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1.
J Stroke Cerebrovasc Dis ; 30(10): 106020, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34365121

RESUMEN

OBJECTIVES: A paucity of treatments to prevent delayed cerebral ischemia (DCI) has stymied recovery after aneurysmal subarachnoid hemorrhage (aSAH). Nicardipine has long been recognized as a potent cerebrovascular vasodilator with a history off-label use to prevent vasospasm and DCI. Multiple centers have developed nicardipine prolonged release implants (NPRI) that are directly applied during clip ligation to locally deliver nicardipine throughout the vasospasm window. Here we perform a systematic review and meta-analysis to assess whether NPRI confers protection against DCI and improves functional outcomes after aSAH. MATERIALS AND METHODS: A systematic search of PubMed, Ovid Embase, and Cochrane databases was performed for studies reporting the use of NPRI after aSAH published after January 1, 1980. We included all studies assessing the association of NPRI with DCI and or functional outcomes. Findings from studies with control arms were analyzed using a random effects model. A separate network meta-analysis was performed, including controlled NPRI studies, single-arm NPRI reports, and the control-arms of modern aSAH randomized clinical trials as additional comparators. RESULTS: The search identified 214 unique citations. Three studies with 284 patients met criteria for the random effects model. The pooled summary odds ratio for the association of NPRI and DCI was 0.21 (95% CI 0.09-0.49, p = 0.0002) with no difference in functional outcomes (OR 1.80, 95% CI 0.63 - 5.16, p = 0.28). 10 studies of 866 patients met criteria for the network meta-analysis. The pooled summary odds ratio for the association of NPRI and DCI was 0.30 (95% CI 0.13-0.89,p = 0.017) with a trend towards improved functional outcomes (OR 1.68, 0.63 - 4.13 95% CI, p = 0.101). CONCLUSIONS: In these meta-analyses, NPRI decreases the incidence of DCI with a non-significant trend towards improvement in functional outcomes. Randomized trials on the role of intrathecal calcium channel blockers are warranted to evaluate these observations in a prospective manner.


Asunto(s)
Isquemia Encefálica/prevención & control , Nicardipino/administración & dosificación , Hemorragia Subaracnoidea/tratamiento farmacológico , Vasodilatadores/administración & dosificación , Vasoespasmo Intracraneal/prevención & control , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/epidemiología , Isquemia Encefálica/fisiopatología , Implantes de Medicamentos , Humanos , Incidencia , Metaanálisis en Red , Nicardipino/efectos adversos , Recuperación de la Función , Factores de Riesgo , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/epidemiología , Hemorragia Subaracnoidea/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Vasodilatadores/efectos adversos , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/epidemiología , Vasoespasmo Intracraneal/fisiopatología
2.
Crit Care Med ; 47(11): e854-e862, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31389834

RESUMEN

OBJECTIVES: There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome. DESIGN: Multicenter prospective registry. SETTING: Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network. PATIENTS: Eight-hundred one spinal cord injury patients enrolled by participating centers. INTERVENTIONS: Appropriate spinal cord injury treatment at individual centers. MEASUREMENTS AND MAIN RESULTS: A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores. CONCLUSIONS: Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.


Asunto(s)
Traumatismos de la Médula Espinal/epidemiología , Escala Resumida de Traumatismos , Adulto , Depresión/epidemiología , Femenino , Humanos , Hipotensión/epidemiología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Limitación de la Movilidad , América del Norte/epidemiología , Neumonía/epidemiología , Sistema de Registros , Respiración Artificial/estadística & datos numéricos , Úlcera Cutánea/epidemiología , Supositorios , Vejiga Urinaria Neurogénica/epidemiología , Cateterismo Urinario/estadística & datos numéricos
3.
Ann Neurol ; 80(1): 46-58, 2016 07.
Artículo en Inglés | MEDLINE | ID: mdl-27129898

RESUMEN

OBJECTIVE: To create a multidimensional tool to prognosticate long-term functional, cognitive, and quality of life outcomes after spontaneous subarachnoid hemorrhage (SAH) using data up to 48 hours after admission. METHODS: Data were prospectively collected for 1,619 consecutive patients enrolled in the SAH outcome project July 1996 to March 2014. Linear models (LMs) were applied to identify factors associated with outcome in 1,526 patients with complete data. Twelve-month functional, cognitive, and quality of life outcomes were measured using the modified Rankin scale (mRS), Telephone Interview for Cognitive Status, and Sickness Impact Profile. Based on the LM residuals, we constructed the FRESH score (Functional Recovery Expected after Subarachnoid Hemorrhage). Score performance, discrimination, and internal validity were tested using the area under the receiver operating characteristic curve (AUC), Nagelkerke and Cox/Snell R(2) , and bootstrapping. For external validation, we used a control population of SAH patients from the CONSCIOUS-1 study (n = 413). RESULTS: The FRESH score was composed of Hunt & Hess and APACHE-II physiologic scores on admission, age, and aneurysmal rebleed within 48 hours. Separate scores to prognosticate 1-year cognition (FRESH-cog) and quality of life (FRESH-quol) were developed controlling for education and premorbid disability. Poor functional outcome (mRS = 4-6) for score levels 1 through 9 respectively was present in 3, 6, 12, 38, 61, 83, 92, 98, and 100% at 1-year follow-up. Performance of FRESH (AUC = 0.90), FRESH-cog (AUC = 0.80), and FRESH-quol (AUC = 0.78) was high. External validation of our cohort using mRS as endpoint showed satisfactory results (AUC = 0.77). To allow for convenient score calculation, we built a smartphone app available for free download. INTERPRETATION: FRESH is the first clinical tool to prognosticate long-term outcome after spontaneous SAH in a multidimensional manner. Ann Neurol 2016;80:46-58.


Asunto(s)
Técnicas de Diagnóstico Neurológico/estadística & datos numéricos , Hemorragia Subaracnoidea/diagnóstico , Cognición , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Calidad de Vida , Recuperación de la Función , Hemorragia Subaracnoidea/psicología
4.
Crit Care ; 21(1): 37, 2017 Feb 23.
Artículo en Inglés | MEDLINE | ID: mdl-28228155

RESUMEN

BACKGROUND: Elevated catecholamine levels might be associated with unfavorable outcome after traumatic brain injury (TBI). We investigated the association between catecholamine levels in the first 24 h post-trauma and functional outcome in patients with isolated moderate-to-severe TBI. METHODS: A cohort of 174 patients who sustained isolated blunt TBI was prospectively enrolled from three Level-1 Trauma Centers. Epinephrine (Epi) and norepinephrine (NE) concentrations were measured at admission (baseline), 6, 12 and 24 h post-injury. Outcome was assessed at 6 months by the extended Glasgow Outcome Scale (GOSE) score. Fractional polynomial plots and logistic regression models (fixed and random effects) were used to study the association between catecholamine levels and outcome. Effect size was reported as the odds ratio (OR) associated with one logarithmic change in catecholamine level. RESULTS: At 6 months, 109 patients (62.6%) had an unfavorable outcome (GOSE 5-8 vs. 1-4), including 51 deaths (29.3%). Higher admission levels of Epi were associated with a higher risk of unfavorable outcome (OR, 2.04, 95% CI: 1.31-3.18, p = 0.002) and mortality (OR, 2.86, 95% CI: 1.62-5.01, p = 0.001). Higher admission levels of NE were associated with higher risk of unfavorable outcome (OR, 1.59, 95% CI: 1.07-2.35, p = 0.022) but not mortality (OR, 1.45, 95% CI: 0.98-2.17, p = 0.07). There was no relationship between the changes in Epi levels over time and mortality or unfavorable outcome. Changes in NE levels with time were statistically associated with a higher risk of mortality, but the changes had no relation to unfavorable outcome. CONCLUSIONS: Elevated circulating catecholamines, especially Epi levels on hospital admission, are independently associated with functional outcome and mortality after isolated moderate-to-severe TBI.


Asunto(s)
Lesiones Traumáticas del Encéfalo/diagnóstico , Catecolaminas/análisis , Evaluación del Resultado de la Atención al Paciente , Adulto , Anciano , Biomarcadores/análisis , Biomarcadores/sangre , Lesiones Traumáticas del Encéfalo/mortalidad , Canadá , Catecolaminas/sangre , Estudios de Cohortes , Epinefrina/análisis , Epinefrina/sangre , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Norepinefrina/análisis , Norepinefrina/sangre , Estudios Prospectivos , Factores de Tiempo , Centros Traumatológicos/organización & administración , Estados Unidos , Heridas y Lesiones/complicaciones , Heridas y Lesiones/mortalidad
5.
Neurocrit Care ; 25(3): 338-350, 2016 12.
Artículo en Inglés | MEDLINE | ID: mdl-27651379

RESUMEN

BACKGROUND AND PURPOSE: Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population. METHODS: Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment. RESULTS: The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter. CONCLUSION: Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.


Asunto(s)
Evaluación de Resultado en la Atención de Salud , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/mortalidad , Hemorragia Subaracnoidea/terapia , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos
6.
Stroke ; 46(7): 1826-31, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-25977276

RESUMEN

BACKGROUND AND PURPOSE: Patients are classically at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. We validated a grading scale-the VASOGRADE-for prediction of DCI. METHODS: We used data of 3 phase II randomized clinical trials and a single hospital series to assess the relationship between the VASOGRADE and DCI. The VASOGRADE derived from previously published risk charts and consists of 3 categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale [WFNS] 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1-3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade). The relation between the VASOGRADE and DCI was assessed by logistic regression models. The predictive accuracy of the VASOGRADE was assessed by receiver operating characteristics curve and calibration plots. RESULTS: In a cohort of 746 patients, the VASOGRADE significantly predicted DCI (P<0.001). The VASOGRADE-Yellow had a tendency for increased risk for DCI (odds ratio [OR], 1.31; 95% CI, 0.77-2.23) when compared with VASOGRADE-Green; those with VASOGRADE-Red had a 3-fold higher risk of DCI (OR, 3.19; 95% CI, 2.07-4.50). Studies were not a significant confounding factor between the VASOGRADE and DCI. The VASOGRADE had an adequate discrimination for prediction of DCI (area under the receiver operating characteristics curve=0.63) and good calibration. CONCLUSIONS: The VASOGRADE results validated previously published risk charts in a large and diverse sample of subarachnoid hemorrhage patients, which allows DCI risk stratification on presentation after subarachnoid hemorrhage. It could help to select patients at high risk of DCI, as well as standardize treatment protocols and research studies.


Asunto(s)
Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Factores de Tiempo
7.
Neurocrit Care ; 21(3): 551-9, 2014 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24865271

RESUMEN

Researchers and other stakeholders continue to express concern about the failure of randomized clinical trials (RCT) in subarachnoid hemorrhage (SAH) to show efficacy of new treatments. Pooled data may be particularly useful to generate hypotheses about causes of poor outcomes and reasons for failure of RCT in SAH, and strategies to improve them. Investigators conducting SAH research collaborated to share data with the intent to develop a large repository of pooled individual patient data for exploratory analysis and testing of new hypotheses relevant to improved trial design and analysis in SAH. This repository currently contains information on 11,443 SAH patients from 14 clinical databases, of which 9 are datasets of recent RCTs and 5 are datasets of prospective observational studies and hospital registries. Most patients were managed in the last 15 years. Data validation and quality checks have been conducted and are satisfactory. Data is available on demographic, clinical, neuroimaging, and laboratory results and various outcome measures. We have compiled the largest known dataset of patients with SAH. The SAHIT repository may be an important resource for advancing clinical research in SAH and will benefit from contributions of additional datasets.


Asunto(s)
Investigación Biomédica , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de Registros , Hemorragia Subaracnoidea/terapia , Bases de Datos Factuales , Humanos , Estudios Prospectivos , Resultado del Tratamiento
8.
Spine J ; 24(3): 424-434, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-37918571

RESUMEN

BACKGROUND CONTEXT: Existing degenerative cervical myelopathy (DCM) severity scales have significant shortcomings, creating a strong impetus for the development of a practical measurement tool with sound psychometric properties. PURPOSE: This work reports the item generation and reduction of the Cervical Myelopathy Severity Index (CMSI), a new DCM patient-reported outcome measure of symptoms and functional limitations. DESIGN: Prospective observational study. PATIENT SAMPLE: Adult DCM patients belonging to one of three distinct treatment groups: (1) observation cohort, (2) preoperative surgical cohort, (3) 6 to 12 months postoperative cohort. OUTCOME MEASURES: Patient-reported outcome measure of symptoms and functional limitations. METHODS: Item generation was performed using semi-structured patient focus groups emphasizing symptoms experienced and functional limitations. Readability was assessed through think-aloud patient interviews. Item reduction involved surveys of DCM patients with a spectrum of disease severity and board-certified spine surgeons experienced in the treatment of DCM. A priori criteria for item removal included: patient median importance/severity <2 (of 4), 30% or more no severity (response of zero), item severity correlations ≤ 0.80 (Spearman), item severity reliability (weighted kappa <0.60) based on a 2-week interval and clinician median importance <2 with retention of items with very high clinical importance. RESULTS: There were 42 items generated from a combination of specialist input and patient focus groups. Items captured sensorimotor symptoms and limitations related to upper and lower extremities as well as sphincter dysfunction. Ninety-eight patients (43, 30, 25 observation, pre- and postsurgery respectively) and 51 surgeons completed the assessment. Twenty-three items remained after application of median importance and severity thresholds and weighted kappa cutoffs. After elimination of highly correlated (>0.80) items and combining two similar items, the final CMSI questionnaire list included 14 items. CONCLUSIONS: The CMSI is a new DCM patient-reported clinical measurement tool developed using patient and clinician input to inform item generation and reduction. Future work will evaluate the reliability, validity, and responsiveness of the CMSI in relation to existing myelopathy measurement indices.


Asunto(s)
Enfermedades de la Médula Espinal , Adulto , Humanos , Reproducibilidad de los Resultados , Enfermedades de la Médula Espinal/diagnóstico , Enfermedades de la Médula Espinal/cirugía , Psicometría , Medición de Resultados Informados por el Paciente , Estudios Prospectivos , Vértebras Cervicales/cirugía
9.
Stroke ; 44(10): 2842-7, 2013 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-23899917

RESUMEN

BACKGROUND AND PURPOSE: Studies in the United States and Canada have demonstrated socioeconomic gradients in outcomes of acute life-threatening cardiovascular and cerebrovascular diseases. The extent to which these findings are applicable to subarachnoid hemorrhage is uncertain. This study investigated socioeconomic status-related differences in risk of inpatient mortality and use of institutional postacute care after subarachnoid hemorrhage in the United States and Canada. METHODS: Subarachnoid hemorrhage patient records in the US Nationwide Inpatient Sample database (2005-2010) and the Canadian Discharge Abstract Database (2004-2010) were analyzed separately, and summative results were compared. Both databases are nationally representative and contain relevant sociodemographic, diagnostic, procedural, and administrative information. We determined socioeconomic status on the basis of estimated median household income of residents for patient's ZIP or postal code. Multinomial logistic regression models were fitted with adjustment for relevant confounding covariates. RESULTS: The cohort consisted of 31,631 US patients and 16,531 Canadian patients. Mean age (58 years) and crude inpatient mortality rates (22%) were similar in both countries. A significant income-mortality association was observed among US patients (odds ratio, 0.77; 95% CI, 0.65-0.93), which was absent among Canadian patients (odds ratio, 0.97; 95% CI, 0.85-1.12). Neighborhood income status was not significantly associated with use of postacute care in the 2 countries. CONCLUSIONS: Socioeconomic status is associated with subarachnoid hemorrhage inpatient mortality risk in the United States, but not in Canada, although it does not influence the pattern of use of institutional care among survivors in both countries.


Asunto(s)
Bases de Datos Factuales , Pacientes Internos , Hemorragia Subaracnoidea/mortalidad , Adulto , Anciano , Canadá/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores Socioeconómicos , Hemorragia Subaracnoidea/terapia , Estados Unidos/epidemiología
10.
Neurocrit Care ; 18(1): 143-53, 2013 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-23138544

RESUMEN

BACKGROUND: Clinical prediction models can enhance clinical decision-making and research. However, available prediction models in aneurysmal subarachnoid hemorrhage (aSAH) are rarely used. We evaluated the methodological validity of SAH prediction models and the relevance of the main predictors to identify potentially reliable models and to guide future attempts at model development. METHODS: We searched the EMBASE, MEDLINE, and Web of Science databases from January 1995 to June 2012 to identify studies that reported clinical prediction models for mortality and functional outcome in aSAH. Validated methods were used to minimize bias. RESULTS: Eleven studies were identified; 3 developed models from datasets of phase 3 clinical trials, the others from single hospital records. The median patient sample size was 340 (interquartile range 149-733). The main predictors used were age (n = 8), Fisher grade (n = 6), World Federation of Neurological Surgeons grade (n = 5), aneurysm size (n = 5), and Hunt and Hess grade (n = 3). Age was consistently dichotomized. Potential predictors were prescreened by univariate analysis in 36 % of studies. Only one study was penalized for model optimism. Details about model development were often insufficiently described and no published studies provided external validation. CONCLUSIONS: While clinical prediction models for aSAH use a few simple predictors, there are substantial methodological problems with the models and none have had external validation. This precludes the use of existing models for clinical or research purposes. We recommend further studies to develop and validate reliable clinical prediction models for aSAH.


Asunto(s)
Técnicas de Apoyo para la Decisión , Recuperación de la Función , Hemorragia Subaracnoidea/mortalidad , Humanos , Resultado del Tratamiento
11.
J Neurosurg Spine ; : 1-9, 2023 Mar 17.
Artículo en Inglés | MEDLINE | ID: mdl-36933253

RESUMEN

OBJECTIVE: There is a need to better understand and predict postsurgical outcomes for degenerative cervical myelopathy (DCM) patients, particularly to support treatment decisions for patients with mild DCM. The goal of this study was to identify and predict outcome trajectories for DCM patients up to 2 years postsurgery. METHODS: The authors analyzed two North American multicenter prospective DCM studies (n = 757). Functional recovery and physical health component quality of life were assessed in DCM patients at baseline, 6 months, and 1 and 2 years postoperatively using the modified Japanese Orthopaedic Association (mJOA) score and Physical Component Summary (PCS) of the SF-36, respectively. Group-based trajectory modeling was used to identify recovery trajectories for mild, moderate, and severe DCM. Prediction models for recovery trajectories were developed and validated in bootstrap resamples. RESULTS: Two recovery trajectories were identified for the functional and physical components of quality of life: good recovery and marginal recovery. Depending on outcome and myelopathy severity, one-half to three-fourths of the study patients followed the good recovery trajectory characterized by improvement in mJOA and PCS scores over time. The remaining one-half to one-fourth of patients followed the marginal recovery trajectory, experiencing little improvement and, in certain cases, worsening postoperatively. The prediction model for mild DCM had an area under the curve of 0.72 (95% CI 0.65-0.80), with preoperative neck pain, smoking, and posterior surgical approach noted as dominant predictors of marginal recovery. CONCLUSIONS: Surgically treated DCM patients follow distinct recovery trajectories in the first 2 years postoperatively. While most patients experience substantial improvement, a significant minority experience little improvement or worsening. The ability to predict DCM patient recovery trajectories in the preoperative setting facilitates the formulation of individualized treatment recommendations for patients with mild symptoms.

12.
Sci Rep ; 13(1): 7578, 2023 05 10.
Artículo en Inglés | MEDLINE | ID: mdl-37165004

RESUMEN

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [- 8.72 × 10-4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.


Asunto(s)
Fragilidad , Traumatismos de la Médula Espinal , Humanos , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/mortalidad , Médula Cervical , Hospitalización , Fragilidad/complicaciones , Pronóstico , Estudios Retrospectivos , Modelos Logísticos , Factores de Edad , Masculino , Femenino , Persona de Mediana Edad
13.
Neurosurgery ; 93(6): 1305-1312, 2023 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-37341486

RESUMEN

BACKGROUND AND OBJECTIVES: It is believed that early tracheostomy in patients with traumatic cervical spinal cord injury (SCI) may lessen the risk of developing complications and reduce the duration of mechanical ventilation and critical care stay. This study aims to assess whether early tracheostomy is beneficial in patients with traumatic cervical SCI. METHODS: We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program database from 2010 to 2018. Adult patients with a diagnosis of acute complete (ASIA A) traumatic cervical SCI who underwent surgery and tracheostomy were included. Patients were stratified into those receiving early (at or before 7 days) and delayed tracheostomy. Propensity score matching was used to assess the association between delayed tracheostomy and the risk of in-hospital adverse events. Risk-adjusted variability in tracheostomy timing across trauma centers was investigated using mixed-effects regression. RESULTS: The study included 2001 patients from 374 North American trauma centers. The median time to tracheostomy was 9.2 days (IQR: 6.1-13.1 days), with 654 patients (32.7%) undergoing early tracheostomy. After matching, the odds of a major complication were significantly lower for early tracheostomy patients (OR: .90; 95% CI: .88-.98). Patients were also significantly less likely to experience an immobility-related complication (OR: .90; 95% CI: .88-.98). Patients in the early group spent 8.2 fewer days in the critical care unit (95% CI: -10.2 to -6.61) and 6.7 fewer days ventilated (95% CI: -9.44 to -5.23). There was significant variability in tracheostomy timeliness between trauma centers with a median odds ratio of 12.2 (95% CI: 9.7-13.7), which was not explained by case-mix and hospital-level characteristics. CONCLUSION: A 7-day threshold to implement tracheostomy seems to be associated with reduced in-hospital complications, time in the critical care unit, and time on mechanical ventilation.


Asunto(s)
Médula Cervical , Traumatismos del Cuello , Traumatismos de la Médula Espinal , Adulto , Humanos , Estudios Retrospectivos , Traqueostomía/efectos adversos , Respiración Artificial , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/epidemiología , Traumatismos de la Médula Espinal/cirugía , Traumatismos del Cuello/cirugía
14.
Sci Rep ; 13(1): 6276, 2023 04 18.
Artículo en Inglés | MEDLINE | ID: mdl-37072405

RESUMEN

Odontoid fractures are increasingly prevalent in older adults and associated with high morbidity and mortality. Optimal management remains controversial. Our study aims to investigate the association between surgical management of odontoid fractures and in-hospital mortality in a multi-center geriatric cohort. We identified patients 65 years or older with C2 odontoid fractures from the Trauma Quality Improvement Program database. The primary study outcome was in-hospital mortality. Secondary outcomes were in-hospital complications and hospital length of stay. Generalized estimating equation models were used to compare outcomes between operative and non-operative cohorts. Among the 13,218 eligible patients, 1100 (8.3%) were treated surgically. The risk of in-hospital mortality did not differ between surgical and non-surgical groups, after patient and hospital-level adjustment (OR: 0.94, 95%CI: 0.55-1.60). The risks of major complications and immobility-related complications were higher in the operative cohort (adjusted OR: 2.12, 95%CI: 1.53-2.94; and OR: 2.24, 95%CI: 1.38-3.63, respectively). Patients undergoing surgery had extended in-hospital length of stay compared to the non-operative group (9 days, IQR: 6-12 days vs. 4 days, IQR: 3-7 days). These findings were supported by secondary analyses that considered between-center differences in rates of surgery. Among geriatric patients with odontoid fractures surgical management was associated with similar in-hospital mortality, but higher in-hospital complication rates compared to non-operative management. Surgical management of geriatric patients with odontoid fractures requires careful patient selection and consideration of pre-existing comorbidities.


Asunto(s)
Fracturas Óseas , Apófisis Odontoides , Fracturas de la Columna Vertebral , Humanos , Anciano , Estudios Retrospectivos , Fracturas de la Columna Vertebral/cirugía , Resultado del Tratamiento , Apófisis Odontoides/cirugía
15.
J Neurosurg ; 136(1): 115-124, 2022 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-34087804

RESUMEN

OBJECTIVE: Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication. METHODS: Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. RESULTS: The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44-0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61-2.91). CONCLUSIONS: IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.


Asunto(s)
Bloqueadores de los Canales de Calcio/administración & dosificación , Bloqueadores de los Canales de Calcio/uso terapéutico , Nicardipino/administración & dosificación , Nicardipino/uso terapéutico , Hemorragia Subaracnoidea/complicaciones , Vasoespasmo Intracraneal/tratamiento farmacológico , Vasoespasmo Intracraneal/etiología , Adulto , Factores de Edad , Anciano , Aneurisma Roto , Rotura de la Aorta/complicaciones , Rotura de la Aorta/cirugía , Bloqueadores de los Canales de Calcio/efectos adversos , Cuidados Críticos , Procedimientos Endovasculares , Femenino , Humanos , Inyecciones Espinales , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos , Nicardipino/efectos adversos , Puntaje de Propensión , Estudios Retrospectivos , Resultado del Tratamiento
16.
J Neurosurg ; 136(1): 134-147, 2022 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-34214980

RESUMEN

OBJECTIVE: Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy. METHODS: Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. RESULTS: The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17). CONCLUSIONS: Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.


Asunto(s)
Hemorragia Subaracnoidea/complicaciones , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/terapia , Factores de Edad , Anciano , Infarto Encefálico/complicaciones , Isquemia Encefálica/etiología , Isquemia Encefálica/terapia , Infarto Cerebral , Análisis por Conglomerados , Análisis Factorial , Femenino , Teoría del Juego , Escala de Consecuencias de Glasgow , Humanos , Aprendizaje Automático , Masculino , Persona de Mediana Edad , Pronóstico , Puntaje de Propensión , Resultado del Tratamiento
17.
Neurology ; 2021 Apr 13.
Artículo en Inglés | MEDLINE | ID: mdl-33849991

RESUMEN

OBJECTIVE: To test the hypothesis that sensorimotor complete traumatic cervical spinal cord injury is a heterogenous clinical entity comprising several subpopulations that follow fundamentally different trajectories of neurologic recovery. METHODS: We analyzed demographic and injury data from 655 patients who were pooled from 4 prospective longitudinal multicenter studies. Group based trajectory modeling was applied to model neurologic recovery trajectories over the initial 12-months postinjury and to identify predictors of recovery trajectories. Neurologic outcomes included: Upper Extremity Motor Score, Total Motor Scores and AIS grade improvement. RESULTS: The analysis identified 3 distinct trajectories of neurologic recovery. These clinical courses included: (1) Marginal recovery trajectory: characterized by minimal or no improvement in motor strength or change in AIS grade status (remained grade A); (2) Moderate recovery trajectory: characterized by low baseline motor scores that improved approximately 13 points; or AIS conversion of one grade point; (3) Good recovery trajectory: characterized by baseline motor scores in the upper quartile that improved to near maximum values within 3 months of injury. Patients following the moderate or good recovery trajectories were of younger age, had more caudally located injuries, a higher degree of preserved motor and sensory function at baseline examination and exhibited a greater extent of motor and sensory function in the zone of partial preservation. CONCLUSION: Cervical complete SCI can be classified into one of 3 distinct subpopulations with fundamentally different trajectories of neurologic recovery. This study defines unique clinical phenotypes based on potential for recovery, rather than baseline severity of injury alone. This approach may prove beneficial in clinical prognostication and in the design and interpretation of clinical trials in SCI.

18.
Neurosurgery ; 87(4): 672-678, 2020 09 15.
Artículo en Inglés | MEDLINE | ID: mdl-31642497

RESUMEN

BACKGROUND: Degenerative spondylolisthesis (DS) is often treated with lumbar spinal fusion (LSF). However, there is concern that the morbidity of LSF may be prohibitively high in older adults. OBJECTIVE: To evaluate the impact of advanced age on the safety of LSF for DS. METHODS: Patients who underwent LSF for DS were retrospectively identified from National Surgical Quality Improvement Program datasets for 2011 to 2015 using Current Procedural Terminology codes. Data on demographic characteristics, comorbidities, surgical factors, and 30-d morbidity and mortality were collected. Propensity score matching (nearest neighbor) was performed with age (<70 vs ≥70 yr) as the dependent variable and sex, type of fusion procedure, number of levels fused, diabetes, smoking, hypertension, and chronic steroid use as covariates. Outcomes were compared between age <70 and ≥70 groups. RESULTS: The study cohort consisted of 2238 patients (n = 1119, age <70; n = 1119, age ≥70). The 2 age groups were balanced for key covariates including sex, race, diabetes, hypertension, CHF, smoking, chronic steroid use, type of fusion, and number of levels. Rates of all complications were similar between younger and older age groups, except urinary tract infection, which was more frequent among the ≥70 age group (OR 2.32, P = .009). Further, patients in the older age group were more likely to be discharged to a rehabilitation (OR 2.94, P < .001) or skilled care (OR 3.66, P < .001) facility, rather than directly home (OR 0.25, P < .001). CONCLUSION: LSF may be performed safely in older adults with DS. Our results suggest older age alone should not exclude a patient from undergoing lumbar fusion for DS.


Asunto(s)
Degeneración del Disco Intervertebral/cirugía , Fusión Vertebral/métodos , Espondilolistesis/cirugía , Resultado del Tratamiento , Factores de Edad , Anciano , Estudios de Cohortes , Femenino , Humanos , Degeneración del Disco Intervertebral/mortalidad , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios Retrospectivos , Fusión Vertebral/mortalidad , Espondilolistesis/mortalidad
19.
World Neurosurg ; 134: e112-e119, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31574327

RESUMEN

BACKGROUND: The optimal surgical approach for multilevel degenerative cervical myelopathy (DCM) is unclear, and there is significant variation in practice patterns. We sought to compare inpatient complications and costs of anterior (ACDF) versus posterior cervical decompression and fusion (PCDF). METHODS: Patients who underwent multilevel ACDF or PCDF for DCM were identified from the National Inpatient Sample for 2004-2014 using ICD-9-CM codes. Propensity score matching was performed with age, sex, comorbidities, hospital bed size, and use of intraoperative monitoring as covariates. Hospitalization charges/costs, length of stay (LOS), discharge disposition, and inpatient morbidity/mortality were compared between matched ACDF and PCDF groups. RESULTS: Propensity score matching generated a cohort of 13,884 patients (n = 6,942 ACDF; n = 6,942 PCDF). PCDF was associated with greater LOS (mean difference [MD] +1.7 days, P < 0.001) and less frequent routine discharge home (odds ratio [OR] 0.26, P < 0.01). With regard to complications, PCDF had a higher rate of myocardial infarction (OR 1.6, P = 0.007), pulmonary embolism (OR 2.6, P = 0.009), deep vein thrombosis (OR 3.7, P < 0.001), neurological complications (OR 1.7, P = 0.037), hardware-related complications (OR 2.7, P < 0.001), wound infection/breakdown (OR 6.8, P < 0.001), and cerebrospinal fluid leak (OR 1.7, P = 0.011). By contrast, rates of postoperative hematoma (OR 0.61, P = 0.007), hoarseness (OR 0.13, P < 0.001), and dysphagia (OR 0.20, P < 0.001) were higher after ACDF. Mortality was comparable. Hospital charges (MD +$26,259, P < 0.001) and costs (MD +$7,728, P < 0.001) were significantly higher for PCDF. CONCLUSIONS: At a national level, for multilevel DCM, we found PCDF to be associated with greater LOS, in-hospital costs, and general medical and surgical complications. ACDF carried higher risk of postoperative hematoma, hoarseness, and dysphagia.


Asunto(s)
Descompresión Quirúrgica/economía , Costos de la Atención en Salud/estadística & datos numéricos , Procedimientos Neuroquirúrgicos/economía , Enfermedades de la Médula Espinal/cirugía , Fusión Vertebral/economía , Vértebras Cervicales/cirugía , Femenino , Humanos , Pacientes Internos , Masculino , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Espondilosis/cirugía , Resultado del Tratamiento
20.
Mult Scler Relat Disord ; 34: 17-28, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31226545

RESUMEN

BACKGROUND: Emotions play a critical role in our daily decisions. However, it remains unclear how and what sort of emotional expressions are associated with therapeutic decisions in multiple sclerosis (MS) care. Our goal was to evaluate the relationship between emotions and affective states (as captured by muscle facial activity and emotional expressions) and TI amongst neurologists caring for MS patients when making therapeutic decisions. METHODS: 38 neurologists with expertise in MS were invited to participate in a face-to-face study across Canada. Participants answered questions regarding their clinical practice, aversion to ambiguity, and the management of 10 simulated case-scenarios. TI was defined as lack of treatment initiation or escalation when there was clear evidence of clinical and radiological disease activity. We recorded facial muscle activations and their associated emotional expressions during the study, while participants made therapeutic choices. We used a validated machine learning algorithm of the AFFDEX software to code for facial muscle activations and a predefined mapping to emotional expressions (disgust, fear, surprise, etc.). Mixed effects models and mediation analyses were used to evaluate the relationship between ambiguity aversion, facial muscle activity/emotional expressions and TI measured as a binary variable and a continuous score. RESULTS: 34 (89.4%) neurologists completed the study. The mean age [standard deviation (SD)] was 44.6 (11.5) years; 38.3% were female and 58.8% self-identified as MS specialists. Overall, 17 (50%) participants showed TI in at least one case-scenario and the mean (SD) TI score was 0.74 (0.90). Nineteen (55.9%) participants had aversion to ambiguity in the financial domain. The multivariate analysis adjusted for age, sex and MS expertise showed that aversion to ambiguity in the financial domain (OR 1.56, 95%CI 1.32-1.86) was associated with TI. Most common muscle activations included mouth open (23.4%), brow furrow (20.9%), brow raise (17.6%), and eye widening (13.1%). Most common emotional expressions included fear (5.1%), disgust (3.2%), sadness (2.9%), and surprise (2.8%). After adjustment for age, sex, and physicians' expertise, the multivariate analysis revealed that brow furrow (OR 1.04; 95%CI 1.003-1.09) and lip suck (OR 1.06; 95%CI 1.01-1.11) were associated with an increase in TI prevalence, whereas upper lip raise (OR 0.30; 95%CI 0.15-0.59), and chin raise (OR 0.90; 95%CI 0.83-0.98) were associated with lower likelihood of TI. Disgust and surprise were associated with a lower TI score (disgust: p < 0.001; surprise: p = 0.008) and lower prevalence of TI (ORdisgust: 0.14, 95%CI 0.03-0.65; ORsurprise: 0.66, 94%CI 0.47-0.92) after adjusting for covariates. The mediation analysis showed that brow furrow was a partial mediator explaining 21.2% (95%CI 14.9%-38.9%) of the association between aversion to ambiguity and TI score, followed by nose wrinkle 12.8% (95%CI 8.9%-23.4%). Similarly, disgust was the single emotional expression (partial mediator) that attenuated (-13.2%, 95%CI -9.2% to -24.3%) the effect of aversion to ambiguity on TI. CONCLUSIONS: TI was observed in half of participants in at least one case-scenario. Our data suggest that facial metrics (e.g. brow furrow, nose wrinkle) and emotional expressions (e.g. disgust) are associated with physicians' choices and partially mediate the effect of aversion to ambiguity on TI.


Asunto(s)
Toma de Decisiones Clínicas , Emociones , Expresión Facial , Esclerosis Múltiple/terapia , Neurólogos/psicología , Adulto , Estudios Transversales , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Riesgo , Especialización , Incertidumbre
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