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Multicenter Cohort Study (multicenter + cohort_study)
Selected AbstractsUndulating toe movements in brain death,EUROPEAN JOURNAL OF NEUROLOGY, Issue 11 2004G. Saposnik For many years, death implied immobility. Nevertheless, there are anecdotal reports of spontaneous or reflex movements (SRMs) in patients with Brain death (BD). The presence of some movements can preclude the diagnosis of BD, and consequently, the possibility of organ donation for transplantation. McNair and Meador [(1992), Mov Dord7: 345,347] described the presence of undulating toe flexion movements (UTF) in BD patients. UTF consists in a sequential brief plantar flexion of the toes. Our aim was to determine the frequency, characteristics and predisposing factors of UTF movements in a prospective multicenter cohort study of patients with BD. Patients with confirmed diagnosis of BD were assessed to evaluate the presence of UTF using a standardized protocol. All patients had a routine laboratory evaluation, CT scan of the head, and EEG. Demographic, clinical, hemodynamic and blood gas concentration factors were analyzed. amongst 107 BD patients who fulfilled the AAN requirements, 47 patients (44%) had abnormal movements. UTF was observed in 25 (23%) being the most common movement (53%). Early evaluation (OR 4.3, CI95% 1.5,11.9) was a predictor of UTF in a multivariate regression model. The somato-sensory evoked potential (SSEPs) as well as brainstem auditory evoked potentials (BAEPs) did not elicit a cortical response in studied patients with UTF. This spinal reflex is probably integrated in the L5 and S1 segments of the spinal cord. Abnormal movements are common in BD, being present in more than 40% of individuals. UTF was the most common spinal reflex. In our sample, early evaluation was a predictor of UTF. Health care professionals, especially those involved in organ procurement for transplantation, must be aware of this sign. The presence of this motor phenomenon does not preclude the diagnosis of BD. [source] Patients with a first symptomatic unprovoked deep vein thrombosis are at higher risk of recurrent venous thromboembolism than patients with a first unprovoked pulmonary embolismJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 9 2010M. J. KOVACS Summary.,Background:,Previous studies are mixed as to whether patients with unprovoked pulmonary embolism (PE) have a higher rate of venous thromboembolism (VTE) recurrence after anticoagulation is discontinued than patients with unprovoked deep vein thrombosis (DVT). Objectives:,To determine whether patients with unprovoked PE have a higher rate of VTE recurrence than patients with unprovoked DVT in a prospective multicenter cohort study. Patients/Methods:,Six hundred and forty-six patients with a first episode of symptomatic unprovoked VTE were treated with heparin and subsequent oral anticoagulation for 5,7 months, and were followed every 6 months for recurrent VTE after their anticoagulant therapy was discontinued. Results:,Of 646 patients, 194 had isolated PE, 339 had isolated DVT, and 113 had both DVT and PE. After a mean of 18 months of follow-up, there were 91 recurrent VTE events (9.5% annualized risk of recurrent VTE in the total population). The crude recurrent VTE rate for the isolated PE, isolated DVT and DVT and PE groups were 7.7%, 16.5% and 17.7%, respectively. The relative risk of recurrent VTE for isolated DVT vs. isolated PE was 2.1 (95% confidence interval 1.2,3.7). Conclusions:,This study has demonstrated that patients with a first episode of unprovoked isolated DVT are 2.1 times more likely to have a recurrent VTE episode than patients with a first episode of unprovoked isolated PE. These findings need to be considered when determining the optimal duration of anticoagulant therapy for patients with unprovoked VTE. [source] Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphyJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 1 2005M. J. L. VAN STRIJEN Summary.,Background: Spiral computed tomography (CT) has emerged as a potentially conclusive diagnostic test to exclude pulmonary embolism (PE) in patients with non-high probability scintigraphy and is already widely used,sometimes as the sole primary diagnostic test in the diagnosis of suspected PE. Its true sensitivity and specificity has, however, not been evaluated previously in a large cohort of consecutive patients. Methods: In a multicenter prospective study 627 consecutive patients with clinically suspected PE were studied. Patients with normal perfusion scintigraphy were excluded from further analysis. Single-detector spiral CT scanning and ventilation scintigraphy were then performed in all patients to diagnose PE, while pulmonary angiography was performed as the gold standard. The only exceptions were those patients who had both a high-probability VQ scan and a CT scan positive for PE: these patients were considered to have PE and did not undergo additional pulmonary angiography. All imaging tests were read by independent expert panels. Results: Five hundred and seventeen patients were available for complete analysis. The prevalence of PE was 32%. Spiral CT correctly identified 88 of 128 patients with PE, and 92 of 109 patients without PE, for a sensitivity and specificity of 69%[95% confidence interval (CI) 63,75] and 84% (95% CI 80,89), respectively. The sensitivity of spiral CT was 86% (95% CI 80,92) for segmental or larger PE and 21% (95% CI 14,29) in the group of patients with subsegmental PE. Conclusion: The overall sensitivity of spiral CT for PE is too low to endorse its use as the sole test to exclude PE. This holds true even if one limits the discussion to patients with larger PE in segmental or larger pulmonary artery branches. We conclude that, in patients with clinically suspected PE and an abnormal perfusion scintigraphy, single-slice detector spiral CT is not sensitive enough to be used as the sole test to exclude PE. [source] Impact of environmental and hereditary risk factors on the clinical manifestation of thrombophilia in homozygous carriers of factor V:G1691AJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 3 2004S. Ehrenforth Summary.,Background:,Limited data exist on the clinical manifestations of homozygous factor (F)V:G1691A mutation (FV Leiden) and the impact of environmental and genetic risk factors. Objectives:,To assess the contribution of these factors on the thrombophilic phenotype. Patients and methods:,In a retrospective multicenter cohort study 165 individuals with homozygous FV:G1691A mutation, of whom 129 had previous venous thromboembolism (VTE), were included. To study the role of environmental risk factors, patients were compared by the use of a standardized questionnaire to 165 sex- and age-matched individuals (reference group A); of these, two had previous VTE. To assess the role of genetic risk factors, factor (F)II:G20210A and MTHFR:C677T were determined in individuals homozygous for FV:G1691A and in 177 healthy individuals without previous VTE (reference group B). Results:,The first VTE occurred significantly earlier in women (median age 25 years) than men (35.5 years). In 81% of women and 29% of men an environmental risk factor was present before first VTE. Oral contraceptives increased the risk of thrombosis 4-fold [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.7, 10.4] in women with homozygous FV:G1691A. Postoperative and post-traumatic VTE as first manifestation occurred in 13% and 15% of surgical/traumatic events in patients and in 0.7% and 1.8% in reference group A, respectively (OR 19.7, 95% CI 2.5, 154 and OR 9.2, 95% CI 1.1, 79.4). Heterozygous FII:G20210A was more prevalent in symptomatic patients (11.7%) compared with reference group B (2.8%, OR 4.6, 95% CI 1.6, 13.2). The prevalence of homozygous MTHFR:C677T genotype was similar in patients and reference group B. Conclusions:,Our study supports the concept of thrombophilia as a multifactorial disorder. The knowledge of coexisting factors predisposing to VTE is useful for medical advice for primary and secondary prophylaxis in these patients. [source] Emergency Department Patient Flow: The Influence of Hospital Census Variables on Emergency Department Length of StayACADEMIC EMERGENCY MEDICINE, Issue 7 2009Ray Lucas MD Abstract Objectives:, The objective was to evaluate the association between hospital census variables and emergency department (ED) length of stay (LOS). This may give insights into future strategies to relieve ED crowding. Methods:, This multicenter cohort study captured ED LOS and disposition for all ED patients in five hospitals during five 1-week study periods. A stepwise multiple regression analysis was used to examine associations between ED LOS and various hospital census parameters. Results:, Data were analyzed on 27,325 patients on 161 study days. A significant positive relationship was demonstrated between median ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the percentage of ED patients admitted each day. There was no relationship in this cohort between ED LOS and ED volume, total hospital occupancy rate, or the number of scheduled cardiac or surgical procedures. Conclusions:, In multiple hospital settings, ED LOS is correlated with the number of admissions and census of the higher acuity nursing units, more so than the number of ED patients each day, particularly in larger hospitals with busier EDs. Streamlining ED admissions and improving availability of inpatient critical care beds may reduce ED LOS. [source] Safety and efficacy of meningococcal c vaccination in juvenile idiopathic arthritisARTHRITIS & RHEUMATISM, Issue 2 2007Evelien Zonneveld-Huijssoon Objective To determine whether vaccinations aggravate the course of autoimmune diseases such as juvenile idiopathic arthritis (JIA) and whether the immune response to vaccinations may be hampered by immunosuppressive therapy for the underlying disease. Methods In this multicenter cohort study, 234 patients with JIA (ages 1,19 years) were vaccinated with meningococcal serogroup C (MenC) conjugate to protect against serogroup C disease (caused by Neisseria meningitidis). Patients were followed up for disease activity for 1 year, from 6 months before until 6 months after vaccination. IgG antibody titers against MenC polysaccharide and the tetanus carrier protein were determined by enzyme-linked immunosorbent assay and toxin binding inhibition assay, respectively. A serum bactericidal assay was performed to determine the function of the anti-MenC antibodies. Results No change in values for any of the 6 components of the core set criteria for juvenile arthritis disease activity was seen after MenC vaccination. Moreover, no increase in the frequency of disease relapse was detected. Mean anti-MenC IgG concentrations in JIA patients rose significantly within 6,12 weeks after vaccination. Of 157 patients tested, 153 were able to mount anti-MenC IgG serum levels >2 ,g/ml, including patients receiving highly immunosuppressive medication. The 4 patients with a lower anti-MenC antibody response displayed sufficient bactericidal activity despite receiving highly immunosuppressive medication. Conclusion The MenC conjugate vaccine does not aggravate JIA disease activity or increase relapse frequency and results in adequate antibody levels, even in patients receiving highly immunosuppressive medication. Therefore, patients with JIA can be vaccinated safely and effectively with the MenC conjugate. [source] Anxiety disorders in advanced cancer patientsCANCER, Issue 7 2010Correlates, predictors of end-of-life outcomes Abstract BACKGROUND: The authors explored associations between anxiety disorders and advanced cancer patients' physical performance status, physician-patient relationships, end-of-life (EOL) treatment preferences and outcomes, and quality of death. METHODS: The Coping with Cancer study was a National Cancer Institute/National Institute of Mental Health-sponsored, prospective, longitudinal, multicenter cohort study of patients with advanced cancer. Six hundred thirty-five patients completed the anxiety disorders module of the Structured Clinical Interview for the Diagnostic Statistical Manual IV. The results were compared with patients' baseline physical performance status, treatment preferences, perceptions of the physician-patient relationship, and advance care planning (ACP). RESULTS: Approximately 7.6% of patients met criteria for an anxiety disorder. Patients who were diagnosed with an anxiety disorder were more likely to be women and younger and to have a worse physical performance status. Although there were no significant differences in patients' EOL treatment preferences or care, ACP, hospice enrollment, or patients' location of death, there were significant differences in how patients with anxiety disorders perceived the physician-patient relationship. Patients with anxiety disorders had less trust in their physicians, felt less comfortable asking questions about their health, and felt less likely to understand the clinical information that their physicians presented. They also were more likely to believe that their physicians would offer them futile therapies and would not adequately control their symptoms. CONCLUSIONS: Women, patients who were more physically impaired, and younger patients with advanced cancer were more likely to meet criteria for an anxiety disorder. Patients with advanced cancer who had an anxiety disorder were more likely to experience greater challenges to the physician-patient relationship. Cancer 2010. © 2010 American Cancer Society. 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