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S Hasan - One of the best experts on this subject based on the ideXlab platform.
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tp1 7 extended glasgow outcome scale when would you rather die
Journal of Neurology Neurosurgery and Psychiatry, 2019Co-Authors: S HasanAbstract:Objectives Extended Glasgow Outcome Scale is the primary outcome measure in trials involving neurotrauma patients. Conventional dichotomization characterises unfavourable outcomes as upper Severe Disability or worse, however RESCUE-ICP changed this to consider upper Severe Disability as a favourable outcome. As the recent consensus meeting in Cambridge proved, opinion of what constitutes acceptable recovery can vary widely between individuals. Design To survey patients with brain injury and compare them to the opinions of staff routinely involved in the care of such patients. Subjects Patients with brain injuries, neurosurgery staff and ITU staff. Method GOS-E sheets were given to neurotrauma patients and asked to circle the outcome they considered unfavourable and therefore would rather not survive. This was compared to the same question posed to neurosurgery staff members, and ITU staff members. Results 67 responses collected (20 patients, 27 neurosurgery staff, 20 ITU staff). Mean GOS-E score deemed unfavourable and therefore not worth survival was 3.6, mode 3 (Patient mean 3.15, mode 3. Neurosurgery mean 3.63, mode 4. ITU mean 4.0, mode 5. p>0.05). Conclusion What constitutes unfavourable outcome varies between each group of people questioned. Patients who have experienced brain injuries were more likely to feel that upper Severe Disability was an acceptable outcome when compared to the staff that care for them. It is imperative we take this in to consideration when recommending treatment strategies in an acute setting.
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TP1-7 Extended glasgow outcome scale – when would you rather die?
Journal of Neurology Neurosurgery and Psychiatry, 2019Co-Authors: S HasanAbstract:Objectives Extended Glasgow Outcome Scale is the primary outcome measure in trials involving neurotrauma patients. Conventional dichotomization characterises unfavourable outcomes as upper Severe Disability or worse, however RESCUE-ICP changed this to consider upper Severe Disability as a favourable outcome. As the recent consensus meeting in Cambridge proved, opinion of what constitutes acceptable recovery can vary widely between individuals. Design To survey patients with brain injury and compare them to the opinions of staff routinely involved in the care of such patients. Subjects Patients with brain injuries, neurosurgery staff and ITU staff. Method GOS-E sheets were given to neurotrauma patients and asked to circle the outcome they considered unfavourable and therefore would rather not survive. This was compared to the same question posed to neurosurgery staff members, and ITU staff members. Results 67 responses collected (20 patients, 27 neurosurgery staff, 20 ITU staff). Mean GOS-E score deemed unfavourable and therefore not worth survival was 3.6, mode 3 (Patient mean 3.15, mode 3. Neurosurgery mean 3.63, mode 4. ITU mean 4.0, mode 5. p>0.05). Conclusion What constitutes unfavourable outcome varies between each group of people questioned. Patients who have experienced brain injuries were more likely to feel that upper Severe Disability was an acceptable outcome when compared to the staff that care for them. It is imperative we take this in to consideration when recommending treatment strategies in an acute setting.
Thomas M Gill - One of the best experts on this subject based on the ideXlab platform.
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Recovery from Severe Disability that Develops Progressively Versus Catastrophically: Incidence, Risk Factors, and Intervening Events.
Journal of the American Geriatrics Society, 2020Co-Authors: Thomas M Gill, Evelyne A. Gahbauer, Linda Leo-summers, Terrence E MurphyAbstract:Background Few prior studies have evaluated recovery after the onset of Severe Disability or have distinguished between the two subtypes of Severe Disability. Objectives To identify the risk factors and intervening illnesses and injuries (i.e., events) that are associated with reduced recovery after episodes of progressive and catastrophic Severe Disability. Design Prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older. Setting Greater New Haven, CT, March 1998 to December 2016. Participants A total of 431 episodes of Severe Disability were evaluated from 385 participants: 116 progressive (115 participants) and 315 catastrophic (270 participants). Measurements Candidate risk factors were assessed every 18 months. Functional status and exposure to intervening events leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Severe Disability was defined as the need for personal assistance with three or more of four essential activities of daily living. Recovery was defined as return to independent function (no Disability) within 6 months of developing Severe Disability. Results Recovery occurred among 35.3% (95% confidence interval [CI] = 26.0%-48.0%) and 61.6% (95% CI = 53.5%-70.9%) of the 116 progressive and 315 catastrophic Severe Disability episodes, respectively. In the multivariable analyses, lives alone, frailty, and intervening hospitalization were each independently associated with reduced recovery from progressive Disability, with adjusted hazard ratios (95% CIs) of 0.31 (0.15-0.64), 0.23 (0.12-0.45), and 0.27 (0.08-0.95), respectively, whereas low functional self-efficacy, intervening restricted activity, and intervening hospitalization were each independently associated with reduced recovery from catastrophic Disability, with adjusted hazard ratios (95% CIs) of 0.56 (0.40-0.81), 0.55 (0.35-0.85), and 0.45 (0.31-0.66), respectively. Conclusions Recovery of independent function is considerably more likely after the onset of catastrophic than progressive Severe Disability, the risk factors for reduced recovery differ between progressive and catastrophic Severe Disability, and subsequent exposure to intervening illnesses and injuries considerably diminishes the likelihood of recovery from both subtypes of Severe Disability.
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risk factors and precipitants of Severe Disability among community living older persons
JAMA Network Open, 2020Co-Authors: Thomas M Gill, Evelyne A. Gahbauer, Ling Han, Linda Leosummers, Terrence E MurphyAbstract:Importance Severe Disability greatly diminishes quality of life and often leads to a protracted period of long-term care or death, yet the processes underlying Severe Disability have not been fully evaluated. Objective To evaluate potential risk factors and precipitants associated with Severe Disability that develops progressively (during ≥2 months) vs catastrophically (from 1 month to the next). Design, Setting, and Participants Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2016, with 754 nondisabled community-living persons aged 70 years or older. Data analysis was conducted from November 2018 to May 2019. Main Outcomes and Measures Candidate risk factors were assessed every 18 months. Functional status and potential precipitants, including illnesses or injuries leading to hospitalization, emergency department visit, or restricted activity, were assessed each month. Severe Disability was defined as the need for personal assistance with at least 3 of 4 essential activities of daily living. The analysis was based on person-months within 18-month intervals. Results The mean (SD) age for the 754 participants was 78.4 (5.3) years, 487 (64.6%) were women, and 683 (90.5%) were non-Hispanic white participants. The incidence of progressive and catastrophic Severe Disability was 3.5% and 9.7%, respectively, based on 3550 intervals. In multivariable analysis, 6 risk factors were independently associated with progressive Disability (≥85 years: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; hearing impairment: HR, 1.7; 95% CI, 1.0-2.8; frailty: HR, 2.4; 95% CI, 1.6-3.7; cognitive impairment: HR, 2.0; 95% CI, 1.3-3.1; low functional self-efficacy: HR, 1.8; 95% CI, 1.2-2.8; low peak flow: HR, 1.7; 95% CI, 1.2-2.4), and 4 were independently associated with catastrophic Disability (visual impairment: HR, 1.4; 95% CI, 1.1-1.8; hearing impairment: HR, 1.3; 95% CI, 1.0-1.7; poor physical performance: HR, 1.8; 95% CI, 1.3-2.5; low peak flow: HR, 1.3; 95% CI, 1.0-1.7). The associations of the precipitants were much more pronounced than those of the risk factors, with HRs as high as 321.4 (95% CI, 194.5-531.0) for hospitalization and catastrophic Disability and 48.3 (95% CI, 31.0%-75.4%) for hospitalization and progressive Disability. Elimination of an intervening hospitalization was associated with a decrease in the risk of progressive and catastrophic Severe Disability of 3.0% (95% CI, 3.0%-3.1%) and 12.3% (95% CI, 12.1%-12.5%), respectively. Risk differences were 0.6% (95% CI, 0.6%-0.6%) and 1.3% (95% CI, 1.3%-1.4%) for emergency department visit and 0.1% (95% CI, 0.1%-0.2%) and 0.4% (95% CI, 0.4%-0.4%) for restricted activity, and ranged from 0.1% (95% CI, 0.1%-0.1%) to 0.3% (95% CI, 0.3%-0.3%) for the independent risk factors, for progressive and catastrophic Disability, respectively. Conclusions and Relevance The findings of this study suggest that whether it develops progressively or catastrophically, Severe Disability among older community-living adults arises most commonly in the setting of an intervening illness or injury. To reduce the burden of Severe Disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.
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establishing a hierarchy for the two components of restricted activity
Journals of Gerontology Series A-biological Sciences and Medical Sciences, 2015Co-Authors: Thomas M Gill, Heather G. Allore, Evelyne A. Gahbauer, Ling HanAbstract:Background: Increasing evidence suggests that illnesses and injuries leading to restricted acti vity have adverse functional consequences, but whether the two components of restricted activity have comparable effects is unknown. We evaluated whether an illness/injury leading to bed rest represents a more potent exposure than one leading to cutting down on one’s usual activities without bed rest. Methods: W e prospectively evaluated 754 community-living persons, 70+ years. Telephone interviews were completed monthly for >15 years to assess Disability in four basic, five instrumental, and four mobility activities and to ascertain exposure to illnesses/injuries leading to cut down activities and bed rest, respectively. For each of the three functional domains, transitions between no Disability, mild Disability, and Severe Disability were evaluated each month. Results: F or each domain, cut down activities and bed rest were significantly associated with at least one transition. The associations were consistently stronger, however, for bed rest than for cut down activities. Bed rest was a particularly potent exposure for transitions from no Disability to Severe Disability, with hazard ratios as high as 8.94 (95% CI, 5.69–14.1) for the mobility activities, and for all transitions from Severe Disability (representing recovery), with hazard ratios as low as 0.25 (0.12–0.54) for the transition to no Disability for the basic activities. Conclusions: In the set ting of an illness/injury, bed rest was more strongly associated with a set of clinically meaningful transitions in functional status than cut down activities. Prompt medical attention may be warranted when an older person takes to bed because of an illness/injury.
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change in Disability after hospitalization or restricted activity in older persons
JAMA, 2010Co-Authors: Thomas M Gill, Heather G. Allore, Evelyne A Gahbaue, Terrence E MurphyAbstract:Context Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of Disability. The role of intervening illnesses and injuries (ie, events) on these transitions is uncertain. Objectives To evaluate the relationship between intervening events and transitions among states of no Disability, mild Disability, Severe Disability, and death and to determine the association of physical frailty with these transitions. Design, Setting, and Participants Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess Disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months. Main Outcome Measure Transitions between no Disability, mild Disability, and Severe Disability and 3 transitions from each of these states to death, evaluated each month. Results Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval [CI], 118-239) for the transition from no Disability to Severe Disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild Disability to no Disability. Restricted activity also increased the likelihood of transitioning from no Disability to both mild and Severe Disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild Disability to Severe Disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or Severe Disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no Disability to mild Disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening Disability. Conclusions Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening Disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from Disability.
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trajectories of Disability in the last year of life
The New England Journal of Medicine, 2010Co-Authors: Thomas M Gill, Evelyne A Gahbaue, Heather G. AlloreAbstract:Methods We evaluated data on 383 decedents from a longitudinal study involving 754 community-dwelling older persons. None of the subjects had Disability in essential activities of daily living at the beginning of the study, and the level of Disability was ascertained during monthly interviews for more than 10 years. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed at 18-month intervals after the baseline assessment. Results In the last year of life, five distinct trajectories were identified, from no Disability to the most Severe Disability: 65 subjects had no Disability (17.0%), 76 had catastrophic Disability (19.8%), 67 had accelerated Disability (17.5%), 91 had progressive Disability (23.8%), and 84 had persistently Severe Disability (21.9%). The most common condition leading to death was frailty (in 107 subjects [27.9%]), followed by organ failure (in 82 subjects [21.4%]), cancer (in 74 subjects [19.3%]), other causes (in 57 subjects [14.9%]), advanced dementia (in 53 subjects [13.8%]), and sudden death (in 10 subjects [2.6%]). When the distribution of the Disability trajectories was evaluated according to the conditions leading to death, a predominant trajectory was observed only for subjects who died from advanced dementia (67.9% of these subjects had a trajectory of persistently Severe Disability) and sudden death (50.0% of these subjects had no Disability). For the four other conditions leading to death, no more than 34% of the subjects had any of the Disability trajectories. The distribution of Disability trajectories was particularly heterogeneous among the subjects with organ failure (from 12.2 to 32.9% of the subjects followed a specific trajectory) and frailty (from 14.0 to 27.1% of the subjects followed a specific trajectory). Conclusions In most of the decedents, the course of Disability in the last year of life did not follow a predictable pattern based on the condition leading to death.
Rakesh Shukla - One of the best experts on this subject based on the ideXlab platform.
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Intracranial tuberculomas in patients with tuberculous meningitis: predictors and prognostic significance.
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2011Co-Authors: H.k. Anuradha, Ravindra Kumar Garg, Manish Kumar Sinha, Ayush Agarwal, Verma R, Mastan Singh, Rakesh ShuklaAbstract:SETTING: Intracranial tuberculomas are commonly observed neuroimaging abnormalities in tuberculous meningitis (TBM). OBJECTIVE : To evaluate the predictors and prognostic significance of tuberculomas in patients with TBM. DESIGN: In a retrospective follow-up study, contrast-enhanced magnetic resonance imaging was performed at study inclusion and after 9 months of follow-up. Univariate analysis and multivariate analysis were used to identify predictive factors for tuberculoma. Prognosis (death and Severe Disability) was assessed using the modified Rankin scale. RESULTS: At inclusion, 43 of 110 patients had cerebral tuberculomas. Seven patients developed paradoxical tuberculomas. Predictors of tuberculomas were raised cerebrospinal fluid (CSF) protein (>3 g/l) and meningeal enhancement. Multivariate analysis did not show any significant predictors. During follow-up, the only significant predictor of paradoxical development of tuberculomas was raised CSF protein (>3 g/l). After 9 months of follow-up, 32 patients had died or had Severe Disability. Survival analysis revealed that patients with tuberculomas and those without tuberculomas had a similar prognosis. CONCLUSION: Tuberculomas occurred in approximately 39% of the patients with TBM. Significant predictors were meningeal enhancement and raised CSF protein. TBM patients with or without tuberculomas had a similar prognosis.
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Vision impairment in tuberculous meningitis: predictors and prognosis.
Journal of the Neurological Sciences, 2010Co-Authors: Manish Kumar Sinha, H.k. Anuradha, Ravindra Kumar Garg, Atul Agarwal, Maneesh Kumar Singh, Rajesh Verma, Rakesh ShuklaAbstract:Abstract Background Vision impairment is a devastating complication of tuberculous meningitis. In the present study we evaluated the predictors and prognostic significance of vision impairment in tuberculous meningitis. Methods In this study, 101 adult patients with tuberculous meningitis were evaluated for vision status and physical Disability and were followed up for 6 months. Contrast enhanced magnetic resonance imaging (MRI) was performed at baseline and 6 months. Result Out of 101 patients, 74 patients had normal vision and 27 patients had low vision or blindness at enrollment. Thirteen patients died during the study period. Out of 88 patients who survived at 6 months, 68 patients had good vision, 11 patients had low vision and 9 patients had blindness. Predictors of vision deterioration were papilledema, cranial nerve palsies, raised cerebrospinal fluid protein (> 1 g/L), and presence of optochiasmatic arachnoiditis in MRI. Predictors of blindness, at 6 months, were found to be papilledema, vision acuity ≤ 6/18, cranial nerve palsies, tuberculous meningitis stage II or III, raised cerebrospinal fluid protein (> 1 g/L), optochiasmatic arachnoiditis, and optochiasmal tuberculoma. At 6 months, 27 patients had death or Severe Disability. Predictors of death or Severe Disability at 6 months were vision acuity ≤ 6/18, cranial nerve deficits, hemiparesis, clinical stage II or III, and presence of infarct in MRI. Conclusion Vision impairment occurred in one-fourth of patients with tuberculous meningitis. Principal causes of vision loss were optochiasmatic arachnoiditis and optochiasmal tuberculoma. Impaired vision predicted death or Severe Disability.
Heather G. Allore - One of the best experts on this subject based on the ideXlab platform.
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establishing a hierarchy for the two components of restricted activity
Journals of Gerontology Series A-biological Sciences and Medical Sciences, 2015Co-Authors: Thomas M Gill, Heather G. Allore, Evelyne A. Gahbauer, Ling HanAbstract:Background: Increasing evidence suggests that illnesses and injuries leading to restricted acti vity have adverse functional consequences, but whether the two components of restricted activity have comparable effects is unknown. We evaluated whether an illness/injury leading to bed rest represents a more potent exposure than one leading to cutting down on one’s usual activities without bed rest. Methods: W e prospectively evaluated 754 community-living persons, 70+ years. Telephone interviews were completed monthly for >15 years to assess Disability in four basic, five instrumental, and four mobility activities and to ascertain exposure to illnesses/injuries leading to cut down activities and bed rest, respectively. For each of the three functional domains, transitions between no Disability, mild Disability, and Severe Disability were evaluated each month. Results: F or each domain, cut down activities and bed rest were significantly associated with at least one transition. The associations were consistently stronger, however, for bed rest than for cut down activities. Bed rest was a particularly potent exposure for transitions from no Disability to Severe Disability, with hazard ratios as high as 8.94 (95% CI, 5.69–14.1) for the mobility activities, and for all transitions from Severe Disability (representing recovery), with hazard ratios as low as 0.25 (0.12–0.54) for the transition to no Disability for the basic activities. Conclusions: In the set ting of an illness/injury, bed rest was more strongly associated with a set of clinically meaningful transitions in functional status than cut down activities. Prompt medical attention may be warranted when an older person takes to bed because of an illness/injury.
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change in Disability after hospitalization or restricted activity in older persons
JAMA, 2010Co-Authors: Thomas M Gill, Heather G. Allore, Evelyne A Gahbaue, Terrence E MurphyAbstract:Context Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of Disability. The role of intervening illnesses and injuries (ie, events) on these transitions is uncertain. Objectives To evaluate the relationship between intervening events and transitions among states of no Disability, mild Disability, Severe Disability, and death and to determine the association of physical frailty with these transitions. Design, Setting, and Participants Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess Disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months. Main Outcome Measure Transitions between no Disability, mild Disability, and Severe Disability and 3 transitions from each of these states to death, evaluated each month. Results Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval [CI], 118-239) for the transition from no Disability to Severe Disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild Disability to no Disability. Restricted activity also increased the likelihood of transitioning from no Disability to both mild and Severe Disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild Disability to Severe Disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or Severe Disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no Disability to mild Disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening Disability. Conclusions Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening Disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from Disability.
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trajectories of Disability in the last year of life
The New England Journal of Medicine, 2010Co-Authors: Thomas M Gill, Evelyne A Gahbaue, Heather G. AlloreAbstract:Methods We evaluated data on 383 decedents from a longitudinal study involving 754 community-dwelling older persons. None of the subjects had Disability in essential activities of daily living at the beginning of the study, and the level of Disability was ascertained during monthly interviews for more than 10 years. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed at 18-month intervals after the baseline assessment. Results In the last year of life, five distinct trajectories were identified, from no Disability to the most Severe Disability: 65 subjects had no Disability (17.0%), 76 had catastrophic Disability (19.8%), 67 had accelerated Disability (17.5%), 91 had progressive Disability (23.8%), and 84 had persistently Severe Disability (21.9%). The most common condition leading to death was frailty (in 107 subjects [27.9%]), followed by organ failure (in 82 subjects [21.4%]), cancer (in 74 subjects [19.3%]), other causes (in 57 subjects [14.9%]), advanced dementia (in 53 subjects [13.8%]), and sudden death (in 10 subjects [2.6%]). When the distribution of the Disability trajectories was evaluated according to the conditions leading to death, a predominant trajectory was observed only for subjects who died from advanced dementia (67.9% of these subjects had a trajectory of persistently Severe Disability) and sudden death (50.0% of these subjects had no Disability). For the four other conditions leading to death, no more than 34% of the subjects had any of the Disability trajectories. The distribution of Disability trajectories was particularly heterogeneous among the subjects with organ failure (from 12.2 to 32.9% of the subjects followed a specific trajectory) and frailty (from 14.0 to 27.1% of the subjects followed a specific trajectory). Conclusions In most of the decedents, the course of Disability in the last year of life did not follow a predictable pattern based on the condition leading to death.
Manish Kumar Sinha - One of the best experts on this subject based on the ideXlab platform.
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Intracranial tuberculomas in patients with tuberculous meningitis: predictors and prognostic significance.
The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2011Co-Authors: H.k. Anuradha, Ravindra Kumar Garg, Manish Kumar Sinha, Ayush Agarwal, Verma R, Mastan Singh, Rakesh ShuklaAbstract:SETTING: Intracranial tuberculomas are commonly observed neuroimaging abnormalities in tuberculous meningitis (TBM). OBJECTIVE : To evaluate the predictors and prognostic significance of tuberculomas in patients with TBM. DESIGN: In a retrospective follow-up study, contrast-enhanced magnetic resonance imaging was performed at study inclusion and after 9 months of follow-up. Univariate analysis and multivariate analysis were used to identify predictive factors for tuberculoma. Prognosis (death and Severe Disability) was assessed using the modified Rankin scale. RESULTS: At inclusion, 43 of 110 patients had cerebral tuberculomas. Seven patients developed paradoxical tuberculomas. Predictors of tuberculomas were raised cerebrospinal fluid (CSF) protein (>3 g/l) and meningeal enhancement. Multivariate analysis did not show any significant predictors. During follow-up, the only significant predictor of paradoxical development of tuberculomas was raised CSF protein (>3 g/l). After 9 months of follow-up, 32 patients had died or had Severe Disability. Survival analysis revealed that patients with tuberculomas and those without tuberculomas had a similar prognosis. CONCLUSION: Tuberculomas occurred in approximately 39% of the patients with TBM. Significant predictors were meningeal enhancement and raised CSF protein. TBM patients with or without tuberculomas had a similar prognosis.
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Vision impairment in tuberculous meningitis: predictors and prognosis.
Journal of the Neurological Sciences, 2010Co-Authors: Manish Kumar Sinha, H.k. Anuradha, Ravindra Kumar Garg, Atul Agarwal, Maneesh Kumar Singh, Rajesh Verma, Rakesh ShuklaAbstract:Abstract Background Vision impairment is a devastating complication of tuberculous meningitis. In the present study we evaluated the predictors and prognostic significance of vision impairment in tuberculous meningitis. Methods In this study, 101 adult patients with tuberculous meningitis were evaluated for vision status and physical Disability and were followed up for 6 months. Contrast enhanced magnetic resonance imaging (MRI) was performed at baseline and 6 months. Result Out of 101 patients, 74 patients had normal vision and 27 patients had low vision or blindness at enrollment. Thirteen patients died during the study period. Out of 88 patients who survived at 6 months, 68 patients had good vision, 11 patients had low vision and 9 patients had blindness. Predictors of vision deterioration were papilledema, cranial nerve palsies, raised cerebrospinal fluid protein (> 1 g/L), and presence of optochiasmatic arachnoiditis in MRI. Predictors of blindness, at 6 months, were found to be papilledema, vision acuity ≤ 6/18, cranial nerve palsies, tuberculous meningitis stage II or III, raised cerebrospinal fluid protein (> 1 g/L), optochiasmatic arachnoiditis, and optochiasmal tuberculoma. At 6 months, 27 patients had death or Severe Disability. Predictors of death or Severe Disability at 6 months were vision acuity ≤ 6/18, cranial nerve deficits, hemiparesis, clinical stage II or III, and presence of infarct in MRI. Conclusion Vision impairment occurred in one-fourth of patients with tuberculous meningitis. Principal causes of vision loss were optochiasmatic arachnoiditis and optochiasmal tuberculoma. Impaired vision predicted death or Severe Disability.
