Thanh G N Ton

University of Washington Seattle, Seattle, Washington, United States

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Publications (40)230.01 Total impact

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    ABSTRACT: Parkinson disease (PD) is the second most common neurodegenerative disorder. Its diagnosis relies solely on a clinical examination and is not straightforward because no diagnostic test exists. Large, population-based, prospective cohort studies designed to examine other outcomes that are more common than PD might provide cost-efficient alternatives for studying the disease. However, most cohort studies have not implemented rigorous systematic screening for PD. A majority of epidemiologic studies that utilize population-based prospective designs rely on secondary data sources to identify PD cases. Direct validation of these secondary sources against clinical diagnostic criteria is lacking. The Framingham Heart Study has prospectively screened and evaluated participants for PD based on clinical diagnostic criteria. We assessed the predictive value of secondary sources for PD identification relative to clinical diagnostic criteria in the Framingham Heart Study (2001-2012). We found positive predictive values of 1.0 (95% confidence interval: 0.868, 1.0), 1.0 (95% confidence interval: 0.839, 1.0), and 0.50 (95% confidence interval: 0.307, 0.694) for PD identified from self-report, use of antiparkinsonian medications, and Medicare claims, respectively. The negative predictive values were all higher than 0.99. Our results highlight the limitations of using only Medicare claims data and suggest that population-based cohorts may be utilized for the study of PD determined via self-report or medication inventories while preserving a high degree of confidence in the validity of PD case identification. © The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
    American Journal of Epidemiology 12/2014; · 4.98 Impact Factor
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    ABSTRACT: The Fogarty International Center (FIC) Global Health Fellows Program provides trainees with the opportunity to develop research skills through a mentored research experience, increase their content expertise, and better understand trends in global health research, funding organizations, and pathways to generate support. The Northern Pacific Global Health Fellows Research and Training Consortium, which hosts one of the FIC Global Health Programs, sought to enhance research training by developing, implementing, and evaluating a competency-based curriculum that uses a modular, asynchronous, web-based format. The curriculum has 8 core competencies, 36 learning objectives, and 58 assignments. Nineteen trainees completed their 11-month fellowship, engaged in the curriculum, and provided pre- and post-fellowship self-assessments. Self-assessed scores significantly improved for all competencies. Trainees identified the curriculum as one of the strengths of the program. This competency-based curriculum represents a first step toward creating a framework of global health research competencies on which further efforts could be based.
    The American journal of tropical medicine and hygiene 11/2014; · 2.74 Impact Factor
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    ABSTRACT: Hormone therapy (HT) is a class of medications widely prescribed to women in the Western world. Evidence from animal models and in vitro studies suggests that estrogen may protect against nigrostriatal system injury and increase dopamine synthesis, metabolism, and transport. Existing epidemiologic research indicates a possible reduced risk of Parkinson's disease (PD) associated with HT use. The objective of this study was to evaluate PD risk associated with specific HT formulations. Neurologist-confirmed cases and age-matched controls were identified from Group Health Cooperative (GHC) of Washington State. Final analysis included 137 female cases and 227 controls. Hormone therapy use was ascertained from the GHC pharmacy database, further classified as conjugated estrogens, esterified estrogens, and progestin. Ever use of HT formulation demonstrated a suggested elevated risk with esterified estrogen use (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.0-9.8), and no risk associated with conjugated estrogen use (OR, 0.6; 95% CI, 0.6-1.3). Restricting this analysis to prescriptions that included progestin further elevated the risk associated with esterified estrogen use (OR, 6.9; 95% CI, 2.1-22.9); again, no risk was associated with conjugated estrogen use (OR, 1.7; 95% CI, 0.6-5.0). The findings from this study suggest an increase in PD risk associated with esterified estrogen use combined with progestin, and no risk associated with conjugated estrogen with progestin. These findings could have important implications for choice of HT in clinical practice. © 2014 International Parkinson and Movement Disorder Society
    Movement Disorders 09/2014; · 5.63 Impact Factor
  • Sleep Science. 03/2014; 7(1):5-12.
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    ABSTRACT: We sought to improve a previous algorithm to ascertain Parkinson's disease (PD) in the Cardiovascular Health Study by incorporating additional data from Medicare outpatient claims. We compared our results to the previous algorithm in terms of baseline prevalence and incidence of PD, as well as associations with baseline smoking characteristics. Our original case ascertainment used self-reported diagnosis, antiparkinsonian medication, and hospitalization discharge International Classification of Diseases-Ninth version code. In this study, we incorporated additional data from fee-for-service Medicare claims, extended follow-up time, review of hospitalization records, and adjudicated cause of death. Two movement disorders specialists adjudicated final PD status. We used logistic regression models and controlled for age, sex, African American race, and education. We identified 75 additional cases but reclassified 80 previously identified cases as not having PD. We observed significant inverse association with smoking status (odds ratio = 0.42; 95% confidence interval (CI) = 0.22, 0.79), and inverse linear trends with pack-years (p = 0.005), and cigarettes per day (p = 0.019) with incident PD. All estimates were stronger than those from the previous algorithm. Our enhanced method did not alter prevalence and incidence estimates compared with our previous algorithm. However, our enhanced method provided stronger estimates of association, potentially due to reduced level of disease misclassification. Copyright © 2013 John Wiley & Sons, Ltd.
    Pharmacoepidemiology and Drug Safety 12/2013; · 2.90 Impact Factor
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    ABSTRACT: Background Neonatal jaundice (NNJ) is an important cause of brain damage, physical and mental handicap, and early death among infants in many communities in Africa, but little is known about the burden of NNJ in Ghana. Objectives This study aimed to assess the relative NNJ burden and NNJ risk factors among infants presenting to the Mother-Baby Unit (MBU) at a secondary government hospital in Kumasi, Ghana. Methods A retrospective chart review was performed for all neonates admitted to a 16-bed MBU between June 1, 2011 and September 30, 2012. In addition, a prospective study was initiated in January 2013 for all patients on admission, including a 57-item questionnaire designed to assess biological and sociocultural NNJ risk factors as well as maternal knowledge about the etiology and signs/symptoms of NNJ. Data were imported into Stata v. 12.0 and frequencies and descriptive statistics were calculated for all key variables. Results Chart review demonstrated that NNJ was the second most common diagnosis among admitted infants during the 16-month study period (30%; 279/944) and 88% of NNJ patients were treated with phototherapy. Total serum bilirubin (TSB) was tested in only 12.5% of jaundiced infants. Jaundiced babies did not have increased risk of adverse outcomes (readmission, transfer to a tertiary care facility, or death) compared to non-jaundiced babies (OR = 0.93; 95% CI: 0.48-1.77). While 90% of mothers had heard of jaundice, only 1 in 4 mothers could accurately describe NNJ etiology and/or signs/symptoms. Conclusions NNJ was the second most common diagnosis for admitted neonates at the MBU. Most NNJ patients were managed empirically with phototherapy, often due to limited hospital and patient resources. Future research is needed to determine the cost-effectiveness of empiric phototherapy in under-resourced settings. Furthermore, study findings demonstrate a significant knowledge gap among mothers about NNJ, suggesting a role for maternal education to aid in the early identification and treatment of NNJ.
    2013 American Academy of Pediatrics National Conference and Exhibition; 10/2013
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    ABSTRACT: BACKGROUND: Because of the aging population in low- and middle-income countries, cerebrovascular disease is expected to remain a leading cause of death. Little has been published about stroke in Peru. We conducted a retrospective cohort study of hospitalized stroke patients at a referral center hospital in Lima, Peru to explore factors associated with functional outcome among stroke patients. METHODS: We identified 579 patients hospitalized for ischemic stroke or intracerebral hemorrhage stroke at the National Institute of Neurologic Sciences in Lima, Peru in 2008 and 2009. A favorable outcome was defined as a modified Rankin scale score of ≤2 at discharge. RESULTS: The mean age was 63.3 years; 75.6% had ischemic stroke; the average duration of stay was 17.3 days. At hospital discharge, 231 (39.9%) had a favorable outcome. The overall mortality rate was 5.2%. In multivariate models, the likelihood of having a favorable outcome decreased linearly with increasing age (P = .02) and increasing National Institutes of Health Stroke Scale (NIHSS) score (P = .02). Favorable outcome was also associated with male gender (relative risk [RR] 1.2; 95% confidence interval [CI] 1.0-1.5) and divorced status (RR 1.3; 95% CI 1.1-1.7). Patients on Salud Integral de Salud (SIS; public assistance-type insurance; RR 0.7; 95% CI 0.5-1.0) were also less likely to have a favorable outcome. CONCLUSIONS: Favorable outcome after stroke was independently associated with younger age, a lower NIHSS score, male gender, being divorced, and not being on SIS insurance. These findings suggest that additional study of worse functional outcomes in patients with SIS insurance be conducted and confirm the importance of risk adjustment for age, stroke severity (according to the NIHSS scale), and other socioeconomic factors in outcomes studies. Future studies should preferentially assess outcome at 30 days and 6 months to provide more reliable comparisons and allow additional study of Peruvian end-of-life decision-making and care.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 01/2013; · 1.99 Impact Factor
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    ABSTRACT: BACKGROUND: As low and middle-income countries such as Viet Nam experience the health transition from infectious to chronic diseases, the morbidity and mortality from stroke will rise. In line with the recommendation of the Institute of Medicine's report on "Promoting Cardiovascular Health in the Developing World" to "improve local data", we sought to investigate patient characteristics and clinical predictors of mortality among stroke inpatients at Da Nang Hospital in Viet Nam. METHODS: A stroke registry was developed and implemented at Da Nang Hospital utilizing the World Health Organization's Stroke STEPS instrument for data collection. RESULTS: 754 patients were hospitalized for stroke from March 2010 through February 2011 and admitted to either the intensive care unit or cardiology ward. Mean age was 65 years, and 39% were female. Nearly 50% of strokes were hemorrhagic. At 28-day follow-up, 51.0% of patients with hemorrhagic stroke died whereas 20.3% of patients with ischemic stroke died. A number of factors were independently associated with 28-day mortality; the two strongest independent predictors were depressed level of consciousness on presentation and hemorrhagic stroke type. While virtually all patients completed a CT during the admission, evidence-based processes of care such as anti-thrombotic therapy and carotid ultrasound for ischemic stroke patients were underutilized. CONCLUSIONS: This cohort study highlights the high mortality due in part to the large proportion of hemorrhagic strokes in Viet Nam. Lack of hypertension awareness and standards of care exacerbated clinical outcomes. Numerous opportunities for simple, inexpensive interventions to improve outcomes or reduce recurrent stroke have been identified.
    BMC Neurology 12/2012; 12(1):150. · 2.49 Impact Factor
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    ABSTRACT: Viet Nam is experiencing a health transition from infectious to chronic disease. Data on cardiovascular diseases, including strokes, are limited. Data were randomly collected from six communities in Da Nang, Viet Nam, on participant demographics, medical history, blood pressure, anthropometrics and health behavior using World Health Organization (WHO) guidelines. Stroke symptoms were collected by self-report with the standardized Questionnaire for Verifying Stroke Free Status. Multivariate logistic regression was used to identify factors associated with the presence of stroke symptoms. 1,621 adults were examined with a mean age of 52.0 years (± 12.5 years), of which 56.1% were women. 27.3% of the participants were found to have hypertension, 26.2% used tobacco, and 16.1% were overweight. More than two-thirds of the participants with hypertension were unaware of their condition. Almost one fourth of the participants were identified by the questionnaire as previously experiencing at least one stroke symptom. Age, rural residence, and education were associated with the presence of stroke symptoms. Models adjusted for demographics found hypertension, high cholesterol, reported severe chest pain, former smoking, and being overweight to be associated with a higher prevalence of stroke symptoms. The high frequency of stroke symptoms in Da Nang calls for further evaluation and interventions to reduce hypertension and other risk factors for chronic disease.
    Journal of epidemiology and global health. 09/2012; 2(3):155-163.
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    ABSTRACT: Changes in cardiovascular physiology in Parkinson's disease (PD) are common and may occur prior to diagnostic parkinsonian motor signs. We investigated associations of electrocardiographic (ECG) abnormalities, orthostasis, heart rate variability, and carotid stenosis with the risk of PD diagnosis in the Cardiovascular Health Study, a community-based cohort of older adults. ECG abnormality, orthostasis (symptomatic or asymptomatic), heart rate variability (24-hour Holter monitoring), and any carotid stenosis (≥1%) by ultrasound were modeled as primary predictors of incident PD diagnosis using multivariable logistic regression. Incident PD cases were identified by at least 1 of the following: self-report, antiparkinsonian medication use, and ICD-9. If unadjusted models were significant, they were adjusted or stratified by age, sex, and smoking status, and those in which predictors were still significant (P ≤ .05) were also adjusted for race, diabetes, total cholesterol, low-density lipoprotein, blood pressure, body mass index, physical activity, education level, stroke, and C-reactive protein. Of 5888 participants, 154 incident PD cases were identified over 14 years of follow-up. After adjusting models with all covariates, those with any ECG abnormality (odds ratio [OR], 1.45; 95% CI, 1.02-2.07; P = .04) or any carotid stenosis (OR, 2.40; 95% CI, 1.40-4.09; P = .001) at baseline had a higher risk of incident PD diagnosis. Orthostasis and heart rate variability were not significant predictors. This exploratory study suggests that carotid stenosis and ECG abnormalities occur prior to motor signs in PD, thus serving as potential premotor features or risk factors for PD diagnosis. Replication is needed in a population with more thorough ascertainment of PD onset.
    Movement Disorders 06/2012; 27(8):988-95. · 5.63 Impact Factor
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    ABSTRACT: Abstract Human papillomavirus (HPV) infection among men who have sex with men (MSM) is the primary risk factor for anal cancer. Of 105 Peruvian MSM examined, 77.1% were infected with HPV; of these 79.0% were coinfected with two or more types and 47.3% were infected by a carcinogenic type. HPV types 53, 6, 16, and 58 were the most frequent HPV infections detected. High-risk HPV type infection was associated with sex work, HIV status, and having rectal chlamydial or gonorrheal infection. These findings support broadening HPV vaccine coverage and increasing surveillance for the development of cancer in MSM infected with HPV.
    AIDS research and human retroviruses 04/2012; · 2.18 Impact Factor
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    ABSTRACT: American Indians have one of the lowest colorectal cancer (CRC) screening rates for any racial/ethnic group in the U.S., yet reasons for their low screening participation are poorly understood. We examine whether tribal language use is associated with knowledge and use of CRC screening in a community-based sample of American Indians. Using logistic regression to estimate the association between tribal language use and CRC test knowledge and receipt we found participants speaking primarily English were no more aware of CRC screening tests than those speaking primarily a tribal language (OR = 1.16 [0.29, 4.63]). Participants who spoke only a tribal language at home (OR = 1.09 [0.30, 4.00]) and those who spoke both a tribal language and English (OR = 1.74 [0.62, 4.88]) also showed comparable odds of receipt of CRC screening. Study findings failed to support the concept that use of a tribal language is a barrier to CRC screening among American Indians.
    Journal of Immigrant and Minority Health 03/2012; · 1.16 Impact Factor
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    ABSTRACT: Birth order may play a role in autoimmune diseases and early childhood infections, both factors implicated in the etiology of narcolepsy. We investigated the association between birth order and narcolepsy risk in a population-based case-control study in which all study subjects were HLA-DQB1*0602 positive. Subjects were 18-50 years old, residents of King County, Washington, and positive for HLA-DQB1*0602. Birth order was obtained from administered interviews. We used logistic regression to generate odds ratios adjusted for income and African American race. Analyses included 67 cases (mean age 34.3 [SD=9.1], 70.2% female) and 95 controls (mean age 35.1 [SD=8.8], 58.1% female). Associations for birth order were as follows: first born (cases 38.8% vs. controls 50.2%, OR=1.0; reference), second born (cases 29.9% vs. controls 32.9%, OR=1.6; 95% CI 0.7, 3.7), and third born or higher (cases 31.3% vs. controls 16.8%, OR=2.5; 95% CI 1.0, 6.0). A linear trend was significant (p<0.05). Sibling number, sibling gender, having children, and number of children did not differ significantly between narcolepsy cases and controls. Narcolepsy risk was significantly associated with higher birth order in this population-based study of genetically susceptible individuals. This finding supports an environmental influence on narcolepsy risk through an autoimmune mechanism, early childhood infections, or both.
    Sleep Medicine 03/2012; 13(3):310-3. · 3.10 Impact Factor
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    ABSTRACT: Studies demonstrate existence of inflammation in prevalent Parkinson's disease (PD). We assessed associations of baseline levels of inflammatory markers with prevalent PD at baseline (1989) and incident PD identified over 13 years of follow-up of the Cardiovascular Health Study. Blood samples at baseline were measured for fibrinogen, interleukin-6, tumor necrosis factor-α, C-reactive protein, albumin, and white blood cells. The analysis included 60 prevalent and 154 incident PD cases. Risk of prevalent PD was significantly higher per doubling of IL-6 among women (odds ratio [OR]=1.5, 95% confidence interval [CI]: 1.0, 2.4) and WBC among men (OR: 2.4, 95% CI: 1.2, 4.9) in multivariate models. Risk of incident PD was not associated with higher levels of any biomarker after adjusting for age, smoking, African American race, and history of diabetes. Inverse associations with incident PD were observed per doubling of C-reactive protein (OR=0.9; 95% CI: 0.8, 1.0) and of fibrinogen among women (OR=0.4; 95% CI: 0.2, 0.8). Although inflammation exists in PD, it may not represent an etiologic factor. Our findings suggest the need for larger studies that measure inflammatory markers before PD onset.
    Parkinsonism & Related Disorders 11/2011; 18(3):274-8. · 4.13 Impact Factor
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    ABSTRACT: Background/Aims: Studies suggest an inverse association between urate concentration and the risk of Parkinson disease (PD). We investigated this in the Cardiovascular Health Study in an elderly community-based cohort of adults. Methods: The association of baseline urate (μmol/l) and incident PD over 14 years was assessed with locally weighted scatterplot smoothing (LOESS) regression from which categories of low (<300 μmol/l), middle (300-500 μmol/l), and high (>500 μmol/l) urate ranges were derived. Multivariate logistic regression models assessed the risk of PD for each urate range. Linear and quadratic terms were tested when modeling the association between urate and the risk of PD. Results: Women had significantly lower urate concentrations than did men [316.8 μmol/l (SD 88.0) vs. 367.4 μmol/l (SD 87.7), p < 0.0001] and in women no associations between urate and PD risk were observed. In men, LOESS curves suggested a U-shaped or threshold effect between urate and PD risk. With the middle range as reference, the risk of developing PD was significantly increased for urate <300 μmol/l (OR 1.69, 95% CI 1.03-2.78) but not for urate >500 μmol/l (OR 1.55, 95% CI 0.72-3.32) in men. A negative linear term was significant for urate <500 μmol/l, and across the entire range a convex quadratic term was significant. Conclusions: Results suggest a more complex relationship than previously reported between urate levels and the risk of PD in men. Low urate concentrations were associated with a higher PD risk and high urate concentrations were not associated with a further decrease in PD risk.
    Neuroepidemiology 06/2011; 36(4):223-229. · 2.48 Impact Factor
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    ABSTRACT: To determine the prevalence and risk factors for human papillomavirus (HPV) infection in female sex workers (FSW) in Lima, Peru. Cross-sectional study of 87 FSW. Information regarding demographics, sex work practices, and genital and blood specimens was collected. Forty-four (50.6%) of 87 FSW had HPV detected in cervical swabs. The prevalence of coinfection by two or more HPV types was 39.1%. Thirty-one (35.6%) were infected by at least one high-risk HPV type, representing 70.5% of women with HPV infection. HPV infection was associated with younger age but not with any demographic or sexual characteristics. Our study confirms the high prevalence of HPV infection in FSW reported by other groups and suggests that brothel-based FSW may be at lower risk for acquiring high-risk HPV infection.
    Sexually transmitted infections 02/2011; 87(1):81-2. · 3.08 Impact Factor
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    ABSTRACT: Growing evidence supports the hypothesis that narcolepsy with cataplexy is an autoimmune disease. We here report genome-wide association analyses for narcolepsy with replication and fine mapping across three ethnic groups (3,406 individuals of European ancestry, 2,414 Asians and 302 African Americans). We identify a SNP in the 3' untranslated region of P2RY11, the purinergic receptor subtype P2Y₁₁ gene, which is associated with narcolepsy (rs2305795, combined P = 6.1 × 10⁻¹⁰, odds ratio = 1.28, 95% CI 1.19-1.39, n = 5689). The disease-associated allele is correlated with reduced expression of P2RY11 in CD8(+) T lymphocytes (339% reduced, P = 0.003) and natural killer (NK) cells (P = 0.031), but not in other peripheral blood mononuclear cell types. The low expression variant is also associated with reduced P2RY11-mediated resistance to ATP-induced cell death in T lymphocytes (P = 0.0007) and natural killer cells (P = 0.001). These results identify P2RY11 as an important regulator of immune-cell survival, with possible implications in narcolepsy and other autoimmune diseases.
    Nature Genetics 01/2011; 43(1):66-71. · 29.65 Impact Factor
  • Nature Genetics 01/2011; 43(10):1040. · 29.65 Impact Factor
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    ABSTRACT: Photovoice, a qualitative methodology using photography by study participants, is an ideal tool for collecting information on awareness of cardiovascular health from the perspective of persons of different cultural backgrounds and English-speaking abilities who are often subject to health disparities. Participants of Chinese, Vietnamese, and Korean ethnicity were provided disposable cameras to photograph their perceptions of scenes promoting or acting as barriers to cardiovascular health. After the pictures were developed, they returned for a discussion in their native languages to contextualize the stories told in their photographs. Group facilitators spoke the respective native languages and transcribed sessions into English. Twenty-three adults participated (7 to 9 persons per ethnicity), ranging in age from 50 to 88 (mean 71.6) years; 48% were women. The photographs stimulated conversations of knowledge, beliefs, and concerns regarding heart disease and stroke. Issues surrounding food and exercise were most dominant across ethnic groups, focusing on fat and salt intake and the need to remain active. Cultural beliefs and issues of emotional health, including stress and loneliness related to living in a new country, were also depicted. Photovoice provided insight into perceptions of cardiovascular health that is vital for developing health promotion and education interventions in limited-English-speaking communities.
    Health Promotion Practice 11/2010; 13(1):48-54. · 0.55 Impact Factor
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    ABSTRACT: Statistical models predicting outcome after intraparenchymal hemorrhage include patients irrespective of do-not-attempt-resuscitation orders. We built a model to explore how the inclusion of patients with do-not-attempt-resuscitation orders affects intraparenchymal hemorrhage prognostic models. Retrospective, observational cohort study from May 2001 until September 2003. University-affiliated tertiary referral hospital in Seattle, WA. Four hundred twenty-four consecutive patients with spontaneous intraparenchymal hemorrhage. We retrospectively abstracted information from medical records of intraparenchymal hemorrhage patients admitted to a single hospital. Using multivariate logistic regression of presenting clinical characteristics, but not do-not-attempt-resuscitation status, we generated a prognostic score for favorable outcome (defined as moderate disability or better at discharge). We compared observed probability of favorable outcome with that predicted, stratified by do-not-attempt-resuscitation status. We then generated a modified prognostic score using only non-do-not-attempt-resuscitation patients. Records of 424 patients were reviewed: 44% had favorable outcome, 43% had a do-not-attempt-resuscitation order, and 38% died in hospital. The observed and predicted probability of favorable outcome agreed well with all patients taken together. The observed probability of favorable outcome was significantly higher than predicted in non-do-not-attempt-resuscitation patients and significantly lower in do-not-attempt-resuscitation patients. Results were similar when applying a previously published and validated prognostic score. Our modified prognostic score was no longer pessimistic in non-do-not-attempt-resuscitation patients but remained overly optimistic in do-not-attempt-resuscitation patients. Although our prognostic model was well-calibrated when assessing all intraparenchymal hemorrhage patients, predictions were significantly pessimistic in patients without and optimistic in those with do-not-attempt-resuscitation orders. Such pessimism may drive decisions not to attempt resuscitation in patients in whom a favorable outcome may have been possible, thereby creating a self-fulfilling prophecy. To be most useful in clinical decision making, intraparenchymal hemorrhage prognostic models should be calibrated to large intraparenchymal hemorrhage cohorts in whom do-not-attempt-resuscitation orders were not used.
    Critical care medicine 10/2010; 39(1):158-62. · 6.15 Impact Factor

Publication Stats

558 Citations
230.01 Total Impact Points

Institutions

  • 2006–2014
    • University of Washington Seattle
      • • Department of Environmental and Occupational Health Sciences
      • • Department of Neurology
      • • Department of Epidemiology
      Seattle, Washington, United States
  • 2012
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2009–2011
    • Stanford University
      • Department of Neurology and Neurological Sciences
      Palo Alto, CA, United States
  • 2007
    • Fred Hutchinson Cancer Research Center
      • Division of Public Health Sciences
      Seattle, WA, United States