ASSESSMENT OF THE CORRELATION BETWEEN FAMILY BURDEN IN PRIMARY CAREGIVERS AND DISABILITY IN PATIENTS WITH SCHIZOPHRENIA

Background: Schizophrenia is one of the most devastating, and a chronic, relapsing mental illness associated with increased morbidity, poor quality of life and low recovery rates. In India, families are the major providers of long-term care and they represent an important supportive, social network for patients with schizophrenia. Indian families experience significant degrees of burden in the care of their relatives with schizophrenia. Illness severity and patients' disability have a direct positive relationship with perceived family burden. Methods: This study is a cross-sectional study, done to assess the correlation between family burden in primary caregivers and disability in patients with schizophrenia. 60 patients with schizophrenia and their primary caregivers were recruited from the outpatient and inpatient units of Department of Psychiatry, Government Rajaji Hospital, Madurai. IDEAS (Indian Disability Evaluation Assessment Scale) scale was used to assess the disability of patients with schizophrenia and BAS (Burden Assessment Schedule) of SCARF (Schizophrenia Research Foundation) was used to assess the family burden in their primary caregivers. Results: Among the 60 primary caregivers, (48.3%) were having caregiver burden between 50 and 70%. (56.4%) of female caregivers had burden range 50- 70%. (56.5%) of caregivers delivering care for patients with illness between 15 and 20 years experienced burden >70%. Statistical analysis revealed that the correlation between caregiver burden and disability was statistically significant. Conclusions: The severity of caregiver burden increases with increasing grades of disability and indicates that caregiver burden affects the overall outcome of schizophrenia Keywords: Schizophrenia, Caregiver burden, Disability, Outcome

Comparison of the EDSS, Timed 25-Foot Walk, and the 9-Hole Peg Test as Clinical Trial Outcomes in Relapsing-Remitting Multiple Sclerosis

Background:Clinical trials in relapsing-remitting multiple sclerosis (RRMS) usually use the Expanded Disability Status Scale (EDSS) as their primary disability outcome measure, while the more recently developed outcomes timed 25 foot walk (T25FW) and nine hole peg test (NHPT) may be more useful and patient-relevant.Objective:To compare the EDSS to the T25FW and NHPT in a large RRMS randomized controlled trial (RCT) dataset.Methods:We used the dataset from CombiRx (clinicaltrials.gov identifier NCT00211887), a large phase 3 RCT, to compare the EDSS to the alternative outcomes T25FW and NHPT. We investigated disability worsening versus similarly defined improvement, unconfirmed versus confirmed and sustained disability change, and the presentation methods cumulative Kaplan-Meier survival curves versus cross-sectional disability worsening.Results:CombiRx included 1,008 participants. A comparison of confirmed versus sustained worsening events showed that throughout the trial, there were substantially fewer sustained than confirmed events, with a positive predictive value of confirmed for sustained worsening at 24 months of 0.73 for the EDSS, 0.73 for the T25FW, and 0.8 for the NHPT. More concerning was the finding that worsening on the EDSS occurred as frequently as similarly defined improvement throughout the three years of follow up, and that improvement rates increased in parallel with worsening rates. The T25FW showed low improvement rates of below 10% throughout the trial. We also found that Kaplan-Meier survival analysis, the standard presentation and analysis method in modern RRMS trials, yields exaggerated estimates of disability worsening. Using the Kaplan-Meier method, the proportion of patients with worsening events steadily increases, until it reaches several fold the number of events seen with more conservative analysis methods. For 3 month CDW at 36 months the ‘Kaplan-Meier’ method yields 2.6 fold higher estimates for the EDSS, 2.9 fold higher estimates for the T25FW and 5.1 fold higher estimates for the NHPT compared to a more conservative presentation of the same data.Discussion:Our analyses raise concerns about using the EDSS as the standard disability outcome in RRMS trials, and suggest that the T25FW may be a more useful measure. These findings are relevant for the design and critical appraisal of RCTs.

The Association Between Serum Endocan Level and Short-Term Prognosis of Patients With Acute Ischemic Stroke

This cohort study was designed to assess the association between serum endocan levels and the prognosis of acute ischemic stroke. A total of 227 patients were recruited consecutively. Study outcome data on death and major disability (modified Rankin Scale score ≥3) were collected at 3 months after stroke onset. After 3 months of follow-up, death and disability occurred in 48 and 85 patients, respectively, while the primary (death) and secondary (death or disability) outcome incident rate was 21.15% and 37.44%, respectively. The multivariable adjusted odds ratio (OR) (95% confidence interval, 95% CIs) of the highest endocan quartile for death or major disability was 1.21 (1.10, 4.13) compared with the lowest quartile. After adjusting for confounding factors, the increase in the risk of death was not significant. Receiver operating characteristic curve analysis showed that endocan predicted primary and secondary outcomes with C-statistical values (95% CIs) of 0.61 (0.55–0.67, P = .001) and 0.68 (0.59–0.76, P < .001), respectively. Elevated endocan levels were independently related to increased risk of poor outcome at 3 months after ischemic stroke onset. Endocan is a potential prognostic factor for ischemic stroke.

Decision-Making Visual Aids for Late, Imaging-Guided Endovascular Thrombectomy for Acute Ischemic Stroke

Background and Purpose Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging.Methods For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification.Results Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone.Conclusions Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.

FAKTOR PREDIKTOR LUARAN DISABILITAS PADA PASIEN STROKE ISKEMIK DI RUMAH SAKIT BETHESDA YOGYAKARTA

PREDICTING FACTOR FOR DISABILITY OUTCOME IN PATIENT WITH ISCHEMIC STROKE IN BETHESDA HOSPITAL YOGYAKARTAABSTRACTIntroduction: It is estimated that around 25% to 74% of the 50 million stroke patients who live become independent either need the full or partial assistance due to decreased physical abilities, cognition, and emotions.Aims: The aim of this study is to measure the determinant factors for disability in patients with ischemic stroke.Methods: Cohort retrospective study using stroke registry and medical records on stroke patients in Bethesda Hospital, Yogyakarta, from 2015 to 2017. The inclusion criteria included patients ≥40 years old, that has been diagnosed with ischemic stroke using CT scan, had complete stroke registry data and medical record. For the analysis this study used univariate, Chi–square method for bivariate, and logistic regression method for multivariate analysis.Results: Based on multivariate analysis, muscle strength 0-4 (p=0.023), 3 (p=0.267), 2 (p=0.579), and 1 (p=0.049), 0 (p=0.003), also aphasia (p<0.001), dysphagia (p<0.001), and triglyceride levels (p=0.043) were significant predictors of disability outcomes in patients with ischemic stroke.Discussion: Motor strength, aphasia, dysphagia, and serum triglyceride were significant for disabillity outcome in patient with ischemic stroke.Keywords: Disability, outcome, ischemic strokeABSTRAKPendahuluan: Diperkirakan sampai saat ini sekitar 25% sampai 74% dari 50 juta pasien stroke yang hidup menjadi tidak mandiri baik membutuhkan bantuan seluruhnya atau hanya sebagian akibat penurunan kemampuan fisik, kognisi, dan emosi.Tujuan: Untuk mengetahui faktor yang berpengaruh pada luaran disabilitas pasien dengan stroke iskemik.Metode: Penelitian analitik secara retrospektif berdasarkan data stroke registry dan rekam medis pasien stroke iskemik di RS Bethesda, Yogyakarta, pada tahun 2015-2017. Kriteria inklusi adalah pasien berusia ≥40 tahun yang telah terdiagnosis dengan CT scan kepala, serta memiliki data stroke registry dan rekam medis yang lengkap. Analisis data univariat dan bivariat menggunakan metode Chi-square, serta multivariat dengan metode regresi logistik.Hasil: Berdasarkan hasil multivariat didapatkan bahwa kekuatan otot 0-4 (p=0,023), kekuatan otot 3 (p=0,267), kekuatan otot 2 (p=0,579), kekuatan otot 1 (p=0,049), kekuatan otot 0 (p=0,003), afasia (p<0,001), disfagia (p<0,001), dan kadar trigliserida (p=0,043) merupakan faktor prediktor yang signifikan terhadap luaran disabilitas pasien stroke iskemik.Diskusi: Kekuatan otot pasien saat masuk, gejala afasia, disfagia, dan kadar trigliserida berhubungan dengan luaran disabilitas pada pasien stroke iskemik.Kata kunci: Disabilitas, luaran, stroke iskemik

To Treat or Not to Treat: Importance of Functional Dependence in Deciding Intravenous Thrombolysis of “Mild Stroke” Patients

Intravenous thrombolysis (IVT) in patients with a low National Institutes of Health Stroke Scale (NIHSS) score of 0–5 remains controversial. IVT should be used in patients with mild but nevertheless disabling symptoms. We hypothesize that response to IVT of patients with “mild stroke” may depend on their level of functional dependence (FD) at hospital admission. The aims of our study were to investigate the effect of IVT and to explore the role of FD in influencing the response to IVT. This study was a retrospective analysis of a prospectively collected database, including 389 patients stratified into patients receiving IVT (IVT+) and not receiving IVT (IVT −) just because of mild symptoms. Barthel index (BI) at admission was used to assess FD, dividing subjects with BI score < 80 (FD+) and with BI score ≥ 80 (FD−). The efficacy endpoints were the rate of positive disability outcome (DO+) (3-month mRS score of 0 or 1), and the rate of positive functional outcome (FO+) (mRS score of zero or one, plus BI score of 95 or 100 at 3 months). At the multivariate analysis, IVT treatment was an independent predictor of DO+ (OR 3.12, 95% CI 1.34−7.27, p = 0.008) and FO+ (OR: 4.70, 95% CI 2.38−9.26, p = 0.001). However, FD+ IVT+ patients had a significantly higher prevalence of DO+ and FO+ than those FD+ IVT–. Differently, IVT treatment did not influence DO+ and FO+ in FD– patients. In FD+ patients, IVT treatment represented the strongest independent predictor of DO+ (OR 6.01, 95% CI 2.59–13.92, p = 0.001) and FO+ (OR 4.73, 95% CI 2.29–9.76, p = 0.001). In conclusion, alteplase seems to improve functional outcome in patients with “mild stroke”. However, in our experience, this beneficial effect is strongly influenced by FD at admission.