasgow Coma Scale (GCS) score at admission, and neurosurgical interventions. Outcome data included discharge disposition and Glasgow Outcome Scale score and modified Functional Independence Measure (FIM) score at discharge and at 6 months. RESULTS: Two hundred thirty-five patients were enrolled, with 44 (19%) aged greater than or equal to 65 years. Mechanisms of injury were falls (34%), assaults (28%), motor vehicle collisions (14%), pedestrian (11%), and other (12%). Falls were more common in the older patients and assaults in the younger group. The mean admitting GCS score was 12.8 (95% confidence interval [CI], 12.4-13.3), with older patients having a higher mean GCS score, 14.1 (95% CI, 13.6-14.6) versus 12.5 (95% CI, 12.0-13.1; p = 0.03). There were no differences in the percentage of patients admitted to the intensive care unit or requiring neurosurgical intervention between younger and older patients. Because there were few elderly patients with low GCS scores who survived to discharge, outcome measures focused on those patients with GCS scores of 13 to 15. A greater percentage of elderly were discharged to rehabilitation (28% vs. 16%, p =0.08). The mean discharge FIM score was 10.4 (95% CI, 9.8-11.0) for the elderly versus 11.4 (95% CI, 11.1-11.7) for the young (p =0.001), with 68% elderly and 89% young discharged with total independent scores of 11 to 12. At 6 months, the difference narrowed, but the mean FIM score was still greater for the young group, 11.7 (95% CI, 11.6-11.9) versus 11.0 (95% CI, 10.6-11.4; p < 0.001). CONCLUSION: Functional outcome after isolated mild TBI as measured by the Glasgow Outcome Scale and modified FIM is generally good to excellent for both elderly and younger patients. Older patients required more inpatient rehabilitation and lagged behind their younger counterparts but continued to recover and improve after discharge. Although there were statistically significant differences in the FIM score at both discharge and 6 months, the clinical importance of these small differences in the mean FIM score to the patient's quality of life is less clear. Measurable improvement in functional status during the first 6 months after injury is observed in both groups. Aggressive management and care of older patients with TBI is warranted, and efforts should be made to decrease inpatient mortality. Continued follow-up is ongoing to determine whether these outcomes persist at 12 months.

Abbreviated Injury Scale↗

PubMed2025

Brain Health Loss Mediates the Effect of Infarct Volume on Functional Outcome in Ischemic Stroke.

IMPORTANCE: Brain health may facilitate resilience to detrimental consequences from neurological diseases. Infarct volume is associated with poor functional outcome after acute ischemic stroke (AIS), but potential mediating effects through stroke-related brain health loss have not been investigated. OBJECTIVE: To determine whether stroke-related brain health loss, quantified by change in MRI derived effective Reserve (eR), mediates the effect of acute infarct volume on functional outcome after AIS. DESIGN: Observational multicenter cohort study. SETTING: We analyzed data from the GASROS (n=488) and MRI-GENIE (n=560) cohorts, collected 2003-2011. PARTICIPANTS: Adult patients consecutively diagnosed with AIS, with available admission MRI. EXPOSURE: At admission, white matter hyperintensity (WMH) and normal-appearing brain volumes were assessed on T2-FLAIR, and acute infarct volume on diffusion weighted imaging. WMH was normalized by brain volume, creating WMH load. We quantified brain health using eR, a latent variable incorporating age, WMH load, and normal-appearing brain volume. ΔeR reflected the change in eR when acute infarct volume was included, representing stroke-related brain health decline. Mediation analysis was used to determine if ΔeR mediates the effect of infarct volume on functional outcome (modified Rankin Scale [mRS] at 90 days). MAIN OUTCOME MEASURE: Proportion of mediating effect. RESULTS: We included 1,048 patients (median age 67y, 38% females). At baseline, median NIHSS score was 3 (IQR 1-7), median infarct volume 3.1mL (IQR 0.9-15.5). At 90 days, median mRS score was 1 (IQR 1-3) and 51 (5%) patients had died. In mediation analysis, ΔeR significantly mediated 36% (95% CI 16-56%) of the total effect of infarct volume on functional outcome (direct effect (ß=0.15 [95% CI 0.09-0.22], p<0.001; indirect effect mediated through ΔeR: ß=0.09 [95% CI 0.04 to 0.14], p=0.001). In subgroup-analyses, the mediative effect was apparent among female but not male, and among patients aged >67y but not ≤67y. CONCLUSIONS AND RELEVANCE: Stroke-related structural brain health loss mediates about one third of the effect of acute infarct volume on functional outcome after ischemic stroke, with important sex and age differences. Brain health significantly influences outcome and recovery potential, and may be considered a key biomarker when modeling outcome after AIS.

acute ischemic stroke↗

PubMed2006

Nursing diagnoses, interventions and outcomes - application and impact on nursing practice: systematic review.

AIM: This paper reports a systematic review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes. BACKGROUND: Escalating healthcare costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies have evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review has not been carried out. METHOD: A Medline, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceeding articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis; each study was then assessed, and a level of evidence and grades of recommendations assigned. FINDINGS: Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found statistically significant improvements in the documentation of diagnoses, interventions and outcomes. However, limitations in diagnostic accuracy, reporting of signs/symptoms, and aetiology were also reported (14 studies). One meta-analysis of eight trials including 1497 patients showed no evidence that standardized electronic documentation of nursing diagnosis and related interventions led to better nursing outcomes. CONCLUSION: Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and aetiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.

Humans↗