Transient ischaemic attack pre-hospital referral feasibility trial (TIER): recruitment and intervention usage.

AIMS: Early specialist assessment of transient ischaemic attack (TIA) can reduce the risk of stroke and death. This study assessed the feasibility of undertaking a multi-centre randomised trial to evaluate clinical and cost effectiveness of referral of patients attended by emergency ambulance paramedics with low-risk TIA directly to specialist TIA clinics for early review. METHODS: We developed a protocol and referral pathway for paramedics to assess and refer patients directly to a TIA clinic, and administer aspirin. We randomly allocated volunteer paramedics to intervention or control groups. Intervention paramedics were trained to deliver the intervention during the patient recruitment period. Control paramedics continued to deliver care as usual. Patients with TIA were identified from hospital records. We aimed to recruit 86 patients and pre-defined progression criteria related to feasibility of intervention delivery and trial methods. RESULTS: Development and recruitment phases are complete, with outcome follow-up ongoing. Of 134 (66%) paramedics, 89 participated in TIER. Of 1377 patients attended by trial paramedics during the patient recruitment period, 53 (3.8%) were identified as eligible for trial inclusion. Of 36 (8%) patients attended by intervention paramedics, three were referred to the TIA clinic. Of the others, only one appeared to be a missed referral; in one case there was no pre-hospital record of TIA; one was attended by a paramedic who was not TIER trained; one patient record was missing; and all others were recorded with contra-indications: FAST positive (n = 13); ABCD2 score > 3 (n = 5); already taking warfarin (n = 2); crescendo TIA (n = 1); and other clinical factors (n = 8). CONCLUSIONS: Preliminary results indicate challenges in recruitment and low referral rates. The low-risk 999 TIA population suitable for emergency department avoidance may be smaller than previously thought. Further analyses will focus on whether progression criteria for a definitive trial were met, and clinical outcomes from this feasibility trial.

Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review.

BACKGROUND: Displaced proximal humeral fractures have traditionally been treated with hemiarthroplasty in older adults, but sometimes hemiarthroplasty results in poor functional outcomes due to rotator cuff deficiency. Reverse shoulder arthroplasty (RSA) can offer potentially improved outcomes in these situations. We assessed the functional outcomes of older adults treated with RSA for proximal humeral fractures compared with hemiarthroplasty. METHODS: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, and 3 clinical trials registries. We included all studies treating proximal humeral fractures with RSA in adults with a mean age older than 60 years and 1 year of follow-up. We calculated weighted mean differences (WMD) for range of motion and standardized mean differences (SMD) for shoulder scores. Postoperative complications were evaluated qualitatively. RESULTS: Fifteen studies met inclusion criteria, including 377 patients treated with RSA and 504 patients treated with hemiarthroplasty. In controlled studies, the RSA group had improved forward flexion (WMD, 21°;, P = .02) and functional outcome scores (SMD, 0.44; P = .005) compared with the hemiarthroplasty group but decreased external rotation (WMD, -5°; P < .0001). Postoperative complications were similar between the 2 groups. CONCLUSION: RSA results in improved forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures. Complications do not appear to be appreciably higher in the RSA group in the existing follow-up. The results of this review suggest that RSA is a reasonable alternative for treating older adults with proximal humeral fractures, but more research and longer follow-up are needed. LEVEL OF EVIDENCE: Level IV, systematic review.

Hemorrhagic transformation of childhood arterial ischemic stroke.

BACKGROUND AND PURPOSE: The objective of this study was to describe the occurrence of hemorrhagic transformation (HT) among children with arterial ischemic stroke within 30 days after symptom onset and to describe clinical factors associated with HT. METHODS: Sixty-three children aged 1 month to 18 years with arterial ischemic stroke between January 2005 and November 2008 were identified from a single-center prospective pediatric stroke registry. All neuroimaging studies within 30 days of stroke were reviewed by a study neuroradiologist. Hemorrhage was classified according to the European Cooperative Acute Stroke Study-1 definitions. Association of HT with clinical factors, systemic anticoagulation, stroke volume, and outcome was analyzed. RESULTS: HT occurred in 19 of 63 children (30%; 95% CI, 19% to 43%), only 2 (3%) of whom were symptomatic. Hemorrhage classification was hemorrhagic infarction (HI)1 in 14, HI2 in 2, parenchymal hematoma (PH)1 in 2, and PH2 in 1. HT was less common in children with vasculopathy (relative risk, 0.27; 95% CI, 0.07 to 1.06; P=0.04) than in those with other stroke mechanisms. HT was not significantly associated with anticoagulation versus antiplatelet therapy (relative risk, 0.6; 95% CI, 0.2 to 1.5; P=0.26) but was associated with larger infarct volumes (P=0.0084). In multivariable analysis, worse Pediatric Stroke Outcome Measure scores were associated with infarct volume ≥5% of total supratentorial brain volume (OR, 4.0; 95% CI, 1.1 to 15; P=0.04), and a trend existed toward association of worse Pediatric Stroke Outcome Measure scores with HT (OR, 4.0; 95% CI, 0.9 to 18; P=0.07). CONCLUSIONS: HT occurred in 30% of children with arterial ischemic stroke within 30 days. Most hemorrhages were petechial and asymptomatic. Infarct volume was associated with HT and worse outcome.

The association of pretreatment health-related quality of life with surgical complications for patients undergoing open surgical resection for colorectal cancer.

OBJECTIVE: The purpose of this study was to define the association between pretreatment health-related quality of life (HRQL) and surgical complications for patients with colorectal cancer. SUMMARY BACKGROUND DATA: For patients with colorectal cancer, surgical complications arise from an interaction between underlying medical comorbidity, colorectal cancer severity, and quality and type of treatment provided. Measurement of HRQL provides a summarization of well-being in the context of medical comorbidity and colorectal cancer severity. The summarization of these factors may be useful in prospective risk assessment of patients about to undergo surgery for colorectal cancer. METHODS: A single-institution, prospective, cohort study of patients with colorectal adenocarcinoma was performed from August 1, 1999, to March 31, 2002. Before treatment, all participants completed Medical Outcomes Survey SF-36 (SF-36); after the first year of the study, patients also completed the colorectal cancer module of the Functional Assessment of Cancer Therapy survey (FACT-C). Information was collected on demographics, treatment, tumor variables, and complications. RESULTS: Ninety-seven patients have undergone open resection of their colorectal cancer. All patients completed SF-36; 65 completed FACT-C. Thirty patients (31%) experienced complications, including 4 (4%) deaths. Age, race, albumin level, American Society of Anesthesia class, specialty surgical training, tumor location, and stage were not associated with complications in univariate analysis. Patients experiencing surgical complications had significantly lower HRQL scores on SF-36 Social Functioning, General Health Perception, and Mental Health Index scales as well as the Mental Health Component summary score. FACT-C Social/Family, Emotional, Functional Well-Being scores, and the Colorectal Cancer Concerns score were also significantly lower for patients sustaining complications. When these HRQL scales were examined in a multivariate model including albumin level, tumor location, and ASA class, SF-36 Social Functioning (Odds Ratio [OR] = 0.98; 95% Confidence Interval [CI] = 0.97-0.99) and FACT-C Colorectal Cancer Concerns (OR = 0.89; 95% CI = 0.79-0.99) scales retained a significant association with complications. CONCLUSIONS: Pretreatment HRQL scores as measured by several scales of SF-36 and FACT-C were significantly associated with complications. Future studies should concentrate on defining the predictive role of HRQL in determining surgical outcome for patients with colorectal cancer.

Surgical complications exert a lasting effect on disease-specific health-related quality of life for patients with colorectal cancer.

BACKGROUND: For individual patients with colorectal cancer, health-related quality of life (HRQL) after treatment is a function of several factors that include preexisting medical conditions, the disease burden, and the treatment that is rendered. The purpose of this study was to identify the factors that were associated with posttreatment HRQL. METHODS: At baseline and again at 12 months after diagnosis, patients completed the colorectal cancer-specific HRQL survey: Functional Assessment of Cancer Therapy (FACT-C). Univariate and multivariate analyses were performed to test the association between patient-, tumor-, and treatment-related variables and 12-month FACT-C total scores. RESULTS: Seventy-one patients completed the FACT-C at diagnosis and subsequently underwent open surgical removal of their primary tumor; 63 patients completed the 12-month survey. In univariate analysis, only chronic obstructive pulmonary disease at diagnosis or the occurrences of perioperative complications were associated with a reduction in 12-month HRQL scores. Considering both the diagnosis of chronic obstructive pulmonary disease and the occurrence of perioperative complications, along with the patient's FACT-C total score at diagnosis, age, tumor location, and stage of disease in a multivariate model, only the perioperative complications (odds ratio, 10.5; 95% CI, 2.1-52) and FACT-C total score at diagnosis (odds ratio, 1.04; 95% CI, 1.005-1.07) were associated significantly with a lower than median HRQL score at 12 months. CONCLUSIONS: For patients who undergo treatment of colorectal cancer, HRQL at 1 year after diagnosis is still influenced significantly and negatively by the occurrence of surgical complications.

Health-related quality of life and postoperative length of stay for patients with colorectal cancer.

BACKGROUND: Length of stay (LOS) after surgery is a major determinant of resource utilization for colorectal cancer (CRC). The purpose of this study was to examine the association between pretreatment health-related quality of life (HRQL) scores and postoperative hospital LOS in a cohort of patients undergoing surgery for CRC. METHODS: Seventy patients with biopsy-proven CRC were enrolled in an IRB-approved, prospective study. Information was collected concerning standard perioperative variables. Prior to surgery, all patients also completed the CRC-specific module of the Functional Assessment of Cancer Therapy (FACT-C). Perioperative variables and FACT-C scores were compared with LOS in both univariate and multivariate analysis. LOS for those patients scoring in the lowest quartile on FACT-C was compared with LOS for patients scoring in the remaining quartiles. RESULTS: Median length of stay for the entire group was 6 (range 3-25) days. In univariate analysis, surgical complications (10.6 vs 6.6 days; P = 0.001) and with poorer FACT-C individual scale scores for Physical Well-Being (9.1 vs 7.3 days; P = 0.04), Functional Well-Being (9.6 vs 7.1 days; P = 0.006), and Colorectal Cancer Concerns (9.5 vs 7.1 days; P = 0.01) were all significantly associated with increased length of stay. In multivariate analysis, surgical morbidity (OR = 5.6; 95% CI 1.5-21.4), age >72 (OR = 6.0; 95% CI 1.6-23.5), and low FACT-C total score (OR = 4.2; 95% CI 1.1-15.6) were independently associated with increased LOS. CONCLUSIONS: Pretreatment HRQL scores as measured by FACT-C may be of benefit in the prediction of LOS. Such information may be an important and currently neglected means of risk-adjusting populations undergoing surgery for colorectal cancer for this outcome.