Prospective evaluation of the reliability, validity, and minimally important difference of the functional assessment of cancer therapy-gastric (FACT-Ga) quality-of-life instrument.

BACKGROUND: Recently, the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) was developed to measure the quality of life (QoL) of patients with gastric cancer. This newly developed instrument has not yet been validated. METHODS: Eighty-two patients with gastric adenocarcinoma completed questionnaires at baseline. The FACT-Ga scores were measured as a function of disease stage and performance status, and they were correlated with the Medical Outcomes Study 36-item short-form health survey (SF-36), the Beck Depression Inventory-II, the Marlow-Crowne Social Desirability Scale, the Paulhus Deception Scale, and the State-Trait Anxiety Inventory. Patients received a second questionnaire 2 weeks after baseline to evaluate test-retest reliability and again at 3 months to evaluate the sensitivity of the FACT-Ga to changes in performance status and to estimate the minimally important differences in scores that represented meaningful change. RESULTS: The internal and test-retest reliability of the FACT-Ga instrument was adequate. With the exception of the social well being subscale, all FACT-Ga scores were correlated as hypothesized with other measures. Relevant components of the FACT-Ga were sensitive to changes in performance status. CONCLUSIONS: The current results indicated that the FACT-Ga provides a valid and reliable measurement of QoL in patients with gastric adenocarcinoma. It is a useful instrument for QoL assessment in clinical trials, and it also may be useful for the detection of significant changes in the QoL of individual patients.

Referral and treatment rates of neoadjuvant chemotherapy in muscle-invasive bladder cancer before and after publication of a clinical practice guideline.

INTRODUCTION: The objective of this study was to compare referral and treatment rates of neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer before and after publication of a clinical practice guideline. METHODS: This was a retrospective comparative cohort study of 236 patients diagnosed with clinical stage >/= T2 bladder cancer in Alberta, Canada. Patients were divided into 2 groups based on the time of diagnosis relative to the publication of the Alberta Genitourinary Oncology Group Clinical Practice Guideline on Bladder Cancer (CPG), which recommends cisplatin-based neoadjuvant chemotherapy for muscle-invasive disease. The pre-CPG group included patients (n = 129) diagnosed prior to publication of the CPG (November 1, 2002 to October 31, 2004, inclusively). The post-CPG group included patients (n = 107) diagnosed after publication of the CPG (November 1, 2005 to October 31, 2007). There was an accrual blackout period of 6 months before and after the CPG release date. The primary analysis compared the two groups with respect to neoadjuvant chemotherapy referral rates, treatment-offered rates and treatment-administered rates. RESULTS: Referral to medical oncology regarding neoadjuvant chemotherapy occurred in 2.3% and 23.4% of patients in the pre- and post-CPG groups, respectively (p < 0.01). Neoadjuvant chemotherapy was offered to 0.8% and 18.7% of patients in the pre- and post-CPG groups, respectively (p < 0.01). Neoadjuvant chemotherapy was administered to 0.8% and 14.0% of patients in the pre- and post-CPG groups, respectively (p < 0.01). INTERPRETATION: Neoadjuvant referral and treatment rates increased after publication of the CPG. However, overall referral and treatment rates remained low, which warrants additional exploration.

Carotid endarterectomy benefits patients with CKD and symptomatic high-grade stenosis.

Endarterectomy is generally recommended for symptomatic high-grade (70 to 99%) stenosis of the internal carotid artery, but whether this procedure is beneficial among patients with chronic kidney disease (CKD) is unknown. In this re-analysis of data from the North American Symptomatic Carotid Endarterectomy Trial, we included patients with symptomatic stenosis and either stage 3 CKD (n = 524) or preserved kidney function (n = 966; estimated GFR > or = 60). For medically treated patients with high-grade stenosis, risk for ipsilateral stroke at 2 yr was significantly higher in patients with CKD than in those with preserved renal function (31.6 versus 19.3%; P = 0.042); carotid endarterectomy significantly reduced this risk by 82 and 51%, respectively. To prevent one ipsilateral stroke, the number needed to treat by endarterectomy was four for patients with CKD and 10 for patients with preserved renal function. Compared with patients with preserved renal function, those with CKD had similar rates of perioperative stroke and death but higher rates of cardiac events. In conclusion, patients with stage 3 CKD and symptomatic high-grade carotid stenosis gain a large benefit in stroke risk reduction after endarterectomy.

Complication rates after left- versus right-sided carotid endarterectomy.

BACKGROUND: Studies suggest that the side of carotid endarterectomy (CE) may influence the rate of postoperative complications. We sought to clarify this by (1) analysis of individual-level data from 3 large studies and (2) systematic review and meta-analysis of additional published descriptions of outcomes by side. METHODS AND RESULTS: The Western Canada Carotid Endarterectomy (WCCE) study (n=3164) was analyzed for outcomes by side along with data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET; n=1415), and the ASA [Acetylsalicylic Acid] in Carotid Endarterectomy Trial (ACE; n=2469). Pooled analysis of individual-level data from these three studies allowed calculation of rate ratios for stroke or death by side. Medline and EMBASE were searched to identify additional studies reporting CE outcomes by side, and an overall risk ratio for outcomes by side was determined with fixed-effects meta-analysis. The WCCE in-hospital stroke or death rates for left and right-sided CE were 3.72% and 3.07%, respectively (P=0.27). A pooled analysis of the NASCET and ACE trials also revealed higher stroke or death rates for left-sided CE (5.39% versus 2.96%; P<0.001). The corresponding risk-adjusted rate ratios for stroke or death for left- versus right-sided surgery were 1.22 (95% CI, 0.83 to 1.77) for WCCE and 1.82 (1.32 to 2.50) for the pooled NASCET and ACE trials. Systematic review of the literature identified 2 additional studies. Meta-analysis of all 5 available studies yielded a corresponding pooled rate ratio for stroke or death of 1.36 (1.18 to 1.56). CONCLUSIONS: Left-sided CE is consistently associated with higher postoperative adverse event rates. Research into potential mechanisms is required to explain and address this finding.

A longitudinal community study of major depression and physical activity.

BACKGROUND: The objective of this study was to determine whether major depressive episodes (MDEs) are associated transitions between active and inactive recreational activity patterns. METHODS: The data source was the Canadian National Population Health Survey (NPHS). The NPHS included a brief instrument to assess MDEs and collected data on participation in recreational activities. In order to meaningfully categorize participation in recreational activities, the participation data was translated into overall estimated metabolic energy expenditure. A threshold of 1.5 kcal/kg per day was used to distinguish between active and inactive activity patterns. Proportional hazards models were used to compare the incidence of inactivity in initially active respondents with and without MDE and to compare the frequency of becoming active among initially inactive respondents with and without MDE. RESULTS: For active respondents with MDE, an elevated risk of transition into an inactive pattern was observed [adjusted hazard ratio (HR)=1.6; 95% CI 1.2-1.9]. However, MDE did not affect the probability of moving from an inactive to an active lifestyle (adjusted HR=1.0; 95% CI 0.78-1.19). CONCLUSIONS: Major depressive episodes are associated with an increased risk of transition from an active to an inactive pattern of activity.

Phosphate decreases urine calcium and increases calcium balance: a meta-analysis of the osteoporosis acid-ash diet hypothesis.

BACKGROUND: The acid-ash hypothesis posits that increased excretion of "acidic" ions derived from the diet, such as phosphate, contributes to net acidic ion excretion, urine calcium excretion, demineralization of bone, and osteoporosis. The public is advised by various media to follow an alkaline diet to lower their acidic ion intakes. The objectives of this meta-analysis were to quantify the contribution of phosphate to bone loss in healthy adult subjects; specifically, a) to assess the effect of supplemental dietary phosphate on urine calcium, calcium balance, and markers of bone metabolism; and to assess whether these affects are altered by the b) level of calcium intake, c) the degree of protonation of the phosphate. METHODS: Literature was identified through computerized searches regarding phosphate with surrogate and/or direct markers of bone health, and was assessed for methodological quality. Multiple linear regression analyses, weighted for sample size, were used to combine the study results. Tests of interaction included stratification by calcium intake and degree of protonation of the phosphate supplement. RESULTS: Twelve studies including 30 intervention arms manipulated 269 subjects' phosphate intakes. Three studies reported net acid excretion. All of the meta-analyses demonstrated significant decreases in urine calcium excretion in response to phosphate supplements whether the calcium intake was high or low, regardless of the degree of protonation of the phosphate supplement. None of the meta-analyses revealed lower calcium balance in response to increased phosphate intakes, whether the calcium intake was high or low, or the composition of the phosphate supplement. CONCLUSION: All of the findings from this meta-analysis were contrary to the acid ash hypothesis. Higher phosphate intakes were associated with decreased urine calcium and increased calcium retention. This meta-analysis did not find evidence that phosphate intake contributes to demineralization of bone or to bone calcium excretion in the urine. Dietary advice that dairy products, meats, and grains are detrimental to bone health due to "acidic" phosphate content needs reassessment. There is no evidence that higher phosphate intakes are detrimental to bone health.

Low 5-year stability of within-patient ion excretion and urine pH in fasting-morning-urine specimens.

Most analyses of urine ion excretion and pH are based on 24-hour urine collections. However, fasting morning urine, collected in the morning after an initial void and a short fast, is easier to collect and may be sensitive to dietary intake. The objective of this study was to determine whether the within-subject dietary acid load is stable by testing the levels of urine pH and ion excretion (ie, calcium, chloride, magnesium, phosphate, potassium, sodium, sulfate) in fasting morning urine specimens collected at a 5-year interval. Stable variables provide the best utility as potential risk factors. The subjects were 200 randomly selected adults (mean age = 61.5 +/- 11.1 years) from the 420 subjects who donated baseline and 5-year urine samples in the Canadian Multicentre Osteoporosis Study. The samples were collected in the morning after an initial void and a wait of 2 hours, while subjects maintained a fast from the evening before. The intraclass correlation coefficient was calculated to characterize the level of agreement between the baseline and 5-year urine samples as an indirect measure of diet stability. The stability of the within-subject urine measures over 5 years ranged from fair to moderate, and none were ranked as substantially stable. This fair-to-moderate stability of fasting morning urine measures of the diet acid load indicates a limited ability of a single sample of fasting morning urine to estimate subjects' actual long-term urine composition.

Volume imaging in the abdomen with ultrasound: how we do it.

OBJECTIVE: The objective of our study was to evaluate the feasibility of volumetric acquisition of the abdominal organs using performance guidelines that we developed in our preliminary experience. MATERIALS AND METHODS: Mechanical volumetric acquisitions of each abdominal organ, including the liver, gallbladder, pancreas, kidneys, spleen, bowel, and aorta, were performed in 200 consecutive patients. RESULTS: One thousand four hundred fifty-four volume data sets were graded for feasibility of performance and technical adequacy from I (impossible, incomplete) to V (excellent, complete). The most successfully imaged organ was the right kidney (grades IV and V, 95.0%) and the least successfully imaged, the spleen (grades IV and V, 69.0%). Very good to excellent grades (IV and V) were obtained in 1,215 (83.6%) of the 1,454 volumes. One hundred twelve (7.7%) of the 1,454 volumes were failures (grades I and II). The three organs with the highest success compared with the right kidney were the left kidney, gallbladder, and liver. The data sets of all the other organs showed a statistically significant difference in the feasibility of performance from the right kidney. Liver acquisition failures were associated with end-stage liver cirrhosis (n = 6), fatty liver (n = 3), and obesity (n = 3). Other acquisition failures, similar to conventional sonography, were associated with bowel gas interference and poor acoustic window. The technical limitations include poor resolution in the B and C planes and a limited range of frequencies; these limitations can be overcome in the future with matrix transducers and introduction of the technology to a broader frequency range. CONCLUSION: Volumetric acquisition in the abdomen performed using defined guidelines is feasible with recognized limitations. Technology advances will improve this imaging technique in the future.

Meta-analysis of the effect of the acid-ash hypothesis of osteoporosis on calcium balance.

The acid-ash hypothesis posits that protein and grain foods, with a low potassium intake, produce a diet acid load, net acid excretion (NAE), increased urine calcium, and release of calcium from the skeleton, leading to osteoporosis. The objectives of this meta-analysis were to assess the effect of changes in NAE, by manipulation of healthy adult subjects' acid-base intakes, on urine calcium, calcium balance, and a marker of bone metabolism, N-telopeptides. This meta-analysis was limited to studies that used superior methodological quality for the study of calcium metabolism. We systematically searched the literature and included studies if subjects were randomized to the interventions and followed the recommendations of the Institute of Medicine's Panel on Calcium and Related Nutrients for calcium studies. Five of 16 studies met the inclusion criteria. The studies altered the amount and/or type of protein. Despite a significant linear relationship between an increase in NAE and urinary calcium (p < 0.0001), there was no relationship between a change of NAE and a change of calcium balance (p = 0.38; power = 94%). There was no relationship between a change of NAE and a change in the marker of bone metabolism, N-telopeptides (p = 0.95). In conclusion, this meta-analysis does not support the concept that the calciuria associated with higher NAE reflects a net loss of whole body calcium. There is no evidence from superior quality balance studies that increasing the diet acid load promotes skeletal bone mineral loss or osteoporosis. Changes of urine calcium do not accurately represent calcium balance. Promotion of the "alkaline diet" to prevent calcium loss is not justified.

Major depression, antidepressant medication and the risk of obesity.

BACKGROUND: Cross-sectional studies have reported an association between major depressive episode (MDE) and obesity. The objective of this longitudinal analysis was to determine whether MDE increase the risk of becoming obese over a 10-year period. METHOD: We used data from the Canadian National Population Health Survey (NPHS), a longitudinal study of a representative cohort of household residents in Canada. The incidence of obesity, defined as a body mass index (BMI) of > or =30, was evaluated in respondents who were 18 years or older at the time of a baseline interview in 1994. MDE was assessed using a brief diagnostic instrument. RESULTS: The risk of obesity was not elevated in association with MDE, either in unadjusted or covariate-adjusted analyses. The strongest predictor of obesity was a BMI in the overweight (but not obese) range. Effects were also seen for (younger) age, (female) sex, a sedentary activity pattern, low income and exposure to antidepressant medications. Unexpectedly, significant effects were seen for serotonin-reuptake-inhibiting antidepressants and venlafaxine, but neither for tricyclic antidepressants nor antipsychotic medications. CONCLUSIONS: MDE does not appear to increase the risk of obesity. The cross-sectional associations that have been reported, albeit inconsistently, in the literature probably represent an effect of obesity on MDE risk. Pharmacologic treatment with antidepressants may be associated with an increased risk of obesity, and strategies to offset this risk may be useful in clinical practice.

The effect of major depression on participation in preventive health care activities.

BACKGROUND: The objective of this study was to determine whether major depressive episodes (MDE) contribute to a lower rate of participation in three prevention activities: blood pressure checks, mammograms and Pap tests. METHODS: The data source for this study was the Canadian National Population Health Survey (NPHS), a longitudinal study that started in 1994 and has subsequently re-interviewed its participants every two years. The NPHS included a short form version of the Composite International Diagnostic Interview (CIDI-SF) to assess past year MDE and also collected data on participation in preventive activities. Initially, we examined whether respondents with MDE in a particular year were less likely to participate in screening during that same year. In order to assess whether MDE negatively altered the pattern of participation, those successfully screened at the baseline interview in 1994 were identified and divided into cohorts depending on their MDE status. Proportional hazard models were used to quantify the effect of MDE on subsequent participation in screening. RESULTS: No effect of MDE on participation in the three preventive activities was identified either in the cross-sectional or longitudinal analysis. Adjustment for a set of relevant covariates did not alter this result. CONCLUSION: Whereas MDE might be expected to reduce the frequency of participation in screening activities, no evidence for this was found in the current analysis. Since people with MDE may contact the health system more frequently, this may offset any tendency of the illness itself to reduce participation in screening.

Major depression as a risk factor for high blood pressure: epidemiologic evidence from a national longitudinal study.

OBJECTIVE: To determine whether major depression (MD) leads to an increased risk of new-onset high blood pressure diagnoses. METHODS: The data source was the Canadian National Population Health Survey (NPHS). The NPHS included a short-form version of the Composite International Diagnostic Interview (CIDI-SF) to assess MD and collected self-report data about professionally diagnosed high blood pressure and the use of antihypertensive medications. The analysis included 12,270 respondents who did not report high blood pressure or the use of antihypertensive medications at a baseline interview conducted in 1994. Proportional hazards models were used to compare the incidence of high blood pressure in respondents with and without MD during 10 years of subsequent follow-up. RESULTS: After adjustment for age, the risk of developing high blood pressure was elevated in those with MD. The hazard ratio was 1.6 (95% Confidence Interval = 1.2-2.1), p = .001, indicating a 60% increase in risk. Adjustment for additional covariates did not alter the association. CONCLUSIONS: MD may be a risk factor for new-onset high blood pressure. Epidemiologic data cannot definitely confirm a causal role, and the association may be due to shared etiologic factors. However, the increased risk may warrant closer monitoring of blood pressure in people with depressive disorders.

Allergies and major depression: a longitudinal community study.

BACKGROUND: Cross-sectional studies have reported associations between allergies and major depression but in the absence of longitudinal data, the implications of this association remain unclear. Our goal was to examine this association from a longitudinal perspective. METHODS: The data source was the Canadian National Population Health Survey (NPHS). This study included a short form version of the Composite International Diagnostic Interview (CIDI-SF) to assess major depression and also included self report items for professionally diagnosed allergies of two types: non-food allergies and food allergies. A longitudinal cohort was followed between 1994 and 2002. Proportional hazards models for grouped time data were used to estimate unadjusted and adjusted hazard ratios. RESULTS: A slightly increased incidence of non-food allergies in respondents with major depression was observed: adjusted hazard ratio 1.2 (95% 1.0 - 1.5, p = 0.046). Some evidence for an increased incidence of major depression in association with non-food allergies was found in unadjusted analyses, but the association did not persist after multivariate adjustment. Food allergies were not associated with major depression incidence, nor was major depression associated with an increased incidence of food allergies. CONCLUSION: Findings from the present study support the idea that major depression is associated with an increased risk of developing non-food allergies. An effect in the opposite direction could not be confirmed. The observed effect may be due to shared genetic factors, epigenetic factors, or immunological changes that occur during depression.

Does intravenous rtPA benefit patients in the absence of CT angiographically visible intracranial occlusion?

BACKGROUND: In patients with acute stroke receiving intravenous tissue plasminogen activator (tPA), we postulated that the presence of intracranial occlusion on CT angiography (CTA) modifies the benefit of thrombolysis. MATERIALS AND METHODS: Using a retrospective cohort design, we identified patients with acute ischemic stroke in our CTA database between May 2002 and August 2007. All the patients had a CTA within 12 h of onset, a premorbid modified Rankin scale (mRS) < or = 1, and a baseline National Institute of Health Stroke Scale score(NIHSS)f > or = 6. The primary outcome was early effectiveness of tPA defined as an NIHSS score of < or = 2 at 24 h or a 4-point NIHSS improvement at 24 h. Secondary outcome included mRS < or = 1 at 90 days. The relationship between intracranial occlusion on CTA and benefit of tPA was assessed using a test for interaction. RESULTS: A total of 287 patients met the criteria [occlusion present N =168; (98 with tPA; 70 without tPA) and occlusion absent N = 119; (52 with tPA; 67 without tPA)]. Those with intracranial occlusion were likely to have more severe strokes (NIHSS > or = 15; P < 0.001) and abnormal brain imaging (ASPECTS < or =7; P < 0.001). For outcome of 4-point NIHSS score improvement at 24 h, benefit from tPA was observed only among patients with a visible occlusion (absolute difference in favor of tPA: 20.4% vs. 0.7%; P = 0.06). CONCLUSION: In patients with acute ischemic stroke, thrombolysis produced a better early clinical response among patients with intracranial occlusion, which needs to be confirmed in stroke thrombolysis trials.

Prospective evaluation of the effect of major depression on working status in a population sample.

OBJECTIVE: Numerous surveys have reported associations between major depressive episodes (MDEs) and occupational status, but cross-sectional studies cannot quantify the risks of employment transitions nor clarify their temporal direction. The goal of our study was to estimate the impact of MDE on subsequent employment status in a longitudinal community cohort. METHODS: Data from the National Population Health Survey (NPHS) were used. Proportional hazard models and logistic regression were employed to evaluate the effect of MDE on working status during the 1994 to 2004 interval among respondents who reported working at a job or business at baseline. RESULTS: MDE was associated with an increased risk of movement to nonworking status. People aged 26 to 45 years with MDEs have more than double the risk of this transition (HR = 2.6; 95% CI 1.8 to 3.6, P < 0.001). The probability of transition to nonworking status was higher, but the relative effect was smaller in people aged 46 to 65 years (HR = 1.2; 95% CI 0.7 to 2.0, P = 0.47). Retirement or perceived lack of availability of work did not contribute to the association. CONCLUSIONS: MDE is associated with an elevated risk of transition from working to nonworking status, especially in people aged 26 to 45 years.

Meta-analysis of the quantity of calcium excretion associated with the net acid excretion of the modern diet under the acid-ash diet hypothesis.

BACKGROUND: The acid-ash diet hypothesis of osteoporosis suggests that acid from the modern diet causes a demineralization of the skeleton, and mobilized bone calcium is excreted. A systematic approach has not been used to summarize the findings of the numerous studies about the hypothesis. OBJECTIVES: The purpose of this meta-analysis was to estimate the quantity of net acid excretion and calciuria associated with the modern diet, to assess the association between acid excretion and calcium excretion, and to assess the influence of urine preservatives on calcium measurement. DESIGN: We systematically searched for trials of the acid-ash hypothesis and conducted a meta-analysis. RESULTS: Twenty-five of 105 studies met the inclusion criteria. The estimated quantity of net acid excretion from the weighted average of the control diets from 11 studies was 47 mEq/d. The increase in urinary calcium with a change in renal net acid excretion depended on whether the urine was acidic or alkaline (P < 0.001). A significant linear relation was observed between net acid excretion and calcium excretion for both acidic and alkaline urine (P < 0.001). The estimated change in urine calcium associated with a change of 47 mEq of net acid excretion in acidic urine was 1.6 mmol/d (66 mg/d) of calcium. CONCLUSION: Evidence suggests a linear association between changes in calcium excretion in response to experimental changes in net acid excretion. However, this finding is not evidence that the source of the excreted calcium is bone or that this calciuria contributes to the development of osteoporosis.

Major depression as a risk factor for chronic disease incidence: longitudinal analyses in a general population cohort.

OBJECTIVE: Cross-sectional studies have consistently reported associations between major depression (MD) and chronic medical conditions. Such studies cannot clarify whether medical conditions increase the risk for MD or vice versa. The latter possibility has received relatively little attention in the literature. In this study, we evaluate the incidence of several important chronic medical conditions in people with and without MD. METHOD: The data source was the Canadian National Population Health Survey (NPHS). The NPHS included the Composite International Diagnostic Interview Short Form to assess past-year major depressive episodes. The NPHS also collected self-report data about professionally diagnosed long-term medical conditions. A longitudinal cohort was interviewed every 2 years between 1994 and 2002. Proportional hazards models were used to compare the incidence of chronic conditions in respondents with and without MD and to produce age-, sex- and covariate-adjusted estimates of the hazard ratios. RESULTS: The adjusted hazard ratios associated with MD at baseline interview were elevated for several long-term medical conditions: heart disease (1.7), arthritis (1.9), asthma (2.1), back pain (1.4), chronic bronchitis or emphysema (2.2), hypertension (1.7) and migraines (1.9). The incidences of cataracts and glaucoma, peptic ulcers and thyroid disease were not higher in respondents with MD. CONCLUSION: A set of conditions characterized particularly by pain, inflammation and/or autonomic reactivity has a higher incidence in people with MD.

An improved scoring system for identifying patients at high early risk of stroke and functional impairment after an acute transient ischemic attack or minor stroke.

BACKGROUND: Risk of a subsequent stroke following an acute transient ischemic attack (TIA) or minor stroke is high. The ABCD(2) tool was proposed as a method to triage these patients using five clinical factors. Modern imaging of the brain was not included. The present study quantified the added value of magnetic resonance imaging (MRI) factors to the ABCD(2) tool. METHODS: Patients with TIA or minor stroke were examined within 12 h and had a brain MRI within 24 h of symptom onset. Primary outcomes were recurrent stroke and functional impairment at 90 days. A new tool, ABCD(2)+MRI, was created by adding diffusion-weighted imaging lesion and vessel occlusion status to the ABCD(2) tool. The predictive accuracy of both tools was quantified by the area under the curve (AUC). RESULTS: One hundred and eighty patients were enrolled and 11.1% had a recurrent stroke within 90 days. The predictive accuracy of the ABCD(2)+MRI was significantly higher than ABCD(2) (AUC of 0.88 vs. 0.78, P=0.01). Those with a high score (7-9) had a 90-day recurrent stroke risk of 32.1%, moderate score (5-6) risk of 5.4%, and low score (0-4) risk of 0.0%. The ABCD(2) tool did not predict risk of functional impairment at 90 days (P=0.33), unlike the ABCD(2)+MRI (P=0.02): high score (22.9%), moderate (7.5%), low (7.7%). CONCLUSIONS: Risk of recurrent stroke and functional impairment after a TIA or minor stroke can be accurately predicted by a scoring system that utilizes both clinical and MRI information. The ABCD(2)+MRI score is simple and its components are commonly available during the time of admission.

Assessing severity of epilepsy in children: preliminary evidence of validity and reliability of a single-item scale.

The development and initial validity and reliability testing of a single-item, 7-point global rating scale designed for neurologists to assess the overall severity of epilepsy in children, the Global Assessment of Severity of Epilepsy (GASE) Scale, is described. The GASE Scale was quick and easy to use. Median epilepsy severity in the development sample was 3 (moderately severe), with a range from 1 ("not severe at all") in 36 patients (26.9%) to 7 ("extremely severe") in 7 patients (5.2%). Preliminary evidence of construct validity was found in support for our a priori predictions of associations between GASE scores and neurologists' ratings of seven individual clinical aspects of epilepsy and in a cumulative R(2) for the GASE score of 81% using ratings of the clinical aspects of epilepsy. Weighted kappa was 0.85 (95% CI: 0.79, 0.90) for inter-rater reliability and 0.90 (95% CI: 0.82, 0.98) and 0.95 (95% CI: 0.91, 0.98) for test-retest reliability for each of two raters. These promising initial results support continuation of the multistage process of testing the validity and reliability of the GASE Scale within various clinical contexts.

The prevalence and management of current daily pain among older home care clients.

The aim of this cross-sectional study was to examine the prevalence and correlates of pharmacotherapy for current daily pain in older home care clients, focusing on analgesic type and potential contraindications to treatment. The sample included 2779 clients aged 65+years receiving services from Community Care Access Centres in Ontario during 1999-2001. Clients were assessed with the Resident Assessment Instrument-Home Care (RAI-HC). Prescription and over-the-counter (OTC) medications listed on the RAI-HC were used to categorize analgesic treatment into two groups (relative to no analgesic use): use of non-opioids (acetaminophen or non-steroidal anti-inflammatory drugs only); and, use of opioids alone or in combination with non-opioids. Associations between client characteristics and analgesic treatment among those in current daily pain were examined using multivariable multinomial logistic regression. Approximately 48% (n=1,329) of clients had daily pain and one-fifth (21.6%) of this group received no analgesic. In multivariable analyses, clients aged 75+years and those with congestive heart failure, diabetes, other disease-related contraindications, cognitive impairment and/or requiring an interpreter were significantly less likely to receive an opioid alone or in combination with a non-opioid. Clients with congestive heart failure and without a diagnosis of arthritis were significantly less likely to receive a non-opioid alone. A diagnosis of arthritis or cancer and use of nine or more medications were significantly associated with opioid use. The findings provide evidence of both rational prescribing practices and potential treatment bias in the pharmacotherapeutic management of daily pain in older home care clients.