Holly Hollingsworth

Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit.

ObjectiveThe objective of this study was to identify factors associated with the decision to withdraw mechanical ventilation from patients in a neurology/neurosurgery intensive care unit. Specifically, the following factors were considered: the severity of the neurologic illness, the healthcare delivery system, and social factors. DesignRetrospective analysis of prospectively collected clinical database. SettingNeurology/neurosurgery intensive care unit of a large academic tertiary care hospital. PatientsPatients were 2,109 nonelective admissions to the neurology/neurosurgery intensive care unit who received mechanical ventilation over a period of 82 months. InterventionsNone. Measurements and Main Results The average age was 56 ± 19.7 yrs, 53% were male, and 81% were functionally normal before admission. The median Glasgow Coma Scale score was 14, the average Acute Physiology and Chronic Health Evaluation II severity of illness score was 13.5 ± 8.3, and probability of death was 18.2 ± 22.0%. Mechanical ventilation was withdrawn from 284 (13.5%). Factors that were independently associated with withdrawal of mechanical ventilation were as follows: more severe neurologic injury [admission Glasgow Coma Scale score (odds ratio 0.86/point, confidence interval 0.82–0.90), diagnosis of subarachnoid hemorrhage (odds ratio 2.44, confidence interval 1.50–3.99), or ischemic stroke (odds ratio 1.72, confidence interval 1.13–2.60)], older age (odds ratio 1.04/yr, confidence interval 1.03–1.05), and higher Acute Physiology and Chronic Health Evaluation II probability of death (odds ratio 1.03/%, confidence interval 1.02–1.04). Mechanical ventilation was less likely to be withdrawn if patients were African-American (odds ratio 0.50, confidence interval 0.36–0.68) or had undergone surgery (odds ratio 0.44, confidence interval 0.2– 0.67). Marital status, premorbid functional status, clinical service (neurology vs. neurosurgery), attending status (private vs. academic), and type of health insurance were not associated with decisions to withdraw mechanical ventilation. ConclusionsWe conclude that decisions to withdraw mechanical ventilation in the neurology/neurosurgery intensive care unit are based primarily on the severity of the acute neurologic condition and age but not on characteristics of the healthcare delivery system. Care is less likely to be withdrawn from African-American patients or those who had surgery.

A subjective measure of environmental facilitators and barriers to participation for people with mobility limitations

Purpose. The aim of this paper is to describe the development and psychometric properties of a self-report survey of environmental facilitators and barriers to participation by people with mobility impairments. Method. A measure called the Facilitators And Barriers Survey of environmental influences on participation among people with lower limb Mobility impairments and limitations (FABS/M) was developed using items based on focus groups to ensure content validity. Discriminant validity was assessed on 604 individuals who completed the FABS/M once. Internal consistency and test-retest reliabilities were based on 371 individuals who completed two surveys. Results. The FABS/M includes 61 questions, 133 items and six domains including the type of primary mobility device; built features of homes; built and natural features in the community; community destination access; community facilities access; community support network. Environmental items are scored for the frequency of encounter and the magnitude of influence on their participation. The internal consistencies and the test-retest reliabilities of the domains of the FABS/M ranged from low to moderate. The discriminant validity of domains differed for device and diagnostic groups. Conclusion. The FABS/M joins the MQE and the CHIEF as another subjective measure for use in assessing environmental features important for understanding participation. The FABS can be used to assess the influence of environmental interventions at the individual and community levels of analysis. The type of primary mobility device that is used can be related to reported environmental barriers. Community-based improvements in built features, access to destinations, access to facilities and augmented support networks can be tracked through the reports of people with mobility impairments.

Development of a measure of receptivity of the physical environment

Purpose. New models of disability identify the importance of measuring the influence of the environment (environmental barriers) on the performance of persons with disabilities. The objective of this paper is to present a new measure of the receptivity of the physical environment for persons with mobility impairments and to offer preliminary information about its psychometric properties. Methods. The measure, The Community Health Environment Checklist (CHEC), was developed and validated in a community setting with a group of persons with mobility impairments. Sixty-three destinations (buildings, recreational areas or facilities) were assessed using the CHEC. Results. Using Cronbachs alpha, the CHEC was found to have an internal consistency reliability of 0.95. The content validity of the CHEC was assured by the development procedure. Conclusion. The CHEC offers a brief, easily administered measure of receptivity of the physical environment for persons with mobility impairments that is psychometrically sound.

People with mobility impairments: Physical activity and quality of participation.

BACKGROUND we sought to describe the characteristics of physical activity levels, health, community integration, and social participation of people with mobility impairments. METHODS based on responses to a participation survey, respondents, located primarily in the Midwestern United States, were divided into 3 physical activity groups: high, low, and inactive. We chose a purposeful sample of 604 people with mobility limitations who had a diagnosis of spinal cord injury, multiple sclerosis, cerebral palsy, stroke, or poliomyelitis. The Participation Survey/Mobility (PARTS/M) was used to measure participation in 6 domains and 20 different activities, the Physical Activity and Health Status (SF-36) was used to measure health and quality of life, and the Reintegration to Normal Living Index (RNL) was used to measure integration into the community. RESULTS people with mobility impairments who were identified as having a high level of physical activity reported greater participation, better health, and a higher level of reintegration to normal community living compared with participants who described their physical activity level as low or inactive. CONCLUSION positive health status and superior community participation were found in a high physical activity group compared with low active or inactive groups of people with mobility impairments and limitations.

Environmental factors item development for persons with stroke, traumatic brain injury, and spinal cord injury.

OBJECTIVES To describe methods used in operationalizing environmental factors; to describe the results of a research project to develop measures of environmental factors that affect participation; and to define an initial item set of facilitators and barriers to participation after stroke, traumatic brain injury, and spinal cord injury. DESIGN Instrument development included an extensive literature review, item classification and selection, item writing, and cognitive testing following the approach of the Patient-Reported Outcomes Measurement Information System. SETTING Community. PARTICIPANTS Content area and outcome measurement experts (n=10) contributed to instrument development; individuals (n=200) with the target conditions participated in focus groups and in cognitive testing (n=15). INTERVENTIONS None. MAIN OUTCOME MEASURES Environmental factor items were categorized in 6 domains: assistive technology; built and natural environment; social environment; services, systems, and policies; access to information and technology; and economic quality of life. RESULTS We binned 2273 items across the 6 domains, winnowed this pool to 291 items for cognitive testing, and recommended 274 items for pilot data collection. CONCLUSIONS Five of the 6 domains correspond closely to the International Classification of Functioning, Disability and Health taxonomy of environmental factors; the sixth domain, economic quality of life, reflects an important construct that reflects financial resources that affect participation. Testing with a new and larger sample is underway to evaluate reliability, validity, and sensitivity.

Artificial neural networks improve the prediction of mortality in intracerebral hemorrhage

Background: Artificial neural network (ANN) analysis methods have led to more sensitive diagnosis of myocardial infarction and improved prediction of mortality in breast cancer, prostate cancer, and trauma patients. Prognostic studies have identified early clinical and radiographic predictors of mortality after intracerebral hemorrhage (ICH). To date, published models have not achieved the accuracy necessary for use in making decisions to limit medical interventions. We recently reported a logistic regression model that correctly classified 79% of patients who died and 90% of patients who survived. In an attempt to improve prediction of mortality we computed an ANN model with the same data. Objective: To determine whether an ANN analysis would provide a more accurate prediction of mortality after ICH when compared with multiple logistic regression models computed using the same data. Methods: Analyses were conducted on data collected prospectively on 81 patients with supratentorial ICH. Multiple logistic regression was used to predict hospital mortality, then an ANN analysis was applied to the same data set. Input variables were age, gender, race, hydrocephalus, mean arterial pressure, pulse pressure, Glasgow Coma Scale score, intraventricular hemorrhage, hydrocephalus, hematoma size, hematoma location (ganglionic, thalamic, or lobar), cisternal effacement, pineal shift, history of hypertension, history of diabetes, and age. Results: The ANN model correctly classified all patients (100%) as alive or dead compared with 85% correct classification for the logistic regression model. A second ANN verification model was equally accurate. The ANN was superior to the logistic regression model on all objective measures of fit. Conclusions: ANN analysis more effectively uses information for prediction of mortality in this sample of patients with ICH. A well-validated ANN may have a role in the clinical management of ICH.

Preclinical Alzheimer disease and risk of falls

Objective: We determined the rate of falls among cognitively normal, community-dwelling older adults, some of whom had presumptive preclinical Alzheimer disease (AD) as detected by in vivo imaging of fibrillar amyloid plaques using Pittsburgh compound B (PiB) and PET and/or by assays of CSF to identify Aβ42, tau, and phosphorylated tau. Methods: We conducted a 12-month prospective cohort study to examine the cumulative incidence of falls. Participants were evaluated clinically and underwent PiB PET imaging and lumbar puncture. Falls were reported monthly using an individualized calendar journal returned by mail. A Cox proportional hazards model was used to test whether time to first fall was associated with each biomarker and the ratio of CSF tau/Aβ42 and CSF phosphorylated tau/Aβ42, after adjustment for common fall risk factors. Results: The sample (n = 125) was predominately female (62.4%) and white (96%) with a mean age of 74.4 years. When controlled for ability to perform activities of daily living, higher levels of PiB retention (hazard ratio = 2.95 [95% confidence interval 1.01–6.45], p = 0.05) and of CSF biomarker ratios (p < 0.001) were associated with a faster time to first fall. Conclusions: Presumptive preclinical AD is a risk factor for falls in older adults. This study suggests that subtle noncognitive changes that predispose older adults to falls are associated with AD and may precede detectable cognitive changes.

Structural Equation Modeling of the Relationships Between Participation in Leisure Activities and Community Environments by People With Mobility Impairments

OBJECTIVE To examine the linkages between the constructs of participation and the environment for a set of leisure activities (attending concerts, attending movies, attending sporting events). DESIGN Self-report surveys of the influence of the environment on participation were analyzed using structural equation modeling. Temporal, evaluative, and health-related aspects of leisure activities were selected as latent variables associated with participation. The environmental construct consisted of the latent variables of the influence on participation of the natural, interpersonal, built, background, and supportive environments. SETTING Midwestern United States. PARTICIPANTS A purposive sample of people (N=604) with mobility limitations. INTERVENTION None. MAIN OUTCOME MEASURES Measures of relationships between participation in leisure activities and the environment of people with mobility limitations. RESULTS Structural equation modeling can be an important tool for empirically examining the contributions of the component latent variables of participation and the environment. CONCLUSIONS A model that fits participation by people with disabling conditions in their environment can provide guidance for community-based interventions and person-based therapies.

The influence of verbal training and visual feedback on manual wheelchair propulsion

Purpose. To determine if verbal training with visual feedback improved manual wheelchair propulsion; to examine propulsion differences between an individual with paraplegia and an individual with tetraplegia. Method. Quasi-experimental study: Nine manual wheelchair-using adults participated in propulsion assessments and training. Baseline propulsion performance was measured on several tasks on different surfaces. Participants were trained on a wheelchair treadmill with verbal and visual feedback to increase push length, reduce push frequency and to modify propulsion pattern. Handrim biomechanics were measured with an instrumented wheel. Changes in propulsion were assessed. Differences in propulsion characteristics between a participant with paraplegia and a participant with tetraplegia were examined. Results. Push length increased (p < 0.05), push frequency decreased (p < 0.01) and peak (p < 0.05) and average (p < 0.01) forces increased immediately after training. These changes were not sustained over time. Graphic representations showed differences in propulsion characteristics between a participant with paraplegia and a participant with tetraplegia. Conclusions. Verbal training may produce changes in push biomechanics of manual wheelchair users. Longer training periods may be needed to sustain propulsion changes. Findings from this study support other studies that have shown propulsion differences between people with tetraplegia and paraplegia. Propulsion training for populations with upper-extremity impairments warrants further study.

Home Lighting Assessment for Clients With Low Vision

OBJECTIVE The goal was to develop an objective, comprehensive, near-task home lighting assessment for older adults with low vision. METHOD A home lighting assessment was developed and tested with older adults with low vision. Interrater and test-retest reliability studies were conducted. Clinical utility was assessed by occupational therapists with expertise in low vision rehabilitation. RESULTS Interrater reliability was high (intraclass correlation coefficient [ICC] = .83-1.0). Test-retest reliability was moderate (ICC = .67). Responses to a Clinical Utility Feedback Form developed for this study indicated that the Home Environment Lighting Assessment (HELA) has strong clinical utility. CONCLUSION The HELA provides a structured tool to describe the quantitative and qualitative aspects of home lighting environments where near tasks are performed and can be used to plan lighting interventions. The HELA has the potential to affect assessment and intervention practices of rehabilitation professionals in the area of low vision and improve near-task performance of people with low vision.