Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation

BACKGROUND

Lower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.

PATIENTS AND METHODS

In a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.

RESULTS

One hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R²: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).

CONCLUSIONS

Higher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.KEY MESSAGEHigher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.Higher SES is associated with significantly higher utilization of outpatient therapies.Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery. Article registration: clinicaltrials.gov NCT04119479.

Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation

Background

Impaired motor functions after stroke are common and negatively affect patients' activities of daily living and quality of life. In particular, hand motor function is essential for daily activities, but often returns slowly and incompletely after stroke. However, few data are available on the long-term dynamics of motor recovery and self-reported health status after stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) project aims to address this knowledge gap by studying the clinical course of recovery after inpatient rehabilitation.

Methods

In this prospective observational longitudinal multicenter study, patients were included towards the end of inpatient rehabilitation after ischemic or hemorrhagic stroke. Follow-up examination was performed at three, six, and twelve months after enrollment. Motor function was assessed by the Upper Extremity Fugl-Meyer Assessment (FMA), grip and pinch strength, and the nine-hole peg test. In addition, Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) was included. Linear mixed effect models were fitted to analyze change over time. To study determinants of hand motor function, patients with impaired hand function at baseline were grouped into improvers and non-improvers according to hand motor function after twelve months.

Results

A total of 176 patients were included in the analysis. Improvement in all motor function scores and PROMIS-10 was shown up to 1 year after inpatient rehabilitation. FMA scores improved by an estimate of 5.0 (3.7–6.4) points per year. In addition, patient-reported outcome measures increased by 2.5 (1.4–3.6) and 2.4 (1.4–3.4) per year in the physical and mental domain of PROMIS-10. In the subgroup analysis non-improvers showed to be more often female (15% vs. 55%, p = 0.0155) and scored lower in the Montreal Cognitive Assessment (25 [23–27] vs. 22 [20.5–24], p = 0.0252).

Conclusions

Continuous improvement in motor function and self-reported health status is observed up to 1 year after inpatient stroke rehabilitation. Demographic and clinical parameters associated with these improvements need further investigation. These results may contribute to the further development of the post-inpatient phase of stroke rehabilitation.

Trial registration: The trial is registered at ClinicalTrials.gov (NCT04119479).

Protocol for a multicenter observational prospective study of functional recovery from stroke beyond inpatient rehabilitation - The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE)

Introduction

Stroke and its long-term consequences pose major challenges for the lives of those affected and healthcare systems. Neurological rehabilitation therefore primarily attempts to improve function in order to increase independence in activities of daily living, and to enable social participation. There is only scarce data on dynamics of functional recovery after patients discharge from inpatient neurological rehabilitation. Even less is known about the patient's perspective on long-term recovery from stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) aims to address this knowledge gap by providing new insights into the dynamics and extent of functional recovery from stroke beyond inpatient rehabilitation treatment.

Methods

We provide the protocol for an observational, longitudinal, multicenter study conducted in an Universitary Stroke Center in cooperation with five Neurological Rehabilitation Centers in Northern Germany. Patients who suffered from ischemic or hemorrhagic stroke will be enrolled by the end of inpatient rehabilitation and followed up to 1 year. In addition, a group of chronic stroke patients and a group of craniocerebral trauma patients will be enrolled as a comparison group. Data on stroke characteristics, vascular risk factors, co-morbidities, social support, and demographics will be recorded. Comprehensive clinical evaluation will be performed at baseline, three, six, and twelve months after enrollment. The assessments and scores used reflect the three components of the International Classification of Functioning, Disability and Health (ICF), some of them are tests regularly used in rehabilitation settings. Tests of motor function, cognition, and mood are included, as are tests of self-reported health-related quality of life. Primary outcome measure is a hand motor score, built by the sum of the hand items of the Fugl-Meyer Assessment as an objective measurement of hand function at 12 months after enrollment. Predictors of the primary outcome will be analyzed using linear regression analysis.

Perspective

The results of IMPROVE will inform about the long-term dynamics of functional stroke recovery after patients' discharge from inpatient rehabilitation and will provide insights into the association of clinical and demographic factors with recovery of function.

Trial registration

The protocol is registered at ClinicalTrials.gov (NCT04119479).

Seroprevalence of Anti-Yersinia Antibodies in Healthy Austrians

Yersiniosis is caused by Y. enterocolitica and Y. pseudotuberculosis mostly presenting as intestinal infection. The infection is usually acquired from contaminated food. The aim of this study was to determine the seroprevalence of anti-Yersinia antibodies in Austrians. Sera of 750 healthy Austrians from all nine states were tested for anti-Yersinia IgG antibodies using the recomBlot Yersinia Westernblot kit. Overall seroprevalence was 29.7%. Seroprevalence increased significantly with age from 24.7% in the group of the 19 to 24 year olds to 38.5% in the group of persons older than 44 years. The seroprevalence of anti-Yersinia antibodies varied within the states between 18% and 43.5%. The high seroprevalence of anti-Yersinia antibodies in contrast to only approximately 100 reported yersiniosis cases per year points to the fact that the majority of infections is either subclinical or mild.

Prevalence of Anti-Yersinia Outer Protein Antibodies in Goats in Lower Saxony

Little is known about the prevalence of caprine yersiniosis in Germany. Only few cases are reported every year. The intention of the survey was to provide representative data on the seroprevalence of anti-Yersinia antibodies in goats in the German state of Lower Saxony. A commercially available Western blot kit was used to identify caprine and ovine anti-Yersinia antibodies against five proteins [YopM, H, D, E and V-antigen (V-Ag)]. Of the 681 investigated goat sera, 449 (66%) had anti-Yop/V-Ag antibodies. Only two of 28 animal holdings housed sero-negative goats. Boxplot analysis showed that the number of non-reactive animals is correlated to the size of a herd and the fact of milk production, respectively. A tendency was observed that various management factors may influence the anti-Yersinia antibody status. No statement was possible on the impact of keeping additional carrier animals such as pigs, cows or sheep on a farm or the type of husbandry on the seroprevalence of anti-Yersinia antibodies. This study provides trend-setting data for yersiniosis in goat-holdings. The impact on consumer health, i.e. especially for risk groups-like people allergic to cow milk and the impact on the profit of a farm will have to be elucidated in further studies.

[Prevalence of anti-Yersinia antibodies in European brown hares in North-Rhine Westphalia, Germany]

Yersinia (Y.) pseudotuberculosis infections may lead to significant lethality in European brown hare (Lepus europaeus, Pallas) populations especially during the cold and wet seasons. In recent decades, also Y. enterocolitica was isolated from hares found dead. Consequently, a Western-blot technique proved to be valuable for the detection of antibodies against all pathogenic Yersinia isolates was applied to monitor the prevalence of antibodies in hare populations in North-Rhine Westphalia, Germany. A total of 89.6% of the 230 animals tested was seropositive. Further investigations should be performed to elucidate the role of subclinical yersiniosis in the decline of European brown hare populations in Germany.

CGS 21680 exerts marked antidystonic effects in a genetic model of paroxysmal dyskinesia

The effect of the adenosine A(2A) receptor agonist CGS 21680 (2-carboxyethyl)phenylethylamino]-5'-N-ethylcarbonyamido-ade nosine) on severity of dystonia was examined in genetically dystonic hamsters which exhibit attacks of dystonic and choreoathetotic disturbances in response to mild stress. CGS 21680 significantly reduced the severity of dystonia (0.5, 1.0 and 2.0 mg/kg i.p.). The marked antidystonic effects of CGS 21680 in the hamster model suggest that this compound may represent an interesting candidate for the therapy of paroxysmal dystonia. Furthermore, the present data indicate that the precipitating effect of caffeine in patients with paroxysmal dystonia is probably due to its adenosine receptor antagonistic action.

Reaction to disturbances of a walking leg during stance

The ground reaction forces exerted by the legs of freely walking stick insects, Carausius morosus, were recorded during normal and perturbed locomotion. The animals walked along a path into which a three-dimensional force transducer was integrated. The transducer registered all three components of the forces produced by a single leg when, by chance, it walked on the force platform. The stiffness of the walking surface was found to be a critical variable affecting the forces and the trajectories of leg movements during undisturbed walking. The forces produced by a leg were considerably smaller and the trajectories were closer to the body during walking on soft versus stiff surfaces. Perturbations during stance were generated by moving the platform in various directions within the horizontal plane and at two different rates. Perturbations were applied either immediately after leg contact or after a delay of 300 ms. The reactions to these disturbances were compatible with the hypothesis that the velocity of leg movement is under negative feedback control. This interpretation is also supported by comparison with simulations based upon other control schemes. We propose a model circuit that provides a combination of negative and positive feedback control mechanisms to resolve the apparent discrepancies between our results and those of previous studies.

Effects of pH on the potassium current in rabbit corneal epithelial cells

The effects of pH on K+ conductance were measured using the amphotericin perforated-patch whole cell voltage-clamp technique in freshly dispersed rabbit corneal epithelial cells. Bath perfusion with pH 6.00 Ringer solution after standard Ringer solution (pH 7.35) increased outward K+-selective current (I(K)) from 120 +/- 29 to 312 +/- 64 pA during a step depolarization to +50 mV and hyperpolarized the resting membrane potential (Em) from -52 +/- 5 to -62 +/- 3 mV (n = 15, P < or = 0.05). Increasing bath pH to 8.5 decreased I(K) from 183 +/- 40 to 114 +/- 35 pA (n = 6, P < or = 0.05) and depolarized Em from -63 +/- 6 to -53 +/- 5 mV (n = 6, P < or = 0.05). Intracellular acidification using the weak electrolyte (NH4)2SO4 also increased I(K) from 83 +/- 15 to 183 +/- 20 pA (n = 4, P = 0.01) and hyperpolarized Em from -51 +/- 8 to -68 +/- 6 mV (P = 0.002). Intracellular alkalinization reduced I(K) to 66 +/- 10 pA and depolarized Em to -36 +/- 8 mV (P = 0.009). Single channel studies in perforated outside-out vesicles showed that a decrease in bath pH from 7.35 to 6.00 was accompanied by an increase in the single channel open probability (NPo) from 0.43 to 0.64 at an Em of 15 mV. NPo was also increased in cell-attached patches. The unitary conductance, measured from -100 to +100 mV, was not changed. These results indicate that pH modulates I(K) in rabbit corneal epithelial cells by changes in NPo.

Dye transfer between cells of the lens

Dye transfer between lens fiber cells and between lens epithelial cells and underlying fiber cells was studied using a wide dynamic range-cooled CCD camera, H2O immersion objectives and image analysis techniques. Each lens was decapsulated by a new technique which leaves the epithelial cells adherent to the lens fiber mass. Lucifer Yellow CH was injected into either single epithelial cells or single fiber cells using the standard whole cell configuration of the patch voltage clamp technique. The results demonstrate extensive dye communication between fiber cells at the lens posterior surface, anterior surface, and equatorial surface. Dye transfer between deep fiber cells was also observed. Dye transfer between approximately 10% of epithelial cells and their underlying fiber cells was apparent when care was taken to yield wide dynamic range images. This was required because the relatively high concentration of dye in the epithelial cell masks the presence of much lower dye concentrations in the underlying fiber cell. A mathematical model which includes dye concentration, time, and spatial spread suggests that those epithelial cells that are coupled to an underlying fiber cell are about as well dye coupled as the epithelial cells themselves. The relatively low dye concentration in a fiber cell is due to its larger volume and diffusion of the dye along the axis of the fiber away from the fiber/epithelial junction.

A non-enzymatic method for lens decapsulation which leaves the epithelial cells attached to the fibers

We have developed a method to mechanically decapsulate the lens yet leave the epithelial cells attached to the fibers. This method uses divalent ion chelaters to loosen the capsule-epithelial interactions and bumetanide to control cell swelling. Light microscopy, scanning electron microscopy, and in-vitro fluorescence microscopy demonstrate that the capsule is removed and the epithelial cells remain adherent to the fibers when these procedures are used. Ion channel activity and epithelial gap junction communication remain following decapsulation. This decapsulated lens preparation should prove useful for many kinds of lens studies.

A modular artificial neural net for controlling a six-legged walking system

A system that controls the leg movement of an animal or a robot walking over irregular ground has to ensure stable support for the body and at the same time propel it forward. To do so, it has to react adaptively to unpredictable features of the environment. As part of our study of the underlying mechanisms, we present here a model for the control of the leg movement of a 6-legged walking system. The model is based on biological data obtained from the stick insect. It represents a combined treatment of realistic kinematics and biologically motivated, adaptive gait generation. The model extends a previous algorithmic model by substituting simple networks of artificial neurons for the algorithms previously used to control leg state and interleg coordination. Each system controlling an individual leg consists of three subnets. A hierarchically superior net contains two sensory and two 'premotor' units; it rhythmically suppresses the output of one or the other of the two subordinate nets. These are continuously active. They might be called the 'swing module' and the 'stance module' because they are responsible for controlling the swing (return stroke) and the stance (power stroke) movements, respectively. The swing module consists of three motor units and seven sensory units. It can produce appropriate return stroke movements for a broad range of initial and final positions, can cope with mechanical disturbances of the leg movement, and is able to react to an obstacle which hinders the normal performance of the swing movement. The complete model is able to walk at different speeds over irregular surfaces. The control system rapidly reestablishes a stable gait when the movement of the legs is disturbed.