Progressive deterioration scale pdf

The pathomechanics of progressive crouch gait in spastic diplegia. Orthop Clin North Am. The static examination of children and young adults with cerebral palsy in the gait analysis laboratory: technique and observer agreement. J Pediatr Orthop B. Interrater reliability of a modified Ashworth scale of muscle spasticity.

Phys Ther. Wenger DR. Flatfoot and children's shoes. The Art and Practice of Children's Orthopaedics. Quantitative segmental analysis of weight-bearing radiographs of the foot and ankle for children: normal alignment. J Pediatr Orthop. Qualitative vs quantitative radiographic analysis of foot deformities in children with hemiplegic cerebral palsy.

The Functional Mobility Scale: ability to detect change following single event multilevel surgery. Dev Med Child Neurol. Reliability and validity of the Gillette Functional Assessment Questionnaire as an outcome measure in children with walking disabilities. Forbes A, Wolfe R. Analysis of studies with correlated data: a simple approach using robust standard errors.

Australas Epidemiologist. Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments. Neuropsychological aspects of severe myoclonic epilepsy in infancy. Neuropsychology of Childhood Epilepsy.

Severe myoclonic epilepsy of infants Dravet syndrome : natural history and neuropsychological findings. Severe myoclonic epilepsy in infancy: Dravet syndrome. Adv Neurol. Guerruni R, Dravet C. Severe epileptic encephalopathies of infancy, other than West syndrome. Epilepsy: A Comprehensive Textbook. Philadelphia, PA: Lippincott-Raven; Severe myoclonic epilepsy of infancy Dravet syndrome : recognition and diagnosis in adults.

Dravet syndrome severe myoclonic epilepsy in infancy : a retrospective study of 16 patients. J Child Neurol. Severe myoclonic epilepsy in infants: a review based on the Tokyo Women's Medical University series of 84 cases. Brain Dev. Gage JR. Treatment principles for crouch gait. In: Gage JR, ed. London, England: Mac Keith Press; Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery.

J Bone Joint Surg Am. Internal rotation gait: a compensatory mechanism to restore abduction capacity decreased by bone deformity. Mini-symposium: cerebral palsy, II: the management of spastic diplegia. Curr Orthop. Cerebral palsy. Curr Opin Pediatr. Kinematic and kinetic analysis of distal derotational osteotomy of the leg in children with cerebral palsy.

Schwartz M, Lakin G. The effect of tibial torsion on the dynamic function of the soleus during gait. Gait Posture. Gage JR, Schwartz M. Pathological gait and lever-arm dysfunction.

A qualitative description of normal gait. Complications in cerebral palsy treatment. Complications in Pediatric Orthopaedic Surgery. Functional outcomes of strength training in spastic cerebral palsy. At this stage, the senior is considered to be in the early stages of dementia. They can still perform some basic tasks, such as being able to feed themselves, but someone else has to prepare the meals for them.

At this stage, problematic behaviors can start to occur, such as confusion, wandering, hallucinations and suspiciousness. The person with dementia will require a full-time caregiver and will become more and more dependent. Stage 6 can be considered the beginning of late-stage or severe dementia.

They may start losing their ability to speak and have increasingly severe mobility issues. Stage 7 is the final stage of cognitive disease. He or she will lose their remaining abilities, becoming incontinent and unable to walk. Communication with others will soon become impossible. Finally, the body will start to shut down and the individual will pass away.

The green distribution in the middle inset represents 35M everyminute calculations from continuous physiologic measures used for the ECG monitoring statistical models. The area of each histogram indicates the quantity of measurements available. R wave to R wave RR inter-beat and inter-breath intervals gray occur on the order of seconds, 2.

Middle Inset Features from the continuous ECG monitors green were aggregated at q15 minute increments. Upper Right Inset Standard nursing vital signs yellow were most frequently obtained at every 1 to 4 hour intervals, 4.

Automated entries into the EMR are evident at every 1 minute. Laboratory results red were most frequently measured every 12 hours or daily. RR from charted VS was most frequently one of three values: 18 AF was the first detected rhythm in admissions 8.

Heart rate left and respiratory rate right measurement distributions according to source, charted vital signs VS; blue vs electrocardiography ECG; red where each source had equal numbers of measurements.

Missing data were extremely rare among continuously measured data range: 0—2. Missing data were more or extremely common among LABS basic metabolic panel: Many events triggered MET activations n: ; Admissions with events had 3-fold longer median hospital lengths of stay 11 vs 4 respectively and a fold increase in hospital mortality A model derived from intermittently measured VS had a bias-corrected C-statistic of 0.

Heatmap depiction of statistical significance of predictors rows in each model columns with corresponding C-statistics. Hue or color represents the data source: individual data sources green , pairwise combinations blue , fully integrated model using all available data red. Predictors that failed to achieve statistical significance in any of the models are not displayed.

Combining significant terms from the VS model to the cardiorespiratory dynamics model resulted in a C-statistic of 0. A fully integrated model using all available data sources had the best C-statistic: 0. Each circle represents an individual model with the C-statistic reported below each model abbreviation. The incidence of clinical deterioration ranged from 1. While there were differences in model discrimination amongst various hospital services, as additional data sources were integrated into the model, and consistent with our more general analysis, the predictive validity incrementally improved.

The fully integrated model had C-statistics of 0. Fig 6 depicts 4 different admissions marked by deterioration resulting in unanticipated ICU transfer. In panel A , developing shock is recognized by models derived from multiple sources, but charted VS alone would have been sufficient to identify this patient several hours before ICU transfer.

Panel B provides an example of a patient with developing confusion and acute renal failure where laboratory results but neither of the other data sources identified her trajectory. Panel C represents a patient on post-operative day 3 from an uncomplicated vascular surgery whose progressive abdominal pain and tachycardia prompted CT imaging and a lab draw, both of which were consistent with intra-abdominal hemorrhage leading to urgent exploratory laparotomy.

ECG monitoring of cardiorespiratory dynamics identified this deterioration long before the other diagnostic tests were obtained that prompted urgent surgery. Panel D represents a patient with progressive respiratory failure and renal failure despite therapeutic drainage of a pleural effusion.

While all data sources identified her as at increased risk, the integration of all data sources accentuated the severity and acuity of her deterioration. A: Patient post-procedure day 1 from stenting of left posterior tibial artery for non-healing ulcer deteriorated into mixed cardiogenic and septic shock.

Here charted vital signs were sufficient to identify deterioration in the several hours preceding ICU transfer. B: Patient with heart failure undergoing evaluation for coronary artery bypass grafting quickly deteriorated due to acute renal failure. Progressive derangement of laboratory results identified the deterioration without appreciable change in charted vital signs or continuous ECG monitoring.

C: Patient post-operative day 3 from left renal vein transposition who developed abdominal pain with associated tachycardia. CT imaging demonstrated intraabdominal hemorrhage and subsequent hemoglobin level had dropped from 9. EMR charted vital signs and lab results failed to appreciate a trend that was apparent for several hours by analytics of ECG monitoring. D : Patient admitted with acute hypoxic respiratory failure and acute kidney injury post-procedure day 0 from chest tube insertion to drain a pleural effusion.

While charted vital signs and laboratory results were abnormal, integration of all available data sources accentuates her increasing risk in the several hours prior to ICU transfer. We studied continuous physiological monitoring prior to adverse events in patients hospitalized in acute care beds. We found that cardiorespiratory dynamics measured from continuous ECG monitoring improved the predictive validity of models based on intermittent measurements of VS and LABS.

While multiple parameters helped to detect the deteriorating patient, RR, supplemental oxygen use, and SpO 2 were the most important. These findings underscore the need for accurate counts of RR and assessment of respiratory status.

The quality of the ECG signal, measured as the ECG-SNR, was also important; underscoring that careful attention to subtle changes in skin properties—like temperature, dryness, and texture—may provide warning of impending patient decline. Detecting the deteriorating patient on the hospital ward is a major goal. The causes are varied, and range from underestimation of the admission diagnosis to the development of new and unrelated illnesses.

The consequences range from altered management plans on the ward to ICU transfer and in some cases even to cardiac arrest and death. Physicians and nurses agree that early warning signs are often present, but are sometimes recognized only in retrospect.

In , Smith and coworkers reviewed more than 60 such systems using single or multiple predictive parameters. They lack, however, information from continuous physiological monitoring that is available for many hospitalized patients. We hypothesized that the cardiorespiratory dynamics held information about the changing state of the hospital patient vulnerable to deterioration leading to ICU transfer, and we tested this hypothesis using advanced ECG signal processing techniques and a large, well-annotated database.

From the ECG waveform signals, we determined linear and non-linear dynamical properties, identified AF, and detected respiration. From individual review of charts, we selected only patients whose ICU transfer was prompted by clinical deterioration, as opposed to elective transfer such as after cardiac surgery.

The robustness of these approaches enhances, in our view, the validity of the results. Our findings may be viewed in light of a paradigm shift in approaches to early detection of the deteriorating patient. Original research. Predictive role of ultrasound remission for progressive ultrasonography-detected structural damage in patients with rheumatoid arthritis.

Abstract Regarding the persistence of subclinical synovitis, the concept of ultrasound remission has been proposed in addition to clinical remission. Data availability statement Data are available upon reasonable request.

Statistics from Altmetric. Footnotes FL and WL contributed equally. Competing interests None declared.

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