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Biomedical subjects

Mark S Roberts

Publications and source records attributed to Mark S Roberts.

At least 19 recordsLinked to original sources
PubMed2007

Incorporating quality of evidence into decision analytic modeling.

Our objective was to illustrate the effects of using stricter standards for the quality of evidence used in decision analytic modeling. We created a simple 10-parameter probabilistic Markov model to estimate the cost-effectiveness of directly observed therapy (DOT) for individuals with newly diagnosed HIV infection. We evaluated quality of evidence on the basis of U.S. Preventive Services Task Force methods, which specified 3 separate domains: study design, internal validity, and external validity. We varied the evidence criteria for each of these domains individually and collectively. We used published research as a source of data only if the quality of the research met specified criteria; otherwise, we specified the parameter by randomly choosing a number from a range within which every number has the same probability of being selected (a uniform distribution). When we did not eliminate poor-quality evidence, DOT improved health 99% of the time and cost less than 100,000 dollars per additional quality-adjusted life-year (QALY) 85% of the time. The confidence ellipse was extremely narrow, suggesting high precision. When we used the most rigorous standards of evidence, we could use fewer than one fifth of the data sources, and DOT improved health only 49% of the time and cost less than 100,000 dollars per additional QALY only 4% of the time. The confidence ellipse became much larger, showing that the results were less precise. We conclude that the results of decision modeling may vary dramatically depending on the stringency of the criteria for selecting evidence to use in the model.

CD4 Lymphocyte Count↗
PubMed2007

Hospitalization for pelvic inflammatory disease: a cost-effectiveness analysis.

OBJECTIVE: Nulliparous women are frequently hospitalized for treatment of pelvic inflammatory disease (PID). GOAL: The goal of this study was to determine the economic feasibility of hospitalizing adolescents and young women for PID. STUDY DESIGN: The authors conducted a Markov decision model, estimating the cost-effectiveness of hospitalization compared with outpatient therapy for mild to moderate PID for adolescents and young women, calculating costs per quality-adjusted life-year (QALY) gained under various assumptions about hospitalization effects on complications. RESULTS: If hospitalization decreases PID complications by 10%, 20%, or 30%, the cost/QALY gained is 145,000 dollars, 67,400 dollars, or 42,400 dollars, respectively, compared with outpatient therapy. Assumptions about hospitalization effects on the development of chronic pelvic pain heavily weight the analysis; costs/QALY gained by hospitalization increase considerably if chronic pain is unaffected. CONCLUSION: Hospitalization for PID treatment to possibly preserve fertility in nulliparous young women and adolescents is unlikely to be economically reasonable even if substantial improvements in PID complication rates are assumed.

Adolescent↗
PubMed2006

What do patients with cerebral aneurysms know about their condition?

OBJECTIVE: During diagnosis and treatment, patients with cerebral aneurysms receive complex medical information. To study what patients know about their condition, we compared patients' knowledge about their aneurysm-related medical history with information in the medical record. METHODS: Neurosurgery clinic outpatients with cerebral aneurysms were interviewed about their history of subarachnoid hemorrhage, number of aneurysms, aneurysm treatments, and treatment outcomes. Corresponding data were abstracted from the medical record by study personnel. We used kappa scores to assess the agreement between patient responses and the medical record. RESULTS: The 178 study patients were predominantly women (71%), with a mean age of 54.4 years. The medical record showed that 56% of patients currently harbored an unsecured aneurysm, 53% had experienced a subarachnoid hemorrhage, 29% had multiple aneurysms, and 68% had undergone previous surgical or endovascular aneurysm treatment. Patient responses showed that, of the 100 patients with unsecured aneurysms, 33% were not aware that they harbored an unsecured aneurysm. Ninety percent of all patients knew whether they had experienced a subarachnoid hemorrhage (kappa = 0.81, near perfect agreement), 78% knew how many aneurysms they harbored (kappa = 0.57, moderate agreement), and 92% understood whether they had undergone previous aneurysm treatment (kappa = 0.82, near perfect agreement). CONCLUSION: Most patients with cerebral aneurysms had an accurate understanding of many aspects of their aneurysm-related medical history. Of concern, patients were most often incorrect about the presence of an unsecured aneurysm, the issue most relevant to treatment decision-making and to their future risk of subarachnoid hemorrhage, stroke, and premature death.

Adult↗
PubMed2006

Cognitive functioning in patients with cerebral aneurysms measured with the mini mental state examination and the telephone interview for cognitive status.

BACKGROUND: Clinicians and researchers use brief instruments, such as the Mini Mental State Examination (MMSE) and the Telephone Interview for Cognitive Status (TICS), to measure cognitive functioning in patients with cerebral aneurysms. MMSE and TICS scores are often dichotomized to classify patients as cognitively impaired or not. Frequently, after an initial MMSE face-to-face evaluation, the TICS is used for follow-up assessments by telephone. METHODS: A cross-sectional cohort of patients with cerebral aneurysms completed the MMSE at baseline and the MMSE or TICS at the 12-month follow-up examination. Multivariate logistic regression adjusting for demographics was used to model cognitive impairment. MMSE and TICS results were compared using the MMSE as the "gold standard." RESULTS: Eleven out of 171 (6%) patients had baseline MMSE scores less than 24, indicating cognitive impairment. Multivariate analysis showed that a history of subarachnoid hemorrhage was associated with cognitive impairment measured with the MMSE (odds ratio, 13.9; P = 0.021; C statistic = 0.87); there was no relationship between subarachnoid hemorrhage or treatment and TICS cognitive impairment (i.e., score < 27). In patients without recent or interim invasive interventions that might affect cognition (n = 65), raw baseline MMSE and 12-month TICS scores had fair correlations (r = 0.30, P = 0.015); however, dichotomized scores had poor agreement, and TICS sensitivity and positive predictive value was 0% compared with the MMSE. CONCLUSION: The MMSE may be more sensitive than the TICS to the effects of subarachnoid hemorrhage on cognitive functioning. Raw MMSE and TICS scores are well correlated, but dichotomized MMSE and TICS scores are probably not interchangeable in this patient population.

Adult↗
PubMed2006

Deficiencies of cardiovascular risk prediction models for type 1 diabetes.

OBJECTIVE: Cardiovascular risk prediction models are available for the general population (Framingham) and for type 2 diabetes (U.K. Prospective Diabetes Study [UKPDS] Risk Engine) but may not be appropriate in type 1 diabetes, as risk factors including younger age at diabetes onset and presence of diabetes complications are not considered. Therefore, our objective was to examine the accuracy of Framingham and UKPDS models for predicting coronary heart disease (CHD) in a type 1 diabetic cohort. RESEARCH DESIGN AND METHODS: Ten-year follow-up data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, a prospective cohort study of 658 subjects with childhood-onset type 1 diabetes diagnosed between 1950 and 1980 first seen in 1986-1988, were analyzed. EDC study data were used to calculate the 10-year probability of CHD (fatal CHD, nonfatal myocardial infarction, or Q-waves) applying to the Framingham and UKPDS equations. RESULTS: Mean age at CHD onset was 39 years. When fatal/nonfatal myocardial infarction and CHD death were modeled, both the UKPDS and Framingham models showed significant lack of calibration (P < 0.0001) but moderate discrimination (0.76 UKPDS, 0.77 Framingham men, and 0.88 Framingham women). Both the UKPDS and Framingham models underestimated probability of events in highest risk deciles. CONCLUSIONS: Currently available CHD models poorly predict events in type 1 diabetes. Future research should focus on determining the risk factors accounting for the lack of fit and developing prediction models specific to this high-risk group.

Adult↗
PubMed2006

The physical performance test and the evaluation of functional status in patients with cerebral aneurysms.

OBJECT: Cerebral aneurysms can adversely affect the functional status of patients who harbor them through rupture, mass effect, or treatment sequela. The authors compared the Physical Performance Test (PPT)--an observer-administered test requiring the completion of seven tasks--with three functional status measures based on patient self-reports: the Glasgow Outcome Scale (GOS), the modified Rankin Scale (mRS), and the modified Barthel Index (mBI). METHODS: Data were collected from 144 patients with aneurysms who had been recruited from a neurosurgery clinic. The patients completed the PPT and were assigned GOS scores, mRS scores, and mBIs based on their responses during a structured interview. The validity of the PPT was assessed by examining the relationship between the results of the PPT and the values assigned to each patient by using the GOS, mRS, and mBI by applying rank-order methods; the reliability of the PTT was assessed using the Cronbach alpha coefficient. The mean age of the patients was 52.8 years; 72% were women and 54% had survived a subarachnoid hemorrhage. The mean +/- standard deviation PPT score was 24.0 +/- 3.7. The PPT generated a broad distribution of scores, whereas GOS and mRS scores and mBIs displayed significant ceiling effects, that is, 75% of the patients were clustered in the highest categories. The PPT scores were validated by their strong association with GOS scores, mRS scores, and mBIs (for all, p < 0.001), and the reliability of the PPT was demonstrated by a Cronbach alpha value of 0.77. CONCLUSIONS: The PPT provides an objective measure of functional status in patients with cerebral aneurysms. The results suggest that the PPT may differentiate among patients better than the GOS, mRS, or mBL The PPT is a valid and reliable instrument for measuring functional status in patients with cerebral aneurysms.

Activities of Daily Living↗
PubMed2005

Preference-based quality of life in patients with cerebral aneurysms.

BACKGROUND AND PURPOSE: Functional outcome scales are typically used to measure quality of life (QOL) and outcomes in patients with cerebral aneurysms; however, these instruments only examine a limited number of domains that contribute to QOL. An alternative are preference-based QOL methods, which integrate all factors contributing to QOL and provide a comprehensive individualized measure of how patients value their current health state. An additional advantage of preference-based QOL values is that they can be incorporated into decision analyses and cost-effectiveness analyses. METHODS: We used 4 preference-based QOL methods to measure QOL in 176 outpatients with cerebral aneurysms: (1) standard gamble; (2) time trade-off; (3) visual analogue scale; and (4) willingness to pay. We measured functional status with the Glasgow Outcome Scale (GOS), Rankin Scale, and Barthel Index. We then built multivariate linear regression models to examine the relationships between preference-based QOL, functional status, and patient characteristics. RESULTS: Preference-based QOL was moderately diminished in the aneurysm patients. Mean values were: standard gamble, 0.78; time trade-off, 0.79; visual analogue scale, 0.67; and willingness to pay, 121,000 dollars. Preference-based QOL was not well-explained by functional status or patient characteristics, as shown by regression models that accounted for <15% of the variation in preference-based QOL (R2<0.15). CONCLUSIONS: Preference-based QOL instruments capture components of QOL in patients with cerebral aneurysms not assessed by functional status measures or patient characteristics. Studies of patients with cerebral aneurysms should consider incorporating preference-based QOL measures for a fuller evaluation of the impact of aneurysmal disease and its treatment on QOL.

Activities of Daily Living↗
PubMed2005

Estimating the proportion of patients infected with HIV who will die of comorbid diseases.

PURPOSE: Effective antiretroviral therapies have improved the prognosis for patients infected with the human immunodeficiency virus (HIV). We aimed to estimate the likelihood that HIV-infected patients would die of comorbid disease. METHODS: A probabilistic simulation of antiretroviral-naïve HIV-infected patients in the United States was calibrated with data from an observational cohort (N = 3545) and validated with data from a separate patient cohort (N = 12574). The simulation explicitly represents the 2 main determinants of treatment failure and subsequent death from HIV-related causes: nonadherence to combination therapy and accumulation of phenotypic resistance to combination therapy. The likelihood of deaths not directly attributable to HIV was estimated from the Collaborations in HIV Outcomes Research-US (CHORUS) cohort. RESULTS: For patients with newly diagnosed HIV infections, CD4 counts of 500 cells/mm3, and viral loads of 10000 copies/mL, the median estimated survival was 26.8 years for 30-year-olds, 24.4 years for 40-year-olds and 14.6 years for 50-year-olds. The proportion of deaths not directly attributable to HIV was 36% for 30-year-olds, 53% for 40-year-olds, and 72% for 50-year-olds. For patients with characteristics similar to CHORUS participants, the median estimated survival approached 20.4 years, the mean age at death approached 60.4 years, and 41% died of illnesses not directly attributable to HIV. These estimates of non-HIV mortality were likely conservative. CONCLUSION: As HIV-infected patients live longer, our results suggest they will experience increasing mortality from causes not directly attributable to HIV. The projected risk from comorbid disease has clinical and policy implications for future delivery of care to HIV-infected patients.

Adult↗
PubMed2005

Oral anticoagulation strategies after a first idiopathic venous thromboembolic event.

PURPOSE: The optimal duration and intensity of warfarin therapy after a first idiopathic venous thromboembolic event are uncertain. We used decision analysis to evaluate clinical and economic outcomes of different anticoagulation strategies with warfarin. METHODS: We built a Markov model to assess 6 strategies to treat 40- to 80-year-old men and women after their first idiopathic venous thromboembolic event: 3-month, 6-month, 12-month, 24-month, and unlimited-duration conventional-intensity anticoagulation (International Normalized Ratio, 2-3) and unlimited-duration low-intensity anticoagulation (International Normalized Ratio, 1.5-2). The model incorporated age- and sex-specific clinical parameters, utilities, and costs. Using a societal perspective, we compared strategies based on quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios. RESULTS: In our baseline analysis, incremental cost-effectiveness ratios were lower in younger patients and in men, reflecting the higher bleeding risk at older ages, and the lower risk of recurrence among women. Based on a willingness-to-pay of <$50000/QALY, the 24-month strategy was most cost-effective in 40-year-old men ($48805/QALY), while the 6-month strategy was preferred in 40-year-old women ($35977/QALY) and 60-year-old men ($29878/QALY). In patients aged >/=80 years, 3-month anticoagulation was less costly and more effective than other strategies. Cost-effectiveness results were influenced by the risks associated with recurrent venous thromboembolism, the major bleeding risk of conventional-intensity anticoagulation and the disutility of taking warfarin. CONCLUSION: Longer initial conventional-intensity anticoagulation is cost-effective in younger patients while 3 months of anticoagulation is preferred in elderly patients. Patient age, sex, clinical factors, and patient preferences should be incorporated into medical decision making when selecting an appropriate anticoagulation strategy.

Adult↗
PubMed2005

Health utility ratings for a spectrum of alcohol-related health states.

BACKGROUND: Preference-based utility ratings for health conditions are important components of cost-utility analyses and population burden of disease estimates. However, utility ratings for alcohol problems have not been determined. OBJECTIVES: The objectives of this study were to directly measure utility ratings for a spectrum of alcohol-related health states and to compare different methods of utility measurement. DESIGN, SETTING, AND SUBJECTS: The authors conducted a cross-sectional interview of 200 adults from a clinic and community sample. METHODS: Subjects completed computerized visual analog scale (VAS), time tradeoff (TTO), and standard gamble (SG) utility measurement exercises for their current health, a blindness scenario, and for 6 alcohol-related health state scenarios presented in random order. The main outcome measures were the utility ratings, scaled from 0 to 1, and anchored by death (0) and perfect health (1). RESULTS: The 200 subjects were middle-aged (mean, 41 +/- 14 years), 61% women, and racially diverse (48% black, 43% white). Utility ratings decreased as the severity of the alcohol-related health state increased, but differed significantly among the VAS, TTO, and SG methods within each health state. Adjusted mean (95% confidence interval) utility ratings for alcohol dependence (VAS, 0.38 [0.34-0.41]; TTO, 0.54 [0.48-0.60]; SG, 0.68 [0.63-0.73]) and alcohol abuse (VAS, 0.53 [0.49-0.56]; TTO, 0.71 [0.65-77]; SG, 0.76 [0.71-0.81]) were significantly lower than utility ratings for nondrinking, moderate drinking, at-risk drinking, current health, and blindness. CONCLUSIONS: Utility ratings for alcohol-related health states decrease as the severity of alcohol use increases. The low utility ratings for alcohol abuse and alcohol dependence are similar to those reported for other severe chronic medical conditions.

Academic Medical Centers↗
PubMed2005

Cost-effectiveness of low-molecular-weight heparin for secondary prophylaxis of cancer-related venous thromboembolism.

Although extended secondary prophylaxis with low-molecular-weight heparin was recently shown to be more effective than warfarin for cancer-related venous thromboembolism, its cost-effectiveness compared to traditional prophylaxis with warfarin is uncertain. We built a decision analytic model to evaluate the clinical and economic outcomes of a 6-month course of low-molecular-weight heparin or warfarin therapy in 65-year-old patients with cancer-related venous thromboembolism. We used probability estimates and utilities reported in the literature and published cost data. Using a US societal perspective, we compared strategies based on quality-adjusted life-years (QALYs) and lifetime costs. The incremental cost-effectiveness ratio of low-molecular-weight heparin compared with warfarin was 149,865 dollars/QALY. Low-molecular-weight heparin yielded a quality-adjusted life expectancy of 1.097 QALYs at the cost of 15,329 dollars. Overall, 46% (7108 dollars) of the total costs associated with low-molecular-weight heparin were attributable to pharmacy costs. Although the low-molecular-weigh heparin strategy achieved a higher incremental quality-adjusted life expectancy than the warfarin strategy (difference of 0.051 QALYs), this clinical benefit was offset by a substantial cost increment of 7,609 dollars. Cost-effectiveness results were sensitive to variation of the early mortality risks associated with low-molecular-weight heparin and warfarin and the pharmacy costs for low-molecular-weight heparin. Based on the best available evidence, secondary prophylaxis with low-molecular-weight heparin is more effective than warfarin for cancer-related venous thromboembolism. However, because of the substantial pharmacy costs of extended low-molecular-weight heparin prophylaxis in the US, this treatment is relatively expensive compared with warfarin.

Cost-Benefit Analysis↗
PubMed2005

Expectations of groups versus pairs of attendings and residents about phone communications and bedside evaluation of hospitalized patients.

BACKGROUND: Residents covering attendings' patients must decide when to call the attending and when to evaluate patients at the bedside for new clinical events. Conflicts arise when residents and attendings disagree about these decisions. PURPOSE: Our purpose was to determine differences in expectations between attendings and residents concerning the need for phone communication about, and bedside evaluation of, new patient problems in hospitalized patients. METHODS: Teaching attendings and categorical medical residents rated a series of 15 clinical vignettes regarding the importance of phone communication about the problems depicted in the vignettes and rated a second series of 9 vignettes about the need for bedside evaluation of problems depicted. RESULTS: Mean Likert scores were similar between residents and attendings for 70% of the scenarios. When analyzed for disagreement within hypothetical resident/attending pairs, the survey revealed that disagreement would be expected to occur as often as 33% of the time for phone communication and up to 43% of the time for bedside evaluation. Attendings disagreed with each other 41% of the time. Residents were less likely to say they would call attendings at night than attendings wanted to be called (odds ratio=0.74, p=.04). CONCLUSION: There was substantial disagreement among hypothetical resident--attending pairs regarding need for phone communication and bedside evaluation. Residents and attendings need to discuss their expectations regarding these issues to avoid conflict.

Attitude of Health Personnel↗
PubMed2005

Cervical spondylotic myelopathy, depression, and anxiety: a cohort analysis of 89 patients.

OBJECTIVE: To determine the prevalence of depressed and anxious mood states in patients with cervical spondylotic myelopathy (CSM), a degenerative spine condition with symptoms of neck pain, numb clumsy hands, gait difficulties, sphincter dysfunction, and impotence. To examine the relation between mood and functional deficits produced by CSM. METHODS: We surveyed a cohort of 89 patients with CSM recruited during 1 year from a neurosurgery clinic. Patients underwent a structured interview to collect information on demographics, personal habits, CSM symptoms, comorbid diseases, and symptoms of depression and anxiety. Patients self-completed the Hospital Anxiety and Depression scale and were scored on the Nurick, Cooper, Harsh, and modified Japanese Orthopaedic Association (mJOA) scales. RESULTS: According to the Hospital Anxiety and Depression scale threshold value of 11, 29% of the cohort had a depressed mood and 38% had an anxious mood. Higher depression scores were associated with worse myelopathy, as measured by the Nurick scale (P = 0.01), the Cooper leg subscale (P = 0.006), the Harsh scale (P = 0.02), the mJOA arm subscale (P = 0.006), and the mJOA leg subscale (P = 0.004). There was no relation between depression scores and the Cooper arm subscale, Harsh sphincter scale, mJOA sensory subscale, or mJOA bladder subscale. Similar patterns were seen in the relations between myelopathy and anxiety. CONCLUSION: More than one-third of patients with CSM have a depressed or anxious mood. In patients with CSM, depression and anxiety scores are strongly associated with decreased mobility, inconsistently associated with arm dysfunction, and not associated with sensory deficits or sphincter dysfunction, suggesting that ambulatory dysfunction may cause or exacerbate the symptoms of depression and anxiety in patients with CSM.

Adult↗
PubMed2005

Cost-effectiveness of low-molecular-weight heparin for treatment of pulmonary embolism.

BACKGROUND: Low-molecular-weight heparin (LMWH) appears to be safe and effective for treating pulmonary embolism (PE), but its cost-effectiveness has not been assessed. METHODS: We built a Markov state-transition model to evaluate the medical and economic outcomes of a 6-day course with fixed-dose LMWH or adjusted-dose unfractionated heparin (UFH) in a hypothetical cohort of 60-year-old patients with acute submassive PE. Probabilities for clinical outcomes were obtained from a meta-analysis of clinical trials. Cost estimates were derived from Medicare reimbursement data and other sources. The base-case analysis used an inpatient setting, whereas secondary analyses examined early discharge and outpatient treatment with LMWH. Using a societal perspective, strategies were compared based on lifetime costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio. RESULTS: Inpatient treatment costs were higher for LMWH treatment than for UFH (dollar 13,001 vs dollar 12,780), but LMWH yielded a greater number of QALYs than did UFH (7.677 QALYs vs 7.493 QALYs). The incremental costs of dollar 221 and the corresponding incremental effectiveness of 0.184 QALYs resulted in an incremental cost-effectiveness ratio of dollar 1,209/QALY. Our results were highly robust in sensitivity analyses. LMWH became cost-saving if the daily pharmacy costs for LMWH were < dollar 51, if > or = 8% of patients were eligible for early discharge, or if > or = 5% of patients could be treated entirely as outpatients. CONCLUSION: For inpatient treatment of PE, the use of LMWH is cost-effective compared to UFH. Early discharge or outpatient treatment in suitable patients with PE would lead to substantial cost savings.

Anticoagulants↗
PubMed2005

The short form-12 and the measurement of health status in patients with cerebral aneurysms: performance, validity, and reliability.

OBJECT: Cerebral aneurysms can affect a patient's health status by rupture and stroke, impingement on neural structures, treatment side effects, or psychological stress. The authors assessed the performance, validity, and reliability of the Short Form-12 (SF-12), a self-administered written survey instrument, to assess health status in patients with cerebral aneurysms. METHODS: A cohort of 170 patients with cerebral aneurysms who were seen at a neurosurgery clinic underwent structured interviews including measurement of their health statuses (SF-12 physical component summary [PCS] and mental component summary [MCS]), functional status (Glasgow Outcome Scale score, modified Rankin Scale score, and Barthel Index), and mental health (Hospital Anxiety and Depression Scale score). The SF-12 scores were compared with US population norms by performing t-tests with unequal variances. The validity of the SF-12 was assessed by comparing the PCS and MCS scores with each patient's functional status and mental health scores by using rank-order methods. Inter-item reliability was assessed using the Cronbach alpha statistic. Patients with cerebral aneurysms had decreased health status PCS and MCS scores when compared with population norms (p < 0.001 for all). A history of subarachnoid hemorrhage (SAH) (p = 0.006) and previous surgical or endovascular treatment (p = 0.047) was associated with worse PCS scores. The validity of the SF-12 was supported by the relationship between the PCS and MCS scores and the patient's functional status and mental health (p < 0.001 for all). The reliability of the SF-12 was documented by the Cronbach alpha statistic (alpha = 0.76). CONCLUSIONS: Patients with cerebral aneurysms have a diminished physical and mental health status as measured using the SF-12. The presence of SAH and aneurysm treatment are associated with a worse physical health status. The SF-12 is a valid and reliable instrument for measuring health status in patients with cerebral aneurysms.

Adult↗
PubMed2005

Mental health, anxiety, and depression in patients with cerebral aneurysms.

OBJECT: Aneurysm disease and its treatment can have an adverse impact on mental health, yet the affects of cerebral aneurysms on general mental health, anxiety, and depression are poorly understood. METHODS: Patients with cerebral aneurysms who were seen at a neurosurgery clinic underwent a structured interview, completed the Hospital Anxiety and Depression Scale and the Medical Outcomes Study 12-item Short Form Health Survey (providing a mental component summary [MCS] score for general mental health), and were assigned functional status scores based on the Glasgow Outcome Scale (GOS), Rankin Scale, and Barthel Index. Rank-order methods were used to assess the relationship between mental health, aneurysm characteristics and history, and functional status. Data were collected in 166 patients (71% women) with a mean age of 53.7 years. Depression was present in 8% of the study population and an anxiety disorder in 17%. Patients with both an unsecured aneurysm and a history of subarachnoid hemorrhage (SAH) tended toward higher anxiety scores (p = 0.086). Higher depression scores were associated with a decreased functional status on the GOS (p = 0.015) and Rankin Scale (p = 0.010). The mean +/- standard deviation adjusted MCS score (37.9 +/- 7.1) was significantly less than that of the US population (p < 0.001). Lower MCS scores were associated with a decreased functional status on the GOS (p = 0.052), Rankin Scale (p < 0.001), and Barthel Index (p = 0.002). CONCLUSIONS: Patients with cerebral aneurysms have increased levels of anxiety and depression and poor general mental health. Those who have experienced an SAH and harbor an unsecured cerebral aneurysm demonstrate increased levels of anxiety. A lower functional status in patients with aneurysms is associated with depression and decreased general mental health.

Adult↗
PubMed2005

Multimodal assessment after surgery for cervical spondylotic myelopathy.

OBJECT: Investigators reporting decompressive surgery to treat patients with cervical spondylotic myelopathy (CSM) have described inconsistent benefits. In the present study the authors used three types of outcomes instruments to assess the results of CSM surgery. METHODS: The authors collected prospective baseline and 6-month follow-up data in a cohort of 62 patients with CSM. Data collection included those pertaining to demographics; symptoms; physical findings; myelopathy severity; health status measured with the Short Form-36; and health values according to the standard gamble, time trade-off, visual analog scale, and willingness to pay. Rank-order methods were used to compare surgical and nonsurgical patients, and multivariate regression techniques adjusting for baseline characteristics were performed to examine the effects of surgery. During the study period, 28 patients underwent surgery, 34 did not, and there were no baseline differences between the two groups in demographics, symptoms, myelopathy scores, health status, or health values (p > or = 0.120 in all domains); there was a greater prevalence of hand intrinsic muscle atrophy (p = 0.035) and Hoffmann sign (p = 0.006) in the surgery-treated group. Neither raw comparisons nor regression analyses showed a consistent surgery-related benefit. There were sporadic associations between worse outcomes and older patients, higher income, Babinski sign, longer duration of CSM symptoms, hand clumsiness, lower-extremity numbness, and multilevel surgery (p < or = 0.049 for all). CONCLUSIONS: Analysis of results obtained in the 62 patients with CSM failed to show a surgery-related benefit despite the use of three classes of outcomes instruments. Patient demographics, symptoms, physical signs, and the surgical approach may explain some of the variation in outcomes in patients with CSM.

Adult↗