The Impact of Introducing a Physical Medicine and Rehabilitation Trauma Consultation Service to an Academic Level 1 Trauma Center.

OBJECTIVE: Previous retrospective studies suggest that early physical medicine and rehabilitation (PM&R) consultation for trauma patients improves outcome and reduces acute care length of stay (LOS). There have not been controlled studies to evaluate this impact. This study assesses the impact of PM&R consultations on acute trauma patients. DESIGN: This study compared measured outcomes before and after the introduction of a PM&R consultation service to the trauma program at a large academic hospital. The primary outcome measure was acute care LOS. RESULTS: The 274 historical controls and 76 patients who received a PM&R consultation were not different in injury severity score, age, or sex. Length of stay was not different between the two groups. However, when early (≤8 days after injury) versus late (>8 days) consults were compared, the early group had a markedly lower LOS (12 vs. 30 days, P < 0.001). When adjusted for injury severity score, an early consult was associated with an 11.8-day lower LOS (P < 0.001). The early consult group also had fewer complications and less usage of benzodiazepines and antipsychotics. CONCLUSIONS: An acute care PM&R consultation of 8 days or less after admission is associated with a shorter acute care LOS, fewer complications, and less use of benzodiazepines and antipsychotics.

A narrative review of the impact of medical comorbidities on stroke rehabilitation outcomes.

PURPOSE: Medical comorbidities in stroke patients influence acute mortality, but may also affect participation of survivors in rehabilitation. There is limited research investigating the impact of comorbidities on stroke rehabilitation outcomes. The review will explore the literature on the impact of comorbidities on stroke rehabilitation outcome. MATERIALS AND METHODS: The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome. RESULTS: Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes. CONCLUSIONS: There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes. Implications for rehabilitation Benefit of rehabilitation after stroke in improving functional outcome is well-established. Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation. The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.

Impact of global cerebral atrophy on clinical outcome after subarachnoid hemorrhage.

OBJECT: Atrophy in specific brain areas correlates with poor neuropsychological outcome after subarachnoid hemorrhage (SAH). Few studies have compared global atrophy in SAH with outcome. The authors examined the relationship between global brain atrophy, clinical factors, and outcome after SAH. METHODS: This study was a post hoc exploratory analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial, a randomized, double-blind, placebo-controlled trial of 413 patients with aneurysmal SAH. Patients with infarctions or areas of encephalomalacia on CT, and those with large clip/coil artifacts, were excluded. The 97 remaining patients underwent CT at baseline and 6 weeks, which was analyzed using voxel-based volumetric measurements. The percentage difference in volume between time points was compared against clinical variables. The relationship with clinical outcome was modeled using univariate and multivariate analysis. RESULTS: Older age, male sex, and systemic inflammatory response syndrome (SIRS) during intensive care stay were significantly associated with brain atrophy. Greater brain atrophy was significantly associated with poor outcome on the modified Rankin scale (mRS), severity of deficits on the National Institutes of Health Stroke Scale (NIHSS), worse executive functioning, and lower EuroQol Group-5D (EQ-5D) score. Adjusted for confounders, brain atrophy was not significantly associated with Mini-Mental State Examination and Functional Status Examination scores. Brain atrophy was not associated with angiographic vasospasm or delayed ischemic neurological deficit. CONCLUSIONS: Worse mRS score, NIHSS score, executive functioning, and EQ-5D scores were associated with greater brain atrophy and older age, male sex, and SIRS burden. These data suggest outcome is associated with factors that cause global brain injury independent of focal brain injury.

Global cerebral atrophy after subarachnoid hemorrhage: a possible marker of acute brain injury and assessment of its impact on outcome.

There is a correlation between poor neuropsychological outcome and focal regions of atrophy in patients with subarachnoid hemorrhage (SAH). No study has investigated the impact of global brain atrophy on outcome after SAH. In other neurological disorders, such as multiple sclerosis, a correlation has been found between global atrophy and outcome. This analysis of patients entered into a randomized clinical trial of clazosentan in patients with SAH (CONSCIOUS-1) investigated the relationship between global cerebral atrophy, clinical factors, and outcome.The 413 patients in the CONSCIOUS-1 study underwent cranial computed tomography (CT) on admission and 6 weeks after SAH. After patients with large clip/coil artefacts and those with infarctions on CT were excluded, 97 patients remained and had voxel-based volumetric measurements of the baseline and 6-week CT scans. The percentage difference in volume between times was taken and analysed against clinical variables. Relationships were modeled using univariate and multivariate analysis.Age, female gender, and higher body temperature during the patient's stay in the intensive care unit were significantly correlated with brain atrophy. Greater brain atrophy significantly correlated with poor outcome (modified Rankin scale), more severe neurological deficits on the National Institute of Health Stroke Scale (NIHSS), and poorer health status (EQ-5D).

Impact of systemic inflammatory response syndrome on vasospasm, cerebral infarction, and outcome after subarachnoid hemorrhage: exploratory analysis of CONSCIOUS-1 database.

BACKGROUND: Systemic inflammatory response syndrome (SIRS) may develop after aneurysmal subarachnoid hemorrhage (SAH). We investigated factors associated with SIRS after SAH, whether SIRS was associated with complications of SAH such as vasospasm, cerebral infarction, and clinical outcome, and whether SIRS could contribute to a difference in outcome between patients treated by endovascular coiling or neurosurgical clipping of the ruptured aneurysm. METHODS: This was exploratory analysis of 413 patients in the CONSCIOUS-1 study. SIRS was diagnosed if the patient had at least 2 of 4 variables (hypothermia/fever, tachycardia, tachypnea, and leukocytosis/leukopenia) within 4 days of admission. Clinical outcome was measured on the Glasgow outcome scale 3 months after SAH. The relationship between clinical and radiologic variables and SIRS, angiographic vasospasm, delayed ischemic neurologic deficit (DIND), cerebral infarction, vasospasm-related infarction, and clinical outcome were modeled with uni- and multivariable analyses. RESULTS: 63% of patients developed SIRS. Many factors were associated with SIRS in univariate analysis, but only poor WFNS grade and pneumonia were independently associated with SIRS in multivariable analysis. SIRS burden (number of SIRS variables per day over the first 4 days) was associated with poor outcome, but not with angiographic vasospasm, DIND, or cerebral infarction. The method of aneurysm treatment was not associated with SIRS. CONCLUSION: SIRS was associated with poor outcome but not angiographic vasospasm, DIND, or cerebral infarction after SAH in the CONSCIOUS-1 data. There was no support for the notion that neurosurgical clipping is associated with a greater risk of SIRS than endovascular coiling.

Persistent Ca2+ current contributes to a prolonged depolarization in Aplysia bag cell neurons.

Neurons may initiate behavior or store information by translating prior activity into a lengthy change in excitability. For example, brief input to the bag cell neurons of Aplysia results in an approximate 30-min afterdischarge that induces reproduction. Similarly, momentary stimulation of cultured bag cells neurons evokes a prolonged depolarization lasting many minutes. Contributing to this is a voltage-independent cation current activated by Ca(2+) entering during the stimulus. However, the cation current is relatively short-lived, and we hypothesized that a second, voltage-dependent persistent current sustains the prolonged depolarization. In bag cell neurons, the inward voltage-dependent current is carried by Ca(2+); thus we tested for persistent Ca(2+) current in primary culture under voltage clamp. The observed current activated between -40 and -50 mV exhibited a very slow decay, presented a similar magnitude regardless of stimulus duration (10-60 s), and, like the rapid Ca(2+) current, was enhanced when Ba(2+) was the permeant ion. The rapid and persistent Ca(2+) current, but not the cation current, were Ni(2+) sensitive. Consistent with the persistent current contributing to the response, Ni(2+) reduced the amplitude of a prolonged depolarization evoked under current clamp. Finally, protein kinase C activation enhanced the rapid and persistent Ca(2+) current as well as increased the prolonged depolarization when elicited by an action potential-independent stimulus. Thus the prolonged depolarization arises from Ca(2+) influx triggering a cation current, followed by voltage-dependent activation of a persistent Ca(2+) current and is subject to modulation. Such synergy between currents may represent a common means of achieving activity-dependent changes to excitability.