Clinimetric properties of relevant criteria for assessing writing and drawing orientation after right hemisphere stroke

BACKGROUND

Writing and drawing orientation is rarely assessed in clinical routine, although it might have a potential value in detecting impaired verticality perception after right hemispheric stroke (RHS). Assessment tools and criteria must be conceived and validated. We therefore explored the clinimetric properties of a set of quantitative writing and drawing orientation criteria, their ranges of normality, and their tilt prevalence in RHS individuals.

NEW METHODS

We asked 69 individuals with subacute RHS and 64 matched healthy controls to write three lines and to copy the Gainotti Figure (house and trees). We determined six criteria referring to the orientation of writing and drawing main axes: for writing, the line and margin orientations, and for drawing, the tree, groundline, wall, and roofline orientations. Orientations were measured by using an electronic protractor from specific landmarks positioned by independent evaluators.

RESULTS

The set of criteria fulfilling all clinimetric properties (feasibility, measurability, reliability) comprised the line orientation of the writing and the wall and roofline orientations of the drawing. Writing and drawing tilts were frequent after RHS (about 30% by criterion).

COMPARISON WITH EXISTING METHODS

So far, graphomotor orientation was mostly tested qualitatively and could not be objectively appreciated in absence of validated tools and criteria, and without ranges of normality. Writing and drawing tilts may now be assessed both in routine clinical practice and research.

CONCLUSIONS

Our study paves the way for investigating the clinical determinants of graphomotor tilts, including impaired verticality perception, to better understand their underlying mechanisms.

C43 A CASE REPORT OF A GIANT RIGHT CORONARY ARTERY ANEURYSM: ROLE OF CONTRAST ECHOCARDIOGRAPHY

A giant coronary aneurysm is rare entity and it is defined if the diameter is 4–fold greater the reference vessel diameter or if it is > 20 mm in diameter. We report the case of a 73–years–old man without prior history of cardiac disease, admitted in Emergency Department for abdominal pain with normal ECG. Abdominal CT scan showed no pathological findings. At thoracic level it was reported a suspected pericardial cyst (75x80 mm), with partial compression of right chambers (Fig. 1). Echocardiography confirmed the presence of a giant round cystic–appearance lesion characterized by the presence of an anechoic space with internal echogenic swirling flow pattern at the level of right atrioventricular groove with mild compressive effect on right chambers. (Fig. 2). The color Doppler mode showed a faint signal, without a clear evidence of flow origin. A bubble test with agitated saline contrast medium injected through antecubital vein, shows no evidence of contrast uptake by the mass. In order to better characterize the lesion, we use echocardiographic contrast agent (SonoVue®), which showed a clear pattern of blood flow inside the mass with a probable origin at a very limited region (Fig. 2a–2b). At that level it was also possible to sample an ECG–synchronized systo–diastolic pulse–wave (PW)–Doppler pattern (peak velocity 125 cm/s), typical for a coronary artery flow. According to these echocardiographic findings, we supposed a giant right coronary aneurysm. Coronary Computed Tomography Angiography with 3D reconstruction showed a giant aneurysm of the right coronary artery at mid–level, preceded by a mild aneurysm of the proximal tract and two small aneurysms of the circumflex artery and diffuse atherosclerosis diseases with significant stenosis on mid left anterior descending artery (LAD). The coronary angiography confirmed the presence of the giant aneurysm in mild tract of right coronary artery preceded by a small one in the proximal tract andthe two small aneurysm of the circumflex artery and a critical stenosis of mid tract of LAD. The patient underwent surgical treatment of the aneurysm and coronary artery bypass graft (Fig. 3). Computed Tomography Coronary Angiography is the best method for coronary artery anatomy and coronary abnormalities. In case of giant coronary abnormalities, the use of echo contrast agent provides further important information about perfusion and/or flow assessment and it helped to clarify the diagnosis.

VBAC or not VBAC? Improvement of performance and outcome indexes with the promotion of care safety

Background

In a multidisciplinary approach to Quality Management System and humanization of care, we aimed at evaluating the characteristics that influence the request of women to carry out Vaginal Birth after Cesarean (VBAC).

Methods

Skills have been improved, with the use of tests on dummies and case by case assessments. For the psychological-motivational study we have adopted: Informed consent, Semi-structured interview and Big Five Questionnaire. The women were recruited by both Gemelli and Cristo Re Hospital: the women following the counseling decided to undergo a second Caesarean Section (CS) (41, control group) and women who decided to complete a VBAC (22, experimental group).

Results

The analysis of the data shows that the women of the VBAC group are in the average between 31-35 years (57%), 80% has an education = or > at the 3rd level and the choice of the VBAC was conditioned by the partner (64%). The women of the control group are in average > 35 years (51%), 60% have a higher average education and the influence on the choice is oriented by the gynecologist/obstetrician (64%). From the personality test a statistically significant difference emerges between the dimensions Energy and Mental Opening. Past experience influences the choice of the next birth: women who are inclined to a second CS considered the previous CS as a positive event (66%) while only 36% in the VBAC group; 64% of this was the recovery of the painful post-surgery and a certain type of difficulty in the care of the child, in breastfeeding, of having suffered from post-partum mood alterations, which is why they chose to undertake a Trial of Labor After Cesarean.

Conclusions

The deeper knowledge of women as well as the preparation and safety of the same operators has shown that it is possible to perform a greater number of VBACs, with the sharing, participation and satisfaction of women and the entire team, leading to an improvement in outcomes and performance indexes.

Key messages

The promotion of care safety also improves the performance indexes through continuous training to the operators and the study of psychological aspects that lead to the choice to carry out a VBAC. Good Clinical Practice shown that it is possible to perform a greater number of VBACs, with the sharing, participation and satisfaction of women and the entire team.

Vaginal birth after caesarean birth in Italy: variations among areas of residence and hospitals

BACKGROUND

The rates of caesarean section (CS) are increasing globally. CS rates are one of the most frequently used indicators of health care quality. Vaginal Birth After Caesarean (VBAC) could be considered a reasonable and safe option for most women with a previous CS. Despite this fact, in some European countries, many women who had a previous CS will have a routine CS subsequently and VBAC rates are extremely variable across countries. VBAC use is inversely related to caesarean use. The objective of the present study was to analyze VBAC rates with respect to caesarean rates and the variations among areas of residence, hospitals and hospital ownership types in Italy.

METHODS

This study was based on information from the Hospital Information System (HIS). We collected data from all deliveries in Italy from January 1, 2010 to December 31, 2014 and we considered only deliveries with a previous caesarean section. Applying multivariate logistic regression analysis, the adjusted proportions of VBAC for each Local Health Units (LHU), each hospital and by hospital ownership types were calculated. Cross-classified logistic multilevel models were performed to analyze within geographic, hospitals and hospital ownership types variations.

RESULTS

We studied a total of 77,850 deliveries with a previous caesarean section in Italy between January 1, 2010 and December 31, 2014. The proportion of VBAC in Italy slightly increased in the last few years, from 5.8% in 2010 to 7.5% in 2014. Proportions of VBAC ranged from 0.29 to 50.05% in Italian LHUs. The LHUs with lower proportions of VBAC deliveries were characterized by higher values for primary caesarean deliveries. Private hospitals showed the lowest mean of crude VBAC proportions but the highest variation among hospitals, ranging from 0 to 47.1%.

CONCLUSIONS

Hospital rates of caesarean section for women with at least one previous caesarean section vary widely, and only some of the variation can be explained by case-mix and hospital-level factors, suggesting that additional factors influence practices. Identifying disparities in VBAC may have important implications for health services planning and targeted efforts to reduce overall rates of caesarean deliveries.

Assessing the visual vertical: how many trials are required?

Background

The visual vertical (VV) consists of repeated adjustments of a luminous rod to the earth vertical. How many trials are required to reach consistency in this measure? This question has never been addressed despite the widespread clinical use of the measurement in stroke rehabilitation.

Methods

VV perception was assessed (10 trials) in 117 patients undergoing rehabilitation after a first hemisphere stroke. The intraclass correlation coefficient (ICC) and standard error of measurement (SEM) were calculated for each patient category: with contralesional VV bias (n = 48), ipsilesional VV bias (n = 17) and normal VV (n = 52).

Results

For patients with VV biases, 6 trials were required to reach high inter-trial reliability (contralesional: ICC = 0.9, SEM = 1.36°; ipsilesional: ICC = 0.896, SEM = 0.96°). For patients with normal VV, a minimum of 10 trials was required (ICC = 0.728, SEM = 1.13°). A set of 6 trials correctly classified 96 % of patients.

Conclusions

In the literature, 10 is the most frequently used number of trials used to assess VV orientation. Our study shows that 10 trials are required to adequately measure VV orientation in non-selected subacute stroke patients. For complex protocols imposing a decrease in the number of trials in each condition, 6 trials are needed to identify VV biases in most patients.

Feasibility of the cognitive assessment scale for stroke patients (CASP) vs. MMSE and MoCA in aphasic left hemispheric stroke patients

INTRODUCTION

Post-stroke aphasia makes it difficult to assess cognitive deficiencies. We thus developed the CASP, which can be administered without using language. Our objective was to compare the feasibility of the CASP, the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) in aphasic stroke patients.

MATERIAL AND METHODS

All aphasic patients consecutively admitted to seven French rehabilitation units during a 4-month period after a recent first left hemispheric stroke were assessed with CASP, MMSE and MoCA. We determined the proportion of patients in whom it was impossible to administer at least one item from these 3 scales, and compared their administration times.

RESULTS

Forty-four patients were included (age 64±15, 26 males). The CASP was impossible to administer in eight of them (18%), compared with 16 for the MMSE (36%, P=0.05) and 13 for the MoCA (30%, P=0.21, NS). It was possible to administer the CASP in all of the patients with expressive aphasia, whereas the MMSE and the MoCA could not be administered. Administration times were longer for the CASP (13±4min) than for the MMSE (8±3min, P<10(-6)) and the MoCA (11±5min, P=0.23, NS).

CONCLUSION

The CASP is more feasible than the MMSE and the MoCA in aphasic stroke patients.

Piccolipiù, a multicenter birth cohort in Italy: protocol of the study

Background

The fetal and infant life are periods of rapid development, characterized by high susceptibility to exposures. Birth cohorts provide unique opportunities to study early-life exposures in association with child development and health, as well as, with longer follow-up, the early life origin of adult diseases. Piccolipiù is an Italian birth cohort recently set up to investigate the effects of environmental exposures, parental conditions and social factors acting during pre-natal and early post-natal life on infant and child health and development. We describe here its main characteristics.

Methods/design

Piccolipiù is a prospective cohort of expected 3000 newborns, who will be recruiting in six maternity units of five Italian cities (Florence, Rome, Trieste, Turin and Viareggio) since October 2011. Mothers are contacted during pregnancy or at delivery and are offered to participate in the study. Upon acceptance, their newborns are recruited at birth and followed up until at least 18 years of age. At recruitment, the mothers donate a blood sample and complete a baseline questionnaire. Umbilical cord blood, pieces of umbilical cord and heel blood spots are also collected. Postnatal follow-up currently occurs at 6, 12, and 24 months of age using on-line or postal self administered questionnaire; further questionnaires and medical examinations are envisaged. Questionnaires collect information on several factors, including mother’s and/or child’s environmental exposures, anthropometric measures, reproductive factors, diet, supplements, medical history, cognitive development, mental health and socioeconomic factors. Health promotion materials are also offered to parents.

Discussion

Piccolipiù will broaden our understanding of the contribution of early-life factors to infant and child health and development. Several hypotheses on the developmental origins of health can be tested or piloted using the data collected from the Piccolipiù cohort. By pooling these data with those collected by other existing birth cohorts it will be possible to validate previous findings and to study rare exposures and outcomes.

Medicolegal aspects of an unusual uterine perforation with multiload-Cu 375R

Perforation of the uterus is one of the most serious complications associated with insertion of intrauterine contraceptive devices (IUD). According to recent studies, this lesion occurs in 0.87 per 1000 cases, but statistics generally fluctuate between 0.05 and 13 per 1000 insertions. "Primary" perforations occur at the time of IUD insertion, and "secondary," or delayed, perforations are usually assumed to be caused by reactive uterine contractions. We report an unusual case of uterine perforation, which occurred 9 days after the insertion of a Multiload-Cu 375 IUD. The criteria for differential diagnosis between primary and secondary complications are discussed, particularly from the perspective of medical malpractice cases.

[Symptoms, life habits and risk factors in Italian menopause women]

Authors report selected demographic, clinical and behavioral characteristics and symptoms of 2181 post-menopausal women enrolled in the CIOM study (collaborazione inter-ospedaliera per la menopausa) in the period 1990-1994. A computerized clinical record was used which was filled by gynecologist during the first and subsequent visits. The study allows to better understand some epidemiological aspects of menopause in comparison with other national and international surveys. The results support the need of educational interventions, both for women and medical doctors, to promote healthy lifestyle and the use of hormonal replacement therapy to alleviate symptoms and to prevent post-menopausal diseases.