Objective
to identify the predictors of mortality in a cohort of nonagenarians inside the “Mugello study” after 10 years follow-up.
Methods
Information on sociodemographic data, cognitive and ...functional status, lifestyle, medical history, and drug use was collected from 433 non-selected participants aged 90-99 years, living in the Mugello area (Italy). Participants were followed over 10 years and their dates of death were retrieved from the municipal registers. Cox regression analysis was used to determine significant potential prognostic factors.
Results
The mortality rate was 96.5%. Cox proportional hazards analysis showed that a lower cognitive status was significantly associated with higher mortality as well as a poorer functional status, a higher comorbidity, and a higher number of drugs consumption.
Discussion
Impaired cognitive function, loss of functional independence, higher comorbidity, and higher drugs intake were the stronger predictors of mortality.
Life expectancy has increased over the last century and a growing number of people is reaching age 90 years and over. However, data on nonagenarians' health trends are scarce due to difficulties in ...investigating this specific population. This study aims to identify risk factors for one-year mortality in nonagenarians using data collected within the "Mugello Study".
Complete information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 nonagenarians, as well as information about survival after 1 year from the interview.
The sample included 314 women (72.5%) and 119 men (27.5%) with a median age of 92 years (range 90-99 years). The mortality rate was 20.3% (88 deaths). After adjustment for age and sex, a significantly higher risk of dying within 12 months was observed in individuals with more severe cognitive impairment (HR = 5.011, p < 0.001), more severe disability in basic activities of daily living (HR = 4.193, p < 0.001), sedentary lifestyle (HR = 3.367, p < 0.001), higher number of drugs assumed (HR = 1.118, p = 0.031), and kidney dysfunction (HR = 2.609, p = 0.004). When all the variables were included in the analysis, only older age (HR = 1.079, p = 0.048), lower cognitive function (HR = 2.859, p = 0.015), sedentary lifestyle (HR = 2.030, p = 0.026), and kidney dysfunction (HR = 2.322, p = 0.018) remained significantly associated with reduced survival.
Data from the Mugello study support the hypothesis that survival at 12 months in nonagenarians is not a stochastic process and that older age, reduced cognitive function, sedentary lifestyle, and the presence of kidney dysfunction are associated with mortality.
This study aims to evaluate the diagnostic performance of NIHSS extinction and inattention item, compared to the results of the Oxford Cognitive Screen (OCS) heart subtest. Additionally, the possible ...role of the NIHSS visual field subtest on the NIHSS extinction and inattention subtest performance is explored and discussed.
We analysed scores on NIHSS extinction and inattention subtest, NIHSS visual field subtest, and OCS heart subtest on a sample of 118 post-stroke patients.
Compared to OCS heart subtest, the results on NIHSS extinction and inattention subtest showed an accuracy of 72.9% and a moderate agreement level (Cohen's kappa = 0.404). Furthermore, a decrease in NIHSS accuracy detecting neglect (61.1%) was observed in patients with pathological scores in NIHSS visual field item.
Extreme caution is recommended for the diagnostic performance of extinction and inattention item of NIHSS. Signs of neglect may not be detected by NIHSS, and may be confused with visual field impairment.
This study refers to an observational study protocol submitted to ClinicalTrials.gov with identifier: NCT03968627 . The name of the registry is "Development of a National Protocol for Stroke Rehabilitation in a Multicenter Italian Institution" and the date of the registration is the 30th May 2019.
The complex nature of stroke sequelae, the heterogeneity in rehabilitation pathways, and the lack of validated prediction models of rehabilitation outcomes challenge stroke rehabilitation quality ...assessment and clinical research. An integrated care pathway (ICP), defining a reproducible rehabilitation assessment and process, may provide a structured frame within investigated outcomes and individual predictors of response to treatment, including neurophysiological and neurogenetic biomarkers. Predictors may differ for different interventions, suggesting clues to personalize and optimize rehabilitation. To date, a large representative Italian cohort study focusing on individual variability of response to an evidence-based ICP is lacking, and predictors of individual response to rehabilitation are largely unexplored. This paper describes a multicenter study protocol to prospectively investigate outcomes and predictors of response to an evidence-based ICP in a large Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation.
All patients with diagnosis of ischemic or hemorrhagic stroke confirmed both by clinical and brain imaging evaluation, admitted to four intensive rehabilitation units (adopting the same stroke rehabilitation ICP) within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled (expected sample: 270 patients). Measures will be taken at admission (T0), at discharge (T1), and at follow-up 6 months after a stroke (T2), including clinical data, nutritional, functional, neurological, and neuropsychological measures, electroencephalography and motor evoked potentials, and analysis of neurogenetic biomarkers.
In addition to classical multivariate logistic regression analysis, advanced machine learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.
By identifying data-driven prognosis prediction models in stroke rehabilitation, this study might contribute to the development of patient-oriented therapy and to optimize rehabilitation outcomes.
ClinicalTrials.gov, NCT03968627. https://www.clinicaltrials.gov/ct2/show/NCT03968627?term=Cecchi&cond=Stroke&draw=2&rank=2.
Background
Stroke represents the second preventable cause of death after cardiovascular disease and the third global cause of disability. In countries where national registries of the clinical ...quality of stroke care have been established, the publication and sharing of the collected data have led to an improvement in the quality of care and survival of patients. However, information on rehabilitation processes and outcomes is often lacking, and predictors of functional outcomes remain poorly explored. This paper describes a multicenter study protocol to implement a Stroke rehabilitation Registry, mainly based on a multidimensional assessment proposed by the Italian Society of Physical and Rehabilitation Medicine (PMIC2020), in a pilot Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation, to provide a systematic assessment of processes and outcomes and develop data-driven prediction models of functional outcomes.
Methods
All patients with a diagnosis of ischemic or haemorrhagic stroke confirmed by clinical assessment, admitted to intensive rehabilitation units within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled. Measures will be taken at admission (T0), at discharge (T1), and at follow-up, 3 months (T2) and 6 months (T3) after the stroke. Assessment variables include anamnestic data, clinical and nursing complexity information and measures of body structures and function, activity and participation (PMIC2020), rehabilitation interventions, adverse events and discharge data. The modified Barthel Index will be our primary outcome. In addition to classical biostatistical analysis, learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.
Conclusions
This study will test the feasibility of a stroke rehabilitation registry in the Italian health context and provide a systematic assessment of processes and outcomes for quality assessment and benchmarking. By the development of data-driven prediction models in stroke rehabilitation, this study will pave the way for the development of decision support tools for patient-oriented therapy planning and rehabilitation outcomes maximization.
Clinical tial registration
The registration on
ClinicalTrials.gov
is ongoing and under review. The identification number will be provided when the review process will be completed.
Objective. Comparing global postural reeducation (GPR) to a standard physiotherapy treatment (PT) based on active exercises, stretching, and massaging for improving pain and function in chronic low ...back pain (CLBP) patients. Design. Prospective controlled study. Setting. Outpatient rehabilitation facility. Participants. Adult patients with diagnosis of nonspecific, chronic (>6 months) low back pain. Interventions. Both treatments consisted of 15 sessions of one hour each, twice a week including patient education. Measures. Roland Morris Disability Questionnaire to evaluate disability, and Numeric Analog Scale for pain. A score change >30% was considered clinically significant. Past treatments, use of medications, smoking habits, height, weight, profession, and physical activity were also recorded on baseline, on discharge, and 1 year after discharge (resp., T0, T1, and T2). Results. At T0 103 patients with cLBP (51 cases and 52 controls) were recruited. The treatment (T1) has been completed by 79 (T1) of which 60 then carried out the 1-year follow-up (T2). Both GPR and PT at T1 were associated with a significant statistical and clinical improvement in pain and function, compared to T0. At T2, only pain in GPR still registered a statistically significant improvement.
To assess the intra- and inter-rater reliability motor and sensory functioning, balance, joint range of motion and joint pain subscales of the Italian Fugl-Meyer Assessment (FMA) Upper Extremity ...(FMA-UE) and Lower Extremity (FMA-LE) at the item- subtotal- and total-level in patients with sub-acute stroke.
The FMA was administered to 60 patients with sub-acute stroke (mean age ± SD = 75.4 ± 10.7 years; 58.3% men) and independently rated by two physiotherapists on two consecutive days. Intra- and inter-reliability was studied by a rank-based statistical method for paired ordinal data to detect any systematic or random disagreement.
The item-level intra- and inter-rater reliability was satisfactory (>70%). Reliability level >70% was achieved at subscale and total score level when one- or two-points difference was considered. Systematic disagreements were reported for five items of the FMA-UE, but not for FMA-LE.
The Italian version of the FMA showed to be a reliable instrument that can therefore be recommended for clinical and research purposes.
Implications for rehabilitation
The FMA is the gold standard for assessing stroke patients' sensorimotor impairment worldwide.
The Italian Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE) is substantially reliable within and between two raters at the item, subtotal, and total score level in patients with sub-acute stroke.
The use of FMA in the Italian context will provide an opportunity for international comparisons and research collaborations.
To verify whether trunk control test (TCT) upon admission to intensive inpatient post-stroke rehabilitation, combined with other confounding variables, is independently associated with discharge mBI.
...Multicentric retrospective observational cohort study.
Two Italian inpatient rehabilitation units.
A total of 220 post-stroke adult patients, within 30 days from the acute event, were consecutively enrolled.
Not applicable.
The outcome measure considered was the modified Barthel Index (mBI), one of the most widely recommended tools for assessing stroke rehabilitation functional outcomes.
All variables collected at admission and significantly associated with mBI at discharge in the univariate analysis (TCT, mBI at admission, pre-stroke modified Rankin Scale mRS, sex, age, communication ability, time from the event, Cumulative Illness Rating Scale, bladder catheter, and pressure ulcers) entered the multivariate analysis. TCT, mBI at admission, premorbid disability (mRS), communication ability and pressure ulcers (P<.001) independently predicted discharge mBI (adjusted R
=68.5%). Concerning the role of TCT, the model with all covariates and without TCT presented an R
of 65.1%. On the other side, the model with the TCT only presented an R
of 53.1%. Finally, with the inclusion of both TCT and all covariates, the model showed an R
increase up to 68.5%.
TCT, with other features suggesting functional/clinical complexity, collected upon admission to post-acute intensive inpatient stroke rehabilitation, independently predicted discharge mBI.
Introduction
Previous studies showed that depression acts as an independent factor in functional recovery after stroke. In a prospective cohort of patients admitted to intensive inpatient ...rehabilitation after a stroke, we aimed to test depression as a moderator of the relationship between the functional level at admission and the effectiveness of rehabilitation at discharge.
Methods
All patients admitted to within 30 days from an ischemic or hemorrhagic stroke to 4 intensive rehabilitation units were prospectively screened for eligibility to a multicenter prospective observational study. Enrolled patients underwent an evidence-based rehabilitation pathway. We used clinical data collected at admission (T0) and discharge (T1). The outcome was the effectiveness of recovery at T1 on the modified Barthel Index (proportion of achieved over potential functional improvement). Moderation analysis was performed by using the PROCESS macro for SPSS using the bootstrapping procedure.
Results
Of 278 evaluated patients, 234 were eligible and consented to enrolment; 81 patients were able to answer to the Hospital Anxiety and Depression Scale (HADS) and were included in this analysis. The relationship between the functional status at admission and rehabilitation effectiveness was significant only in persons with fewer depressive symptoms; depression (HADS cut-off score: 5.9) moderated this relationship (P = .047), independent from age and neurological impairment.
Conclusions
Our results suggest that depression moderates between the functional status at admission and the functional recovery after post-stroke rehabilitation. This approach facilitates the identification of subgroups of individuals who may respond differently to stroke rehabilitation based on depression.
There is emerging confidence that quantitative EEG (qEEG) has the potential to inform clinical decision-making and guide individualized rehabilitation after stroke, but consensus on the best EEG ...biomarkers is needed for translation to clinical practice. This study investigates the spatial qEEG spectral and symmetry distribution in patients with a left/right hemispheric stroke, to evaluate their side-specific prognostic power in post-acute rehabilitation outcome.
Resting-state 19-channel EEG recordings were collected with clinical information on admission to intensive inpatient rehabilitation (within 30 days post stroke), and six months post stroke. After preprocessing, spectral (Delta-to-Alpha Ratio, DAR) and symmetry (pairwise and hemispheric Brain Symmetry Index) features were extracted. Patients were divided into Affected Right and Left (AR/AL) groups, according to the location of their lesion. Within each group, DAR was compared between homologous electrode pairs and the pairwise difference between pairs was compared across pairs in the scalp. Then, the prognostic power of qEEG admission metrics was evaluated by performing correlations between admission metrics and discharge mBI values.
Fifty-two patients with hemorrhagic or ischemic stroke (20 females, 38.5 %, median age 76 years IQR = 22) were included in the study. DAR was significantly higher in the affected hemisphere for both AR and AL groups, and, a higher frontal (to posterior) asymmetry was found independent of the side of the lesion. DAR was found to be a prognostic marker of 6-months modified Barthel Index (mBI) only for the AL group, while hemispheric asymmetry did not correlate with follow-up outcomes in either group.
While the presence of EEG abnormalities in the affected hemisphere of a stroke is well recognized, we have shown that the extent of DAR abnormalities seen correlates with disability at 6 months post stroke, but only for left hemispheric lesions. Routine prognostic evaluation, in addition to motor and functional scales, can add information concerning neuro-prognostication and reveal neurophysiological abnormalities to be assessed during rehabilitation.
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