Recovery Time of Independent Poststroke Abilities: Part I

The purposes of this study were to determine the time of the recovery of poststroke abilities and to identify prognostic indicators associated with recovery time among stroke patients undergoing a rehabilitation program. A sample of 421 stroke participants admitted to a rehabilitation center was recruited from medical records that were available from January 1987 to December 1992. The mean age was 61.8 years (range, 17-89 years). The relationship between the achievement of independent poststroke abilities and the potential covariates associated with recovery time was assessed through the analysis of survival data. Cox maximum-likelihood proportional hazard models were used for the analysis. Independent poststroke abilities included behavior, cognitive, perceptual, communication, visual, and motor status. The time from rehabilitation admission to complete independence was introduced to the model in relation to the covariates. The mean time of recovery of poststroke abilities ranged from 18.70 to 32.40 days from the rehabilitation admission. The survival analysis revealed that the time of recovery of the selected poststroke abilities was significantly influenced (p <.05) by one or several factors, among these were neuropsychological, physical, and life habits. With this precious information, stroke rehabilitation specialists may be able to reduce the length of time required to recover independent poststroke abilities by treating the specific neuropsychological, physical, and life habit characteristics identified in this study. A faster poststroke recovery will reduce the socioeconomic impact generated by stroke disability and will ensure a better quality of life to the stroke survivor.

Faith, Trust and the Perinatal Healthcare Maze in Urban India

How women access and utilise health services through pregnancy, childbirth and infancy needs to be understood if we are to improve the delivery of and access to appropriate healthcare. Drawing on ethnographic observations of clinic encounters and in-depth interviews with women in Bangalore, South India, this paper reports on the complexities of negotiating healthcare throughout the perinatal continuum in urban India. Key themes identified include faith and trust in health services, confusion over right to healthcare; and the contested nature of choice for women. What is revealed is a socially restrictive framework that results in choices that seem arbitrary, irrational and self-defeating; poor women being particularly vulnerable. Given the current policy support for public-private-partnerships in reproductive healthcare delivery in India, both public and private health services need to move substantially to achieve true partnership and provide care that is respectful and valued by women and children in urban India.

Abstract P2-11-07: Endothelial progenitor cells as novel markers of anthracycline induced cardiac injury

Background: Anthracyclines including doxorubicin (DOX) cause myocardial damage that manifests as either subclinical decrements of left ventricular ejection function (LVEF) or overt cardiomyopathy. LVEF changes and cardiac risk factors are insufficient predictors of future DOX cardiotoxicity. Bone marrow derived endothelial progenitor cells (EPCs) are mobilized and are homed to sites of myocardial injury to help with repair of damaged myocardium. We hypothesized that EPC levels would be indicative of early DOX cardiotoxicity. Hence, we prospectively collected serial blood samples to evaluate functional EPCs, Troponin I (Ti) and B-natriuretic peptide (BNP), in patients (pts) receiving DOX-based chemotherapy.

Methods: Eligible pts were initiating adjuvant DOX for early stage breast cancer. Pts underwent cardiac magnetic resonance (CMR), Ti, BNP, and EPC at baseline, after 1 cycle of DOX, and after completion of DOX. CD133+ progenitor cells were isolated from the peripheral blood mononuclear cells (PBMC) using AutoMACS (automated magnetic cell sorting, Miltenyi Biotech). In vitro colony forming unit (CFU) assay was performed for isolated CD133+ progenitor cells on MethoCult (Stemcell Technology). After 8 days of culture, EPC colonies were counted using a two-step image analysis algorithm. Repeated measures analysis of variance modeled changes in cardiac markers over time. Logistic regression was used to correlate variables with abnormal Ti.

Results: Forty two women were enrolled. The average age was 52 years (range 33–68) and stage distribution was I (14%), II (58%) and III (28%). All but one patient received peg-fligrastim after DOX. Thirty six pts had EPC/cardiac biomarkers and twenty nine pts had CMRs at all three time points. LVEF decreased 1.6% following completion of DOX (95% CI: −3.8 to 0.6, p = 0.16). There was a non-linear trend in EPCs over time (p = 0.05), with an initial increase followed by a decrease, with average values of 59 (95% CI: 50–70), 65 (95% CI: 55–75), and 50 (95% CI: 40–60), respectively, across the three time points. By the end of treatment, 54% (95% CI: 0.37–0.71) of women had abnormal troponins (median: 0.03, range: 0.02 to 0.17). Variables associated with abnormal troponins included lower baseline EPCs (p = 0.095), older age (p = 0.075) and initial increase in BNP post cycle 1 (p &lt; 0.03). In a multivariable model, age (p = 0.04) and BNP (p = 0.04) were independent prognostic factors for abnormal troponins, where the odds of abnormal troponins was 65% higher for every 5-year increase in age (OR = 1.65, 95% CI: 1.02–2.66) and 58% higher for every 1.5-fold increase in BNP (OR = 1.58, 95% CI: 1.01–2.46). Baseline EPC did not remain in the final model with p = 0.12.

Conclusions: DOX was well-tolerated with no significant changes in LVEF as measured by serials CMRs. Older age and increased BNP were independent prognostic factors for rise in Ti. We observed an initial increase of EPCs with DOX exposure followed by a decrease after the end of treatment. Although not statistically significant, lower EPCs at baseline, corresponding to lower cardiac reserve, were correlated with abnormal Ti. This is the first study reporting an intriguing association of EPCs with traditional cardiac biomarkers during DOX chemotherapy. Funded by R21 CA143787-02.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-07.

Volume and accreditation, but not specialty, affect quality standards in colonoscopy

BACKGROUND

The Global Rating Scale, defined by the Joint Advisory Group for Gastrointestinal Endoscopy, requires monitoring of endoscopic performance indicators. There are known variations in colonoscopic performance, and investigation of factors causing this is needed. This study aimed to analyse the impact of endoscopist specialty and procedural volume on the quality of colonoscopy.

METHODS

Data collected prospectively from a UK hospital endoscopy service between June 2007 and January 2010 were analysed. The main endpoint was the adenoma detection rate (ADR). Secondary endpoints were polyp detection rate (PDR), reported caecal intubation rate (CIR) and reported complications. Multivariable binary regression models were built to adjust for confounding patient-level and endoscopist-level variation.

RESULTS

A total of 10,026 colonoscopies were included, with an overall ADR of 19.2 per cent, a CIR of 90.2 per cent and a perforation rate of 0.06 per cent. In univariable analyses, surgeons had a higher ADR and higher PDR, but lower CIR, compared with physicians. Surgeons had a significantly different case mix in terms of age, sex and indication for colonoscopy. After adjusting for this case mix in multivariable analysis, specialty was no longer a significant predictor of ADR; however, surgeons retained their higher PDR and physicians their higher CIR. Endoscopists accredited for screening and those performing more than 100 colonoscopies per year had a higher ADR.

CONCLUSION

Adjusting for case mix, physicians and surgeons performed equally well in terms of ADR. Accreditation and a higher annual number of colonoscopies were more important factors in achieving quality standards.

Renal granular cell tumour (Abrikossoff tumour): case report and review of the literature

A 52-year-old female was referred to our institute for an incidental renal mass. A homogenously enhancing mass was detected on multidetector CT (MDCT) imaging. Histologically, the tumour was consistent with granular cell tumour (GCT). GCT is a benign tumour that often involves the skin and subcutaneous tissue. Rarely has it been reported to involve the genitourinary system. Here we present the first reported case of GCT with renal involvement along with its MDCT imaging features. The authors also present a review of the literature along with a review of typical MDCT imaging features of enhancing renal masses with emphasis given to renal cell carcinoma and its varying subtypes.

Persistence of fruitless caesarean sections in Indian rural women

Caesarean section is one of the commonest major surgical procedures in public and private hospitals. The worldwide rise in the caesarean section rate during the last 50 years is cause for alarm and a matter of concern. This increase deserves international attention not only because of health consequences, resource administration and policies, but also because high caesarean section rates are not associated with low perinatal mortality rates. The present study is an analysis of indications of caesarean sections performed with no take-home baby ('fruitless' caesarean section) between April 1983 and March 2007. It was revealed that the caesarean section rate has increased from 15.47% of births in 1983 to 37.96% births in 2007, and 03.75% of these were fruitless. The overall perinatal mortality rate has reduced from 91.56 in 1983 to 51.20 in 2007, for various reasons. This analysis reveals a large increase in caesarean sections with many being fruitless. While the major causes of perinatal mortality were sepsis, prematurity and congenital anomalies which need to be addressed, it is also essential to review the indications of caesarean section, so as to prevent fruitless caesarean sections.

Update experience of surgery for acute limb ischaemia in a district general hospital - are we getting any better?

INTRODUCTION

The aims of this study were to audit results of a 10-year experience of surgery for acute limb ischaemia (ALI) in terms of limb salvage and mortality rates, and to compare results with a historical published series from our unit.

PATIENTS AND METHODS

All emergency operations performed during the period 1993-2003 were identified from theatre registers and patient notes reviewed to determine indications for, and outcome of, surgery. Data were compared to a similar cohort who underwent surgery from 1980 to 1990.

RESULTS

There was a 33% increase in workload from 87 to 116 patients between the two time periods. The number of patients with idiopathic ALI reduced (24% versus 4%; P < 0.05), and there were fewer smokers (71% versus 39%; P < 0.05) and a greater number of claudicants (17% versus 35%; P < 0.05) in those treated from 1993-2003. Latterly, more patients underwent pre-operative heparinisation (33% versus 80%; P < 0.05), received prophylactic antibiotics (14% versus 63%; P < 0.05), and had anaesthetic presence in theatre (46% versus 88%; P < 0.05). There was also a reduction in local anaesthetic procedures (80% versus 41%; P < 0.05). Despite increased pre-operative (15% versus 47%; P < 0.05) and on-table imaging (0% versus 16%; P < 0.05) technical success did not improve. Whilst complication rates were identical at 62%, there were fewer cardiovascular complications in the recent cohort. The 30-day mortality rate for embolectomy fell from 45% to 33%. Multivariate analysis revealed age > 70 years, prolonged symptom duration, ASA score > or = III, lack of prophylactic antibiotics, absence of an anaesthetist, and operations performed under local anaesthetic to be associated with increased risk of mortality. Factors adversely affecting limb salvage included prolonged duration from symptom onset to operation, and a history of claudication or smoking.

CONCLUSIONS

Despite improvements in pre- and peri-operative management, arterial embolectomy/thrombectomy remains a procedure with a high morbidity and mortality. Further attempts to improve outcome must be directed at early diagnosis and referral as delay from symptom onset to surgery is a major determinant of outcome.

Acute stroke patients with high BMI are less likely to have severe disability at initial presentation

This is a prospective study to determine the severity of disability and prognosis of acute stroke patients related to their Body Mass index (BMI). A total of 79 consecutive CT-scan-proven acute stroke patients who were admitted to Hospital Tuanku Ja'afar, Seremban between November 2006 and April 2007 were recruited (male:female 49:30; mean age 62.7 years; ischemic stroke 70, intracerebral bleed 9). The patients were divided according to BMI less than 25 (Group A) and equal or greater than 25 (Group B). Severity of disability was measured between 24-48 hours by modified Rankin's score. Patients were followed up after one month. Thirty-seven patients had severe disability (Rankin Score 5). Twenty-nine patients had adverse outcomes including 11 deaths and 18 rehospitalizations or prolonged hospital/nursing home stay. 34.3% of Group B had severe disability compared to 56.8% of Group A (chi2 P = 0.046). Conversely 42.9% of Group B had adverse events at one month compared to 31.8% of Group A (chi2 P = 0.312). There were no statistical differences between high- and low-BMI groups for gender ratio, smoking, hypertension, diabetes, prior cardiovascular disease, mean age, mean lipid profile and blood pressure. When comparing patients with Rankin Score 1-4 versus 5, age and BMI were statistically significant between the two groups. By multivariate analysis only age is independent predictor for severe disability (P < 0.05). The results of this pilot study should be confirmed in larger prospective multicentre trial.

Budesonide/formoterol combination therapy as both maintenance and reliever medication in moderate-to-severe asthma: a real-life effectiveness study of Malaysian patients

Budesonide/Formoterol (Symbicort) combination therapy as both maintenance and reliever treatment (SMART) is a novel approach in asthma management. We examined its 'real-life effectiveness' in treating Malaysian patients with moderate-to-severe asthma in whom despite on combined inhaled corticosteroids and long-acting beta2-agonist, were still inadequately controlled. In a retrospective study, 22 eligible adult patients on SMART [mean (range) age: 49 (36-65) years; FEV1: 41 (21-74)% predicted] were identified from medical records of an urban-based university hospital chest clinic, and their clinical outcomes studied at three months. Another 16 patients [50 (14-66) years; 48 (20-91)% predicted] of similar severity and treatment (i.e. Symbicort maintenance treatment plus short-acting beta2-agonist as reliever), but not on SMART, were used as comparator over the same assessment period. In addition, the patients were separately interviewed with standard questionnaire on their satisfaction and compliance to the SMART approach. In SMART group, rescue treatment requirement (p<0.001) and FEV1 [median difference = 2.5%, p=0.015; mean difference: 90 ml, p=0.013] showed significant improvement while in comparator, there was significant improvement only in the requirement for rescue treatment (p=0.023). Hospital admission rates were significantly reduced in SMART group compared to the other (p=0.039), but not in emergency treatment. Five patients asked to discontinue SMART while all others were satisfied, compliant and perceived improvement of their asthma with SMART. The maximum daily doses of inhaled budesonide and formoterol were 1400 microg and 31.5 microg respectively. Our preliminary findings suggest that SMART approach can be attempted as an effective and safe treatment option for patients with inadequately controlled moderate-to-severe asthma in Malaysian setting.

The value of bilateral ipsilateral and contralateral motor evoked potential monitoring in scoliosis surgery

Intraoperative monitoring (IOM) of the motor pathways is a routine procedure for ensuring integrity of corticospinal tracts during scoliosis surgery. We have previously demonstrated presence of ipsilateral motor evoked potentials (MEPs) during IOM for scoliosis surgery, but its significance was uncertain. In this case series, we show concurrent ipsilateral and contralateral MEP amplitude changes obtained with cortical stimulation are of value in reducing false positive observations during IOM. The use of this easily recordable MEP is thus advocated as a diagnostic adjunct to contralateral MEPs for scoliosis and spinal surgery.

Klebsiella pneumoniae respiratory isolates from 2000 to 2004 in a Malaysian hospital: characteristics and relation to hospital antibiotics consumption

INTRODUCTION

Klebsiella pneumoniae ranks high as a cause of community-acquired pneumonia in hospitalised patients in Malaysia.

METHODS

A retrospective study of 5,990 clinical respiratory specimens in patients, with a mean age of 54 (standard deviation 18.5) years, admitted to an urban-based general hospital between 2000 and 2004, was conducted.

RESULTS

The percentages of K. pneumoniae isolates during these years were 11, 19.1, 41.4, 27.8 and 16.6 percent, respectively. During this time, the percentage of isolates resistant to ampicillin were consistently in excess of 80 percent, those resistant to cephalosporins were relatively stable between eight and 23 percent, while those resistant to beta-lactam/beta-lactamase inhibitors [amoxicillin clavulanic acid/ ampicillin-sulbactam] and aminoglycosides steadily increased between six and 58 percent. Compared with hospital consumption of these corresponding antibiotic classes, only beta-lactam/beta-lactamase inhibitors and aminoglycosides showed a clear trend of eight- and four-fold increases, respectively. Co-resistance rates in isolates resistant to ampicillin and amoxicillin-clavulanic acid/ampicillin-sulbactam were generally low to second to third generation cephalosporins (less than 20 percent).

CONCLUSION

Our local findings highlighted the changing trend in respiratory K. pneumoniae over a five-year period, and its escalating resistance to beta-lactam/beta-lactamase inhibitors and aminoglycosides that is possibly attributable to the widespread use of these antibiotics in our hospital.