Evidence-Based, Implementable Motor Rehabilitation Guidelines for Individuals With Cerebral Palsy.

BACKGROUND: Cerebral palsy is a life-long condition that causes heterogeneous motor disorders. Motor rehabilitation interventions must be adapted to the topography of the symptoms, ambulatory capacity, and age of the individual. Current guidelines do not differentiate between the different profiles of individuals with cerebral palsy, which limits their implementation. OBJECTIVES: To develop evidence-based, implementable guidelines for motor rehabilitation interventions for individuals with cerebral palsy according to the age, topography of the cerebral palsy, and ambulatory capacity of the individual and to determine a level of priority for each intervention. METHODS: We used a mixed methods design that combined a systematic review of the literature on available motor rehabilitation interventions with expert opinions. Based on the French National Authority for Health methodology, recommendations were graded as strong, conditional, or weak. Interventions were then prioritized by the experts according to both the evidence and their own opinions on relevance and implementability to provide a guide for clinicians. All recommendations were approved by experts who were independent from the working group. RESULTS: Strong recommendations as first-line treatments were made for gait training, physical activities, and hand-arm bimanual intensive therapy for all children and adolescents with cerebral palsy. Moderate recommendations were made against passive joint mobilizations, muscle stretching, prolonged stretching with the limb fixed, and neurodevelopmental therapies for all children and adolescents with cerebral palsy. Strong recommendations as first-line treatments were made for gait training for all adults with cerebral palsy and moderate recommendations as moderate importance interventions for strengthening exercises and ankle-foot orthoses for motor impairment of the feet and the ankles. DISCUSSION: These guidelines, which combine research evidence and expert opinions, could help individuals with cerebral palsy and their families to codetermine rehabilitation goals with health professionals, according to their preferences.

Outcomes of myocardial infarction in hospitals with percutaneous coronary intervention facilities.

BACKGROUND: Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (herein after, PCI hospitals) have improved outcomes in routine practice. METHODS: We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000. RESULTS: Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P=.75) and reinfarction (1.7% vs 2.5%; P=.25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P=.001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications. CONCLUSIONS: In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.

Predictive factors for masked hypertension within a population of controlled hypertensives.

CONTEXT: Prevalence of masked hypertension (MH) is far from negligible reaching 40% in some studies. The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-Up) and others clearly showed that masked hypertension (MH) as detected by home blood pressure measurement (HBPM) is associated with poor cardiovascular prognosis. OBJECTIVE: Systematic HBPM to detect MH is not yet routine. The aim of this work is to better define the clinical profile of masked hypertensives within a population with controlled office blood pressure (BP) and the factors associated with a higher prevalence of MH. MATERIALS AND METHODS: BP was measured at the clinic by the doctor and at home by the patient himself. Risk factors for MH were analysed in a cohort of 1150 treated hypertensive patients over the age of 60 (mean age 70 +/- 6.5, 48.9% men) with controlled office BP. (SBP < 140 mmHg and DBP < 90 mmHg). RESULTS: 463 patients (40%) were masked hypertensives (SBP > or = 135 mmHg or DBP > or = 85 mmHg at home). Three parameters were associated with MH (odds ratio OR): office SBP (OR = 1.110), male gender (OR = 2.214) and age (OR = 1.031). Decision trees showed a 130 mmHg SBP was an efficient threshold to propose HBPM with a higher probability to detect MH. Subsequent variables were male gender and age over 70 in males. CONCLUSION: To detect masked hypertension, it would be logical to first of all select patients whose office SBP is between 130 and 140 mmHg.

Impact of age and gender on in-hospital and late mortality after acute myocardial infarction: increased early risk in younger women: results from the French nation-wide USIC registries.

AIMS: To determine whether sex differences of in-hospital and after-discharge mortality differ according to the age. METHODS AND RESULTS: Data of 4347 consecutive patients hospitalized within 48 h of the onset of acute myocardial infarction (AMI) were analysed. Patients were classified according to median age (68 years): Group 1 (G1) (308 women, 30-67 years), G2 (1878 men, 30-67 years), G3 (860 women, 68-89 years), and G4 (1301 men, 68-89 years). In both age groups, women were older, had more frequent co-morbidities, lower rate of reperfusion therapy, and received less anti-platelet agents, beta-blockers, and statins than men. The overall 1-year mortality was higher in women (25% vs. 16% in men, P<0.0001). After adjustment, in-hospital mortality was higher only for the women in the younger age group. (G1 vs. G2: OR=2.2, 95%CI=1.3-3.8; G3 vs. G4: OR=1.1, 95%CI=the risk of death, after hospital discharge, was no longer related to gender in any age group. CONCLUSION: The higher 1-year mortality following AMI in women is explained by the higher risk of death in young women during the first days of hospitalization. Further investigations are crucial to determine the cause in order to improve the chance of survival in younger women.

Impact of combined secondary prevention therapy after myocardial infarction: data from a nationwide French registry.

BACKGROUND: Several classes of medications improve survival in patients with coronary artery disease. Whether these medications, as used in the real world, have additive efficacy remains speculative. OBJECTIVES: To assess whether patients discharged on combined secondary prevention medications after acute myocardial infarction (AMI) have improved 1-year survival, compared with the action of any single class of medications. DESIGN AND SETTING: Nationwide registry of consecutive patients admitted to intensive care units for AMI in November 2000 in France. Multivariate Cox regression analysis, including a propensity score for the prescription of combined therapy, was used. RESULTS: Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers, and statins (triple therapy), of whom 567 (27%) also received angiotensin-converting enzyme inhibitors (quadruple therapy) and 528 (25%) did not. One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either none, 1, or 2 of these medications (P < .0001). After multivariate adjustment including the propensity score, the hazard ratio for 1-year mortality in patients with triple combination therapy was 0.52 (95% CI 0.33-0.81). In patients with ejection fraction < or = 35%, beta-blockers and angiotensin-converting enzyme inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value. CONCLUSIONS: Compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with AMI.

Effect of early initiation of statins on survival in patients with acute myocardial infarction (the USIC 2000 Registry).

We evaluated the association of statin initiation within 48 hours of admission for an acute myocardial infarction with a 1-year prognosis on a nationwide scale. Patients who received a statin within 48 hours of admission but not before hospitalization had an improved prognosis (hazard ratio 0.57, 95% confidence interval 0.38 to 0.86, p <0.007) after adjustment for covariates and propensity score.

Role of previous treatment with sulfonylureas in diabetic patients with acute myocardial infarction: results from a nationwide French registry.

BACKGROUND: The cardiovascular effects of sulfonylureas (SU) in diabetic patients are controversial and it has been suggested that diabetic patients with acute myocardial infarction while on SU were at increased risk. OBJECTIVES: To assess the in-hospital outcome of patients with acute myocardial infarction according to the use of SU at the time of the acute episode. METHODS: Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction admitted within 48 h of symptom onset in November 2000. RESULTS: Among the 2320 patients included in the registry, 487 (21%) had diabetes, of whom 215 (44%) were on SU. Patients on SU were older and had a more frequent history of hyperlipidemia than those not receiving SU. Type and location of infarction were similar in the two groups, and there was no difference in Killip class on admission. In-hospital mortality was lower in patients on SU (10.2%) than in those without SU (16.9%) (p = 0.035). There was a trend toward less frequent ventricular fibrillation (2.3% vs 5.9%, p = 0.052). In two models of multivariate analyses, SU therapy was associated with decreased in-hospital mortality (model 1: relative risk: 0.44, p = 0.012; model 2: relative risk: 0.37, p = 0.020). CONCLUSIONS: In this nationwide registry reflecting real-world practice, the use of sulfonylureas in diabetic patients was not associated with increased in-hospital mortality.

[Combination therapy at hospital discharge in the USIC 2000 survey]. / Les associations thérapeutiques a la sortie de l'hôpital dans l'enquête USIC 2000 : corrélations avec la survie a un an.

UNLABELLED: We tried to determine the prognostic impact of triple (antiplatelet agents, statins and beta-blockers) and quadruple (the same+ACE inhibitors) combination therapy at hospital discharge after acute myocardial infarction. The USIC 2000 survey is nationwide registry of consecutive patients admitted to intensive care units for acute myocardial infarction in November 2000 in France. Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers and statins (triple therapy), including 567 (27%) with a similar combination plus ACE inhibitors (quadruple therapy). One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either no, one or two of these medications (p < 0.0001). After multivariate adjustment, the odds ratio for one-year mortality in patients with triple combination therapy was 0.49 (95% confidence interval: 0.32-0.75). Quadruple combination therapy had no additional predictive value in the entire population. In patients with ejection fraction < or = 35%, however, beta-blockers and ACE inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value. CONCLUSIONS: compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with acute myocardial infarction.

Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome: results from the French Nationwide USIC 2000 Registry.

BACKGROUND: Limited data are available on the impact of prehospital thrombolysis (PHT) in the "real-world" setting. METHODS AND RESULTS: Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction (< or =48 hours of symptom onset) in November 2000; 1922 patients (median age, 67 years; 73% men) with ST-segment-elevation infarction were included, of whom 180 (9%) received intravenous thrombolysis before hospital admission (PHT). Patients with PHT were younger than those with in-hospital thrombolysis, primary percutaneous interventions, or no reperfusion therapy. Median time from symptom onset to hospital admission was 3.6 hours for PHT, 3.5 hours for in-hospital lysis, 3.2 hours for primary percutaneous interventions, and 12 hours for no reperfusion therapy. In-hospital death was 3.3% for PHT, 8.0% for in-hospital lysis, 6.7% for primary percutaneous interventions, and 12.2% for no reperfusion therapy. One-year survival was 94%, 89%, 89%, and 79%, respectively. In a multivariate analysis of predictors of 1-year survival, PHT was associated with a 0.49 relative risk of death (95% CI, 0.24 to 1.00; P=0.05). When the analysis was limited to patients receiving reperfusion therapy, the relative risk of death for PHT was 0.52 (95% CI, 0.25 to 1.08; P=0.08). In patients with PHT admitted in < or =3.5 hours, in-hospital mortality was 0% and 1-year survival was 99%. CONCLUSIONS: The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate.

Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients.

CONTEXT: Blood pressure (BP) measurement in clinicians' offices with a mercury sphygmomanometer has numerous drawbacks. In contrast, the use of home BP measurement improves measurement precision and reproducibility. However, data about its prognostic value are lacking. OBJECTIVE: To assess the prognostic value of home vs office BP measurement by general practitioners in a European population of elderly patients being treated for hypertension. DESIGN, SETTING, AND PARTICIPANTS: Office and home BP and cardiac risk factors were measured at baseline in a cohort of 4939 treated hypertensive patients (mean age, 70 [SD, 6.5] years; 48.9% men) who were recruited and followed up by their usual general practitioners without specific recommendations about their management. The cohort was then followed up for a mean of 3.2 (SD, 0.5) years. The thresholds defining uncontrolled hypertension were at least 140/90 mm Hg for office BP and 135/85 mm Hg for home BP. MAIN OUTCOME MEASURES: The primary end point was cardiovascular mortality. Secondary end points were total mortality and the combination of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for angina or heart failure, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery. RESULTS: At the end of follow-up, clinical status was known for 99.9% of patients. At least 1 cardiovascular event had occurred in 324 (incidence, 22.2/1000 patient-years). For BP self-measurement at home, each 10-mm Hg increase in systolic BP increased the risk of a cardiovascular event by 17.2% (95% confidence interval [CI], 11.0%-23.8%) and each 5-mm Hg increase in diastolic BP increased that risk by 11.7% (95% CI, 5.7%-18.1%). Conversely, for the same increase in BP observed using office measurement, there was no significant increase in the risk of a cardiovascular event. In a multivariable model with patients having controlled hypertension (normal home and office BP) as the referent, the hazard ratio of cardiovascular events was 1.96 (95% CI, 1.27-3.02) in patients with uncontrolled hypertension (high BP with both measurement methods), 2.06 (95% CI, 1.22-3.47) in patients with normal office BP and elevated home BP, and 1.18 (95% CI, 0.67-2.10) in patients with elevated office BP and normal home BP. CONCLUSIONS: Our findings suggest that home BP measurement has a better prognostic accuracy than office BP measurement. Blood pressure should systematically be measured at home in patients receiving treatment for hypertension.

Why is hypertension so frequently uncontrolled in secondary prevention?

OBJECTIVE: To analyze blood pressure (BP) control in secondary prevention. DESIGN: Individual data of two cross-sectional studies on preventive cardiology (PRATIK and ESPOIR studies conducted, respectively, in general practice and with private cardiologists) were analyzed. SETTING: Primary care. PARTICIPANTS: Patients both with treated hypertension and coronary disease. MAIN OUTCOME MEASURES: Risk factors, treatments, cardiovascular history and BP were recorded. Each population was divided in three groups: group I, no other risk factor; group II, one or two risk factors; group III, three or more risk factors or diabetes. RESULTS: A total of 1423 and 2596 patients, respectively, recruited in general practice and by cardiologists were analyzed. Of these, 473 (33.24%) and 1060 (40.83%) patients, respectively, had controlled hypertension. Among uncontrolled hypertensives, more than 50% had borderline isolated systolic hypertension. Associated risk factors negatively affect hypertension control, which had been achieved in a lower percentage of patients in group III than in group I (general practice, 26.28 versus 42.20%; cardiological practice, 32.42 versus 56.13%). In general practice, the percentage of patients receiving beta-blockers was significantly lower in group III. Among individuals with uncontrolled hypertension, only 17.58 and 26.69% received at least three-drug treatment including diuretics in general and in cardiological practice, respectively. CONCLUSION: The negative influence of associated risk factors and the under-use of combination therapy contribute to poor BP control. In addition the high frequency of borderline isolated systolic hypertension suggests that the prerequisite to improve hypertension control should be to convince practitioners of the beneficial effect of tight systolic BP control (below 140 mmHg) in secondary prevention.