[Medical rehabilitation in dermatology : Goals, program content, and application process]

BACKGROUND

Medical rehabilitation plays an important role in the management of patients with chronic dermatoses and dermato-oncological diseases.

OBJECTIVES

Which dermatological indications qualify for a medical rehabilitation? What forms need to be completed for a successful application? Which treatments are provided and what are goals to be accomplished during dermatological rehabilitation?

MATERIALS AND METHODS

Evaluation of current guidelines, directives, and recommendations as well as exemplary reviews.

RESULTS

Dermato-oncological diseases and every chronic dermatological disease that is associated with a limitation of body functions and structures, activity and participation is eligible for medical rehabilitation. They include need, ability to absolve a rehabilitation, and a favorable prognosis. Treatments range from therapy of the underlying dermatological condition to interdisciplinary treatment of comorbidities with the aim of restoring functional health.

CONCLUSIONS

Medical rehabilitation follows a holistic approach and represents a significant addition to outpatient and acute inpatient care, often leading to a long-term improvement in clinical outcome, participation, and activity.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

The Combined Effect of Robot-assisted Therapy and Activities of Daily Living Training on Upper Limb Recovery in Persons With Subacute Stroke: A Randomized Controlled Trial

OBJECTIVES

To evaluate the effectiveness of robot-assisted therapy (RAT) followed by activities of daily living (ADL) training in comparison with conventional rehabilitation therapy (CRT) and ADL training in individuals with subacute stroke.

DESIGN

A single-blind, 2-arm, parallel-group, open-level, randomized controlled trial.

SETTING

A tertiary care teaching hospital in India.

PARTICIPANTS

Forty-four persons (n=44) with first-ever stroke (in subacute stage) were enrolled from August 2021 to July 2023.

INTERVENTION

Participants in the RAT group (n=22) received RAT for 30 minutes, followed by ADL training for 30 minutes. In contrast, participants in the CRT group (n=22) received CRT (30 minutes) followed by ADL training (30 minutes). Both groups received allocated interventions for 15 days over 3 weeks (5 days/week, 3 weeks).

MAIN OUTCOME MEASURES

Primary outcome: Motor domain score of the Fugl-Meyer Assessment scale for upper extremity (FMA-UE).

SECONDARY OUTCOMES

the other domains scores of FMA-UE (UL -sensation, -joint motions, -joint pain); Modified Ashworth Scale (MAS) (spasticity); hand-function (HF) and ADL-domain scores of the stroke impact scale (SIS); WHOQQL-BREF questionnaires (QOL). Participants were assessed at enrolment and follow-up at 3, 6, and 12 weeks.

RESULTS

Persons who received RAT and ADL training reported significant improvement (P<.05) in UL motor function (mean difference [MD]=3.54;(95% confidence interval [CI]: 1.28 to 5.79]), UL passive joint motions (MD=2.54; [95% CI: 1.56 to 3.52]), SIS-HF (MD=6.37;[95% CI: 4.75 to 7.99]), SIS-ADL (MD=7.13 [95% CI: 3.52 to 8.74]), and in all domains of WHOQOL-BREF (except environmental domain) compared with persons who received CRT and ADL training at 12 weeks.

CONCLUSIONS

The findings indicate that RAT followed by ADL training is more effective than CRT followed by ADL training in motor improvement, SIS-HF, SIS-ADL, and QOL at 12 weeks.

Cancellous bone graft from the distal radius and headless screw fixation for unstable scaphoid waist nonunion

PURPOSE

Cancellous bone harvested from the distal radius has been used in various hand surgeries, but studies on its use in scaphoid waist nonunions are insufficient. We investigated the usefulness of cancellous bone graft from the distal radius and headless screw fixation in unstable scaphoid waist nonunion.

METHODS

Thirty-one patients who underwent cancellous bone graft from the distal radius and headless screw fixation for unstable scaphoid waist nonunion with follow-up for at least 1 year were included. Bone union time, the number of patients with bone union at six and 12 weeks, total number of patients with bone union at last follow-up, and bone union on the computed tomography (CT) image at postoperative six weeks were evaluated. Further, pre- and postoperative radiological measurements, such as scaphoid length and height, lateral intra-scaphoid angle, and height-to-length ratio, and functional outcomes were compared. Additionally, inter-observer reliability of radiologic parameters was checked.

RESULTS

Bone union was achieved in 29 patients. There were two nonunions (6.5%). Bone union time was 10.7 (range, 6-26) weeks. Eighteen (58%) and 25 patients (80.6%) were diagnosed with bone union on the plain radiographs at six and 12 weeks, respectively. Twenty-two patients (71%) were diagnosed with bone union on CT performed at six weeks. Radiological measurements and functional outcomes improved postoperatively. The scaphoid length showed good inter-observer agreement.

CONCLUSIONS

In treating unstable scaphoid waist nonunion, cancellous bone graft from the distal radius and headless screw fixation achieved 93.5% union and improved radiological measurements as well as functional outcomes.

Effect of foam rolling recovery on pain and physical capacity after resistance exercises: A randomized crossover trial

OBJECTIVES

To compare the effects of passive recovery (PR), active recovery (AR), and recovery through self-massage with the aid of foam rolling (FRR) on pain and physical capacity in healthy volunteers after a resistance exercise (RE) session.

METHODS

The sample of this randomized crossover trial comprised 37 physically healthy men who underwent three sessions of RE (squat, leg press, and leg extension), involving four sets of 10 repetitions with 80% of 10MR, with an interval of seven days between sessions. PR consisted of sitting for 20min, AR included a cycle ergometer for 20min at 50% maximum heart rate, and FRR involved 10 repetitions per target body area, followed by 1min rest. Variables of physical capacity (strength, power, agility, joint range of motion, flexibility, speed, and fatigue resistance) were assessed 1h after RE, whereas pain was assessed 24h, 48h, and 72h after RE.

RESULTS

In the dominant lower limb, the percentage of strength decreased (p < 0.001) by 16.3% after RE but improved (p < 0.001) by 5.2% after AR and FRR in relation to PR. Similar results were observed in the non-dominant lower limb. Agility was enhanced (p < 0.001) by 3.6% in AR and 4.3% in FRR compared with the baseline assessment. The recoveries for the other physical variables were similar. Only FRR reduced (p < 0.001) pain at 24h (22.8%), 48h (39.2%), and 72h (59.7%) compared to PR.

CONCLUSIONS

Self-massage using a foam roll reduced pain and improved agility and muscle strength during recovery after exercise.

TRIAL REGISTRATION NUMBER

NCT04201977.

The effects of isokinetic training in athletes after knee surgery: a systematic review

PURPOSE

To review the effectiveness of isokinetic training as an alternative method to traditional isotonic resistance training.

MATERIALS AND METHODS

Researchers examined data from PubMed, CENTRAL, MEDLINE COMPLETE, and Web of Science until February 2023. A total of 365 entries were obtained from databases, including studies that analyzed the effects of isokinetic vs. isotonic-based rehabilitation in athletes (16-50 years) after a surgical knee intervention. Return to sport (RTS), strength of the flex/extensor compartment of the thigh, muscle mass of the thigh, and knee function were screened as main outcomes. Two reviewers independently screened the studies for eligibility and assessed the risk of bias of the included ones.

RESULTS

Six studies involving 181 athletes were included. Isokinetic training demonstrated significant benefits in peak torque for knee flexor-extensor muscles in four studies. Two studies favored isokinetic training over isotonic for strength. Muscle mass findings were mixed, with one study favoring isokinetic significantly and two showing no significant differences. In terms of returning to sport, the isotonic group displayed slightly better limb symmetry index values, but without significance. Isokinetic training outperformed isotonic in two functionality questionnaire studies, while two others showed no significant differences.

CONCLUSIONS

Isokinetic training appears equally, if not more effective than isotonic, for restoring strength balance between hamstrings and quadriceps. This could lead to more favorable muscle mass changes. Isokinetic training also parallels isotonic rehabilitation for functional outcomes and meeting return-to-sport criteria. Therefore, isokinetic training should be included as one of the main strength restoration strategies after knee surgery, especially in early and middle rehabilitation stages.

REGISTRATION NUMBER

The present systematic review was registered on PROSPERO (registration number: CRD42022370398).

Responsiveness of Section GG Scores in Tracking Post-Stroke Functional Recovery From Inpatient Rehabilitation Admission to 90-Day Follow-Up

OBJECTIVE

To evaluate the responsiveness and scale-to-sample targeting of Section GG of the Inpatient Rehabilitation Facility-Patient Assessment Instrument in measuring the trajectory of functional recovery in patients with stroke from inpatient rehabilitation admission to 90 days after discharge.

DESIGN

Retrospective cohort study.

SETTING

150-bed inpatient rehabilitation facility.

PARTICIPANTS

Patients with stroke (N=1087) discharged between December 2019 to April 2021.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge self-care and mobility scores from Section GG were analyzed for the Inpatient Only group (n= 817). Admission, discharge and 90-day post-discharge Section GG scores from telephone interviews with patients or caregivers were analyzed for the Follow-Up group (n=270). Standardized response means (SRM) determined responsiveness of the tool for each group and time interval. Score means, standard deviations, and floor/ceiling effects illustrated scale-to-sample targeting of the tool.

RESULTS

Self-care and mobility scores improved significantly from admission to discharge (P<.001) for both groups and from discharge to 90 days (P<.001) for the Follow-Up group. Large SRM existed from admission to discharge for self-care and mobility scores in both groups. ​A small-to-moderate SRM was seen from discharge to 90 days for self-care (0.46) and a moderate SRM was observed for mobility (0.68). Overall floor effects were minor at admission for self-care (9.8%) and mobility (7.2.%). Overall ceiling effects were minor at discharge for self-care (11.2%) and mobility (4.6%)​ and significant at follow-up for both self-care (45.2%) and mobility (32.2%).

CONCLUSIONS

Section GG is responsive to change and appropriately measures patients' functional ability during inpatient rehabilitation. More study is required for telephone follow-up after discharge from inpatient rehabilitation.

The effect of animal-assisted interventions on the course of neurological diseases: a systematic review

BACKGROUND

In our experience, working with a therapy animal strengthens endurance, maintains motivation, provides a sense of achievement, and boosts overall mental resilience. The aims of this work were to summarize the results of quantitative research on the possibilities of animal-assisted intervention (AAI) among people with neurodegenerative and cerebrovascular diseases and to attempt to assess the effects of animal-assisted interventions in an objective manner and to find supporting evidence based on published literature.

METHODS

Our target groups are people diagnosed with Parkinson's disease, multiple sclerosis, or stroke. A systematic search of relevant articles was conducted by two independent researchers in April 2021 and August 2023. The search for studies was conducted using PubMed, Google Scholar, Web of Science, Scopus, and Ovid databases, specifying keywords and search criteria. The qualitative evaluation of the research reports was conducted by four independent researchers, using the Newcastle-Ottawa Quality Assessment Form.

RESULTS

According to the scientific criteria and based on the Newcastle-Ottawa Quality Assessment Form, thirteen publications met the search criteria, out of which 9 publications were rated good and 4 publications were rated poor. Evaluating the publications we found evidence that AAI had a measurable impact on participants, as their physical and mental health status significantly improved; however, mental health improvement was more prominent.

CONCLUSIONS

By developing evidence-based research methodology and standardized research settings, AAI could be measured effectively as part of health care practice. This would bring significant benefits to the rehabilitation of patients in need.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021255776.

[Translated article] Closed reduction and intramedullary fixation of fifth metacarpal neck fractures: Retrograde vs. anterograde technique. Prospective study

INTRODUCTION

The fifth metacarpal fracture is a frequent pathology that can cause deformity and functional impairment for the adequate grip of the hand. Reintegration into daily or working activities is related to the treatment received and rehabilitation. In fractures of the neck of the fifth metacarpal, internal fixation with a Kirschner's wire is a conventional treatment method with variants that affect its outcome.

AIM OF THE STUDY

To compare the functional and clinical results of the treatment of fifth metacarpal fracture with the use of retrograde vs. antegrade Kirschner wires.

MATERIAL AND METHODS

Comparative, longitudinal, prospective study at a third-level trauma centre in patients with a fifth metacarpal neck fracture, with clinical, radiographic and Quick DASH scale follow-up at the 3rd, 6th, and 8th postoperative week.

RESULTS

Sixty patients were included (58 men, 2 women), age of 29.63±10.15 years, with a fifth metacarpal fracture, treated by closed reduction and stabilisation with a Kirschner wire. The antegrade approach showed a metacarpophalangeal flexion range at 8 weeks of 89.11° (p<0.001; 95% CI [-26.81; -11.42]), a DASH scale value of 18.17 (p<0.001; 95% CI [23.45; 39.12]), and an average of 27.35 days to return to work (p=0.002; 95% CI [16.22; 62.14]), compared with the retrograde approach.

CONCLUSION

Stabilisation with antegrade Kirschner wire showed superior functional results, and metacarpophalangeal range of motion, compared to those operated via retrograde approach.

Closed reduction and intramedullary fixation of fifth metacarpal neck fractures: Retrograde vs. anterograde technique. Prospective study

INTRODUCTION

The fifth metacarpal fracture is a frequent pathology that can cause deformity and functional impairment for the adequate grip of the hand. Reintegration into daily or working activities is related to the treatment received and rehabilitation. In fractures of the neck of the fifth metacarpal, internal fixation with a Kirschner's wire is a conventional treatment method with variants that affect its outcome.

AIM OF THE STUDY

To compare the functional and clinical results of the treatment of fifth metacarpal fracture with the use of retrograde versus antegrade Kirschner wires.

MATERIAL AND METHODS

Comparative, longitudinal, prospective study at a third-level trauma center in patients with a fifth metacarpal neck fracture, with clinical, radiographic and Quick DASH scale follow-up at the 3rd, 6th, and 8th postoperative week.

RESULTS

Sixty patients were included (58 men, 2 women), age of 29.63±10.15 years, with a fifth metacarpal fracture, treated by closed reduction and stabilization with a Kirschner wire. The antegrade approach showed a metacarpophalangeal flexion range at 8 weeks of 89.11° (p<0.001; 95% CI [-26.81; -11.42]), a DASH scale value of 18.17 (p<0.001; 95% CI [23.45; 39.12]), and an average of 27.35 days to return to work (p=0.002; 95% CI [16.22; 62.14]), compared with the retrograde approach.

CONCLUSION

Stabilization with antegrade Kirschner wire showed superior functional results, and metacarpophalangeal range of motion, compared to those operated via retrograde approach.

Tactile stimulation facilitates functional recovery and dendritic change following neonatal hemidecortication in rats

After large neocortical lesions, such as hemidecortication, children can show significant motor and cognitive impairments. It thus is of considerable interest to identify treatments that might enhance long-term functional outcome. We have previously shown that tactile stimulation enhances recovery from perinatal focal cortical lesions in rats, so the goal of the present experiment was to explore the effectiveness of postlesion tactile stimulation in reducing functional deficits associated with neonatal hemidecortication. Rats were given hemidecortications on postnatal day 10 (P10). Half of the group was then exposed to a daily tactile stimulation treatment for 15 min, three times a day for eleven days following the surgery. All groups were then tested on a number of behavioural tasks (Morris water task, skilled reaching, forelimb placing during spontaneous vertical exploration, and a sunflower seed opening task) beginning at P 120. The brains of the male animals were prepared for Golgi-Cox staining and subsequent analysis of dendritic arborisation and spine density. There were two main findings in this experiment: 1) Tactile stimulation improved cognitive ability and some motor performance after P 10 hemidecortication; and, 2) Tactile stimulation altered cortical organization after P10 hemidecortication. Tactile stimulation may provide an important noninvasive therapy after hemispherectomy in children.

Utilization of overground exoskeleton gait training during inpatient rehabilitation: a descriptive analysis

BACKGROUND

Overground exoskeleton gait training (OEGT) after neurological injury is safe, feasible, and may yield positive outcomes. However, no recommendations exist for initiation, progression, or termination of OEGT. This retrospective study highlights the clinical use and decision-making of OEGT within the physical therapy plan of care for patients after neurological injury during inpatient rehabilitation.

METHODS

The records of patients admitted to inpatient rehabilitation after stroke, spinal cord injury, or traumatic brain injury who participated in at least one OEGT session were retrospectively reviewed. Session details were analyzed to illustrate progress and included: "up" time, "walk" time, step count, device assistance required for limb swing, and therapist-determined settings. Surveys were completed by therapists responsible for OEGT sessions to illuminate clinical decision-making.

RESULTS

On average, patients demonstrated progressive tolerance for OEGT over successive sessions as shown by increasing time upright and walking, step count, and decreased assistance required by the exoskeleton. Therapists place preference on using OEGT with patients with more functional dependency and assess feedback from the patient and device to determine when to change settings. OEGT is terminated when other gait methods yield higher step repetitions or intensities, or to prepare for discharge.

CONCLUSION

Our descriptive retrospective data suggests that patients after neurological injury may benefit from OEGT during inpatient rehabilitation. As no guidelines exist, therapists' clinical decisions are currently based on a combination of knowledge of motor recovery and experience. Future efforts should aim to develop evidence-based recommendations to facilitate functional recovery after neurological injury by leveraging OEGT.

Hemiplegia resulting from acute carbon monoxide poisoning

Carbon monoxide (CO) poisoning can cause neurological complications such as movement disorders and cognitive impairment through hypoxic brain damage. Although peripheral neuropathy of the lower extremities is a known complication of CO poisoning, hemiplegia is very rare. In our case, a patient who developed left hemiplegia due to acute CO poisoning received early hyperbaric oxygen treatment (HBOT). The patient had left hemiplegia and anisocoria at the beginning of HBOT. Her Glasgow coma score was 8. A total of five sessions of HBOT at 243.2 kPa for 120 minutes were provided. At the end of the 5th session, the patient's hemiplegia and anisocoria were completely resolved. Her Glasgow coma score was 15. After nine months of follow-up, she continues to live independently with no sequelae, including delayed neurological sequelae. Clinicians should be aware that CO poisoning can (rarely) present with hemiplegia.

Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Physical activity after revision knee arthroplasty including return to sport and work: a systematic review and meta-analysis including GRADE

BACKGROUND

The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work.

METHODS

A search was conducted in the databases Medline and Embase until February 24^th, 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle-Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 - 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 - 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 - 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18-95%, n = 234).

CONCLUSIONS

The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low.

LEVEL OF EVIDENCE

Level 3.

Diode laser in management of loss of taste sensation in patients with post-COVID syndrome: a randomized clinical trial

OBJECTIVE

Loss of taste (ageusia) is a symptom observed following recovery from COVID-19 infection. The loss of taste and smell sensation may negatively affect patients' quality of life (QoL). The present study aimed to evaluate the effectiveness of the Diode Laser in managing loss of taste sensation in patients with post-COVID syndrome versus the placebo.

MATERIAL AND METHOD

The study sample was 36 patients who complained of persistent loss of taste sensation following COVID-19. The patients were randomly assigned to one of the two groups according to the received treatment: Group I (laser treatment) and Group II (light treatment), with each patient receiving a diode laser treatment or placebo from the same operator. Taste sensation was subjectively measured after treatment for four weeks.

RESULTS

The results demonstrated a significant difference between both groups regarding taste restoration after one month (p = 0.041), with Group II having a significantly higher percentage of cases 7 (38.9%) with partial taste restoration. In contrast, a significantly higher proportion of Group I 17 cases (94.4%) had complete taste restoration (p < 0.001).

CONCLUSION

The present study concluded that using a Diode laser 810 nm aided in a more rapid recovery from loss of taste dysfunction.

The impact of unexpected intensive care unit admission after cancer surgery on long-term symptom burden among older adults: a population-based longitudinal analysis

BACKGROUND

Older adults are at high-risk for a post-operative intensive care unit (ICU) admission, yet little is known about the impact of these admissions on quality of life. The objective of this study was to evaluate the impact of an unexpected post-operative ICU admission on the burden of cancer symptoms among older adults who underwent high-intensity cancer surgery and survived to hospital discharge.

METHODS

We performed a population-based cohort study of older adults (age ≥ 70) who underwent high-intensity cancer surgery and survived to hospital discharge in Ontario, Canada (2007-2017). Using the Edmonton Symptom Assessment System (ESAS), a standardized tool that quantifies patient-reported physical, mental, and emotional symptoms, we described the burden of cancer symptoms during the year after surgery. Total symptom scores ≥ 40 indicated a moderate-to-severe symptom burden. Modified log-Poisson analysis was used to estimate the impact of an unexpected post-operative ICU admission (admission not related to routine monitoring) on the likelihood of experiencing a moderate-to-severe symptom burden during the year after surgery, accounting for potential confounders. We then used multivariable generalized linear mixed models to model symptom trajectories among patients with two or more ESAS assessments. A 10-point difference in total symptom scores was considered clinically significant.

RESULTS

Among 16,560 patients (mean age 76.5 years; 43.4% female), 1,503 (9.1%) had an unexpected ICU admission. After accounting for baseline characteristics, patients with an unexcepted ICU admission were more likely to experience a moderate-to-severe symptom burden relative to those without an unexpected ICU admission (RR 1.64, 95% CI 1.31-2.05). Specifically, among patients with an unexcepted ICU admission the average probability of experiencing moderate-to-severe symptoms ranged from 6.9% (95 CI 5.8-8.3%) during the first month after surgery to 3.2% (95% CI 0.9-11.7%) at the end of the year. Among the 11,229 (67.8%) patients with multiple ESAS assessments, adjusted differences in total scores between patients with and without an unexpected ICU admission ranged from 2.0 to 5.7-points throughout the year (p < 0.001).

CONCLUSION

While unexpected ICU admissions are associated with a small increase in the likelihood of experiencing a moderate-to-severe symptom burden, most patients do not experience a high overall symptom burden during the year after surgery. These findings support the role of aggressive therapy among older adults after major surgery.

Comparison of motor recovery after neonatal and adult hemidecortication

Hemidecortication produces a wide range of cognitive and motor symptoms in both children and lab animals that are generally far greater than smaller bilateral focal lesions of cerebral cortex. Although there have been many studies of motor functions after hemidecortication, the analyses largely have been of general motor functions rather than of more skilled motor functions such as forelimb reaching. The objective of the present experiment was to analyze the sensorimotor forelimb function of rats after infant or adult hemidecortication by utilizing multiple motor analyses. Rats were given hemidecortications either on postnatal day 10 (P10) or day 90 (P90). Both groups were then tested on a number of behavioural tasks (two tests of skilled reaching, forelimb placing during spontaneous vertical exploration, and a sunflower seed opening task) beginning at P 120. In a portion of the P10 female animals, topographic movement representations were derived in the hemisphere contralateral to lesion using Intracortical Microstimulation (ICMS). The brains of the male animals were prepared for Golgi-Cox staining and subsequent analysis of dendritic arborisation and spine density. There were three main findings. 1) Both groups of hemidecorticate animals were impaired when tested on the motor tasks, but the impairments were qualitatively different in the neonatal and adult operates. For example, the P 10 hemidecorticate animals displayed simultaneous bilateral forelimb movement, or "mirror movements." 2) Hemidecortication at P90 but not P10, led to increased dendritic arborisation of Layer III pyramidal cells in the intact parietal cortex but whereas P90 animals showed a decrease in cortical thickness in the intact hemisphere, the P10 animals do not, even though there are no callosal connections. 3) P10 hemidecortication altered the details of the ICMS-delineated motor maps in a small group of female hemidecorticates that were studied. In conclusion, there was postinjury compensation for motor impairments in both P10 and P90 rats but the mechanisms were different. Furthermore, comparisons of postinjury behavioral and anatomical compensation in rats with focal cortical injuries at those ages in our previous studies showed marked differences. These results suggest that there is a fundamental difference in the way that the brain compensates from hemidecortication and focal injury in development.

Artificial cerebrospinal fluid restores aspirin-inhibited physiological hemostasis through recovery of platelet aggregation function

BACKGROUND

Optimal hemostasis provides safety and reliability during neurosurgery which improves surgical outcomes. Previously, artificial cerebrospinal fluid (aCSF) and its component sodium bicarbonate were found to facilitate physiological hemostasis by amplifying platelet aggregation. This study aimed to verify whether aCSF amplifies platelet-dependent hemostasis in the presence of antiplatelet agents.

METHODS

We prepared platelet-rich plasma (PRP) or washed platelets using aspirin (acetylsalicylic acid, (ASA)) or normal saline (NS). We evaluated samples treated with a commercially available aCSF solution or NS for amplification of aggregation, activation of integrin αIIbβ3, phosphatidylserine (PS) exposure, P-selectin (CD62P) expression, and formation of microparticles (MPs). We assessed the effect of aCSF on in vivo hemostasis in the presence of ASA by measuring the tail bleeding time in ASA-or NS-injected C57BL/6 N mice.

RESULTS

Compared with NS, aCSF amplified ASA-inhibited platelet aggregation by recovering platelet activation including PS exposure, MP release, CD62P expression, and integrin αIIbβ3 activation. When using washed platelets, aCSF almost completely counteracted the inhibition of platelet aggregation by ASA. Prolonged bleeding time from the amputated tail of ASA-injected mice was significantly shortened by the treatment with aCSF compared to NS. Sodium bicarbonate also directly amplified ASA-inhibited platelet aggregation.

CONCLUSIONS

aCSF and sodium bicarbonate facilitate physiological hemostasis through the recovery of inhibited platelet aggregation even in the presence of ASA. The utilization of aCSF in the operative field may be advantageous for facilitating hemostasis in patients with impaired platelet function and contribute to improving outcomes of neurosurgery.

Factors Associated With Time to Achieve Physical Functional Recovery in Patients With Severe Stroke After Inpatient Rehabilitation: A Retrospective Nationwide Cohort Study in Japan

Objective

To describe characteristics of patient with severe stroke (FIM motor score [FIM motor] 20-49 at admission) and examine association between pre-specified factors (age, sex, modified Rankin Scale before stroke onset, body mass index, FIM motor, and FIM cognitive) and time to achieve FIM motor ≥70, that is, self-independent level.

Design

Retrospective cohort study using a large database in Japan.

Setting

Rehabilitation wards.

Participants

Patients with severe stroke (N=1422) who received inpatient rehabilitation were included (median age: 76 years; interquartile range [IQR]: 68.0-84.0). A total of 54.6% were men, and 65.8% were ischemic stroke.

Interventions

Not applicable.

Main Outcome Measures

Time to achieve FIM motor ≥70.

Results

After inpatient rehabilitation, 40.4% (N=575) achieved FIM motor ≥70 (admission FIM motor 20-29, 30-39 and 40-49: 18.6%, 33.6%, and 47.8%, respectively). Patients who achieved FIM motor ≥70 stayed median 81.0 days [IQR, 51.0-120.0]) and received median: 6.94 units per day [IQR, 5.48-7.78], 1 unit=20 minutes). Adjusted Fine-Gray regression revealed that shorter time to achieve FIM motor ≥70 was associated with higher admission FIM motor (hazard ratio [HR] 2.87 [95% confidence interval [CI] 2.27-3.62]: 20-29 vs 40-49), higher admission FIM cognitive (HR 1.81 [95% CI: 1.39-2.35]: 5-14 vs 25-35), and younger (HR 3.20 [95% CI: 2.32-4.42]: ≥85 years vs 20-69 years).

Conclusions

Most patients with severe stroke did not achieve FIM motor ≥70 after inpatient rehabilitation. Older patients and patients with lower admission FIM motor require more attention. They should be prioritized for state-of-the-art rehabilitation therapy.

Trajectory of kidney recovery in pediatric patients requiring continuous kidney replacement therapy for acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is commonly seen in the PICU and is associated with poor short-term and long-term outcomes, especially in patients who required continuous kidney replacement therapy (CKRT). However, as the trajectory of kidney recovery in these patients remain uncertain, determination of the timing to convert to permanent kidney replacement therapy (KRT) remains a major challenge. We aimed to examine the frequency and timing of kidney recovery in pediatric AKI survivors that required CKRT.

METHODS

We performed a retrospective study of patients under 18 years old who received CKRT for AKI in a tertiary-care PICU over 6 years. Primary outcomes were the rate of KRT withdrawal due to kidney recovery and KRT-dependent days for those who survived to hospital discharge. Secondary outcomes were all-cause mortality, dialysis dependence, and occurrences of estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73m² and eGFR < 60 mL/min/1.73m² one year after initiation of the index CKRT in survivors.

RESULTS

Thirty-nine patients were included. Of the 28 children who survived to hospital discharge, 26 (93%) withdrew from dialysis due to kidney recovery, all within 30 days. Twenty-three patients were followed up. One had died, five had an eGFR of 60 mL/min/1.73m² or more but less than 90 mL/min/1.73m², and two had an eGFR < 60 mL/min/1.73m², of which one required peritoneal dialysis.

CONCLUSIONS

Over 90% of the survivors withdrew CKRT within 30 days. However, the frequency of abnormal eGFR one year after initiation of CKRT in survivors exceeded 30% and supports the recommendation of post-AKI follow-up.

Association between Baseline Cognitive Function and Longitudinal Functional Outcome Change after Ischemic Stroke

INTRODUCTION

Ischemic stroke can cause impairment of daily function and cognitive function. Higher cognitive function is reported in many studies to be associated with better functional outcomes; however, evidence from longitudinal study is lacking. Therefore, in the present study, the association between cognitive function and longitudinal changes of functional outcome was investigated based on stroke severity. Furthermore, whether the effect of cognitive function remained consistent after controlling for depression was investigated.

METHODS

The data of 423 stroke patients (292 minor strokes, 93 moderate strokes, and 38 severe strokes) were collected. Baseline Mini-Mental State Examination (MMSE) score was considered a predictor, and change of modified Rankin Scale (mRS) score during 12 months of follow-up was the outcome. First, the association between the baseline MMSE score and longitudinal change in the mRS score was analyzed using linear mixed-effects models. Fixed effects were MMSE score group, time, and MMSE score group × time interaction. Additional adjustment was made for the Geriatric Depression Scale (GDS) score.

RESULTS

Among the 423 subjects, the mean age was 73.5 years, and 43.4% were female. In the minor stroke group, the high MMSE score group had a decreased mRS score, and the low MMSE score group had an increased mRS score (p < 0.001). This association remained after additional adjustment of the GDS score. Association was not observed between cognitive function and functional recovery in the moderate or severe stroke group.

CONCLUSION

After ischemic stroke, higher baseline global cognitive function was a predictive factor for better functional recovery regardless of depression symptoms in the minor stroke group.

Functional status and return to work in people with major depression: a 3-year national follow-up study

PURPOSE

Major depressive disorder (MDD) affects a person's function of daily activities, including work participation. Such functional impairments often persist even when other symptoms of MDD are remitted. Increasing evidence highlights the health-promoting effects of returning to work (RTW) in various diseases. However, limited data are available regarding the impact of return to work on functional recovery in MDD. We explored the association between RTW and functional improvements in people with MDD using a large nationally representative database and a 3-year follow-up.

METHODS

Data of people with an MDD diagnosis were selected from the Taiwan Data Bank of Persons with disability for the period between July 11, 2012, and October 31, 2018. We included 4038 adults aged 18-64 years. The World Health Organization Disability Assessment Schedule 2.0 was used for functional assessment. The association between RTW and functional improvements was investigated using a multivariable regression analysis adjusted for confounding variables.

RESULTS

Women aged ≥ 45 years with a lower education level were vulnerable to prolonged unemployment. RTW was significantly associated with better functional improvements in cognition, mobility, self-care, getting along, life activity, and participation than unemployment.

CONCLUSIONS

RTW was positively associated with functional improvements in patients with MDD. A referral system targeting re-employment may be suggested during MDD treatment, especially for individuals at risk of prolonged unemployment.

Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review

PURPOSE

Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion.

METHODS

MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines.

RESULTS

Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8).

CONCLUSIONS

Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.

Clinical characteristics and symptom duration among outpatients with COVID-19

BACKGROUND

Approximately 80% of people with COVID-19 do not require hospitalization. Studies examining the outpatient experience have not tracked symptoms to resolution leading to unknown expected symptom duration. Our objectives were to (1) determine symptom duration among patients with COVID-19 who do not require hospitalization and (2) identify potential risk factors associated with prolonged symptom duration.

DESIGN

This is a retrospective cohort study conducted across an academic healthcare system including adult patients with laboratory-confirmed SARS-CoV-2 infection between March 18th and April 28th, 2020 who were not hospitalized. Symptom duration encompassed time from patient-reported symptom onset as documented in the chart until documented symptom resolution. We calculated the median symptom duration and tested if demographics, comorbidities, or reported symptoms were associated with symptom duration.

KEY RESULTS

Of 294 patients meeting inclusion criteria, 178 (60.5%) had documented symptom resolution. The median [interquartile range (IQR)] symptom duration for included patients was 15 (8-24) days. No associations were found between comorbidities and symptom duration. Factors associated with prolonged symptom duration were presence vs lack of lower respiratory symptoms [median (IQR) 16.5 (10.75-33.5) vs 14.5 (7-21.75) days respectively, P < .001] and neurologic symptoms [median (IQR) 17 (9-28) vs 9.5 (4-17) days, P < .001] at disease onset.

CONCLUSIONS

The median symptom duration in outpatients is 15 days and over 25% of patients have symptoms longer than 21 days.

Parked on the verge: vocational rehabilitation of long-term unemployed citizens - a mixed methods study

BACKGROUND

Vocational rehabilitation programs (VRP) developing and improving work ability are used in Denmark to assist long-term unemployed citizens with complex problems. The aims of this study were to (1) describe VRP-participants in relation to general health, well-being, work ability and self-efficacy at baseline and one-year follow-up, (2) obtain an understanding of VRP-participants' personal development towards improving work ability, and (3) explore VRP-participants' hopes and thoughts about their future.

METHODS

In a mixed methods approach, data from a longitudinal survey and semi-structured interviews were collected. In the quantitative longitudinal survey, all participants completed paper questionnaires at baseline and one-year follow-up. For the qualitative semi-structured interviews, VRP participants were recruited with a maximum variation sampling strategy through VRP coordinators and personal contact. Data were analysed by descriptive statistics and systematic text condensation. Following analysis, data were merged and presented in combination according to identified themes.

RESULTS

At baseline and one-year follow-up 146 (response rate 34%) and 74 participants (response rate 52%) respectively, responded to the questionnaire. Seven participants were interviewed. The analysis revealed four themes: 1) Individual explanations of life situation and health; 2) Finding the path; 3) Work as giving meaning to life; 4) Hope for the future. Despite self-reported scores indicating poor general health, lack of well-being, low work ability and low self-efficacy, VRP-activities seemed to have assisted participants in finding meaning in life. VRP-components that may be drivers of successful recovery processes were identified.

CONCLUSIONS

VRP-participants experienced life situations that include multifactorial burdens, and low levels of general health, well-being, work ability, and self-efficacy at baseline and 1 year later. From the outset, most did not have a clear goal of employment, but over time, new goals were set as realistic opportunities for re-developing their work ability were explored. Successful core components of VRP were individually tailored programs and support, development of new relationships, and accommodated flexible internships and jobs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02641704 , date of registration December 29, 2015.

Not Control but Conquest: Strategies for the Remission of Type 2 Diabetes Mellitus

A durable normoglycemic state was observed in several studies that treated type 2 diabetes mellitus (T2DM) patients through metabolic surgery, intensive therapeutic intervention, or significant lifestyle modification, and it was confirmed that the functional β-cell mass was also restored to a normal level. Therefore, expert consensus introduced the concept of remission as a common term to express this phenomenon in 2009. Throughout this article, we introduce the recently updated consensus statement on the remission of T2DM in 2021 and share our perspective on the remission of diabetes. There is a need for more research on remission in Korea as well as in Western countries. Remission appears to be prompted by proactive treatment for hyperglycemia and significant weight loss prior to irreversible β-cell changes. T2DM is not a diagnosis for vulnerable individuals to helplessly accept. We attempt to explain how remission of T2DM can be achieved through a personalized approach. It may be necessary to change the concept of T2DM towards that of an urgent condition that requires rapid intervention rather than a chronic, progressive disease. We must grasp this paradigm shift in our understanding of T2DM for the benefit of our patients as endocrine experts.

影响全膝关节置换术患者术前预期的患者因素

OBJECTIVE

To investigate the expectations of patients for total knee arthroplasty (TKA), and to analyze its influencing factors.

METHODS

Experimental design: Single center, retrospective, multiple regression analysis. The data including the age, height, and weight of 108 patients undergoing unilateral TKA due to end-stage osteoarthritis were obtained. The patients' preoperative Hospital for Special Surgery (HSS) knee arthroplasty expectation score, the Western Ontario and McMaster Universities (WOMAC) score, Knee Society score (KSS), the MOS 36-item short-from health survey (SF-36) score, and visual analogue scale (VAS) were evaluated, and the 30-second chair-stand test (30-CST), 40-meter fast-paced walk test (40-FPWT), 12-level stair-climb test (12-SCT), 3-meter timed up-and-go test (TUG), 6-minute walk test (6-MWT), and recorded daily steps for 7 consecutive days were performed. The SPSS 22.0 software was used for statistical analysis. The observed values of various data were described. Pearson correlation analysis was used to evaluate the correlation between various parameters, and the multi-factor linear regression analysis was used to investigate the influencing factors of the patients preoperative expectation scores.

RESULTS

The average expectation score of this group of patients was 58.98±5.44. In the Pearson correlation analysis, the patient's preoperative expectation had a weak correlation to the result of the patient's 12-SCT, TUG, 6-MWT, KSS function score, and SF-36 mental component score (correlation coefficient 0.1-0.3). The patient's preoperative expectation had a moderate correlation to the patient's daily average steps, 30-CST, 40-FPWT, KSS, WOMAC and its pain, stiffness, function scores, SF-36 physical functioning, role-physical, bodily pain, vitality, and physical component score (correlation coefficient 0.3-0.6). In the multivariate linear regression analysis, only the results of 30-CST and the role-physical, bodily pain and vitality in the SF-36 scale were related to the patient's expectation score (P < 0.05).

CONCLUSION

The estimated expectation score of patients before TKA is not high. Patients with more severe preoperative pain, worse physical function, and lower overall health are more eager to improve after surgery. Thus surgeons must communicate fully with patients with unrealistic expectations before surgery in order to obtain more satisfactory results postoperatively.

Talonavicular joint mobilization and foot core strengthening in patellofemoral pain syndrome: a single-blind, three-armed randomized controlled trial

Background

Patellofemoral pain syndrome (PFPS) is defined as pain around the patella while performing activities such as squats, running, and climbing steps. One of the inherent risk factors for PFPS is an excessively pronated foot posture. The aim of this study was to investigate the effect of foot intervention, talonavicular joint mobilization (TJM) and foot core strengthening (FCS), on PFPS.

Methods

Forty-eight patients with PFPS (mean age, 21.96 ± 2.34 years; BMI, 22.77 ± 2.95 kg/m²) were enrolled in the study. Participants were randomly assigned in a 1:1:1 ratio to three groups, and received 12 sessions of TJM, FCS, and blended intervention at university laboratory for 4 weeks. The primary outcomes were pain while the secondary outcomes were lower extremity function, valgus knee, foot posture, and muscle activity ratio measured at baseline, after 12 sessions, and at the 4-week follow-up.

Results

The two-way repeated-measures ANOVA revealed significant interactions in all groups (p < 0.05). TJM reduced pain more than the FCS at post-test (mean difference, − 0.938; 95% Confidence interval [CI], − 1.664 to − 0.211; p < 0.05), and blended intervention improved lower extremity function (mean difference, 6.250; 95% CI, 1.265 to 11.235; p < 0.05) and valgus knee (mean difference, − 11.019; 95% CI, − 17.007 to − 5.031; p < 0.05) more than the TJM at 4 weeks follow-up. TJM was more effective in post-test (mean difference, − 1.250; 95% CI, − 2.195 to − 0.305; p < 0.05), and TJM (mean difference, − 1.563; 95% CI, − 2.640 to − 0.485; p < 0.05) and blended intervention (mean difference, − 1.500; 95% CI, − 2.578 to − 0.422; p < 0.05) were more effective in foot posture than the FCS in 4 weeks follow-up. Blended intervention displayed greater improvement in muscle activity than the TJM (mean difference, 0.284; 95% CI, 0.069 to 0.500; p < 0.05) and the FCS (mean difference, 0.265; 95% CI, 0.050 to 0.481; p < 0.05) at 4 weeks follow-up.

Conclusions

Our study is a novel approach to the potential impact of foot interventions on patellofemoral pain. Foot intervention including TJM and FCS is effective for pain control and function improvement in individuals with PFPS.

Trial registration

KCT0003176, 16/08/2018 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05099-x.

Are There Differences in Long-Term Functioning and Recovery Between Hemorrhagic and Ischemic Stroke Patients Receiving Rehabilitation?

OBJECTIVE

Previous research suggested better recovery in functioning of patients with hemorrhagic as compared to ischemic stroke. Now that more effective acute treatment for ischemic stroke, i.e. thrombolysis and thrombectomy, has become available, this observational cohort study aimed to examine if current rehabilitation outcomes differ between patients with hemorrhagic and ischemic stroke.

MATERIALS AND METHODS

The Barthel Index, 4 domains of the Stroke Impact Scale (SIS) and the EuroQol 5Dimensions were completed in all consecutive patients who received stroke rehabilitation at start of rehabilitation and during follow-up (for Barthel Index at discharge, SIS and EuroQol 5D after three and six months). Outcomes and recovery (i.e. change of scores between baseline and last follow-up) were compared between patients with hemorrhagic stroke and ischemic stroke (total and categorized by initial hospital treatment) using the Kruskall Wallis test. In addition, recovery was compared between ischemic and hemorrhagic stroke in multiple regression analyses with bootstrapping.

RESULTS

Baseline functioning did not differ between 117 patients with a hemorrhagic stroke, 118 ischemic stroke patient treated with reperfusion therapy, and 125 ischemic stroke patients without reperfusion therapy. There were no differences in functioning at follow-up nor in recovery concerning the Barthel Index, SIS domains 'mobility', 'communication', 'memory and thinking' and 'mood and emotions', and EuroQoL 5D between the three categories.

CONCLUSIONS

In a rehabilitation population the recovery and functioning at three or six months did not differ between ischemic stroke patients and hemorrhagic stroke patients, regardless of the hospital treatment they had received.

Relationship Between Sensibility Tests and Functional Outcomes in Patients With Traumatic Upper Limb Nerve Injuries: A Systematic Review

Objective

To investigate which tests of hand sensibility correlate with functional outcomes in patients with upper limb traumatic nerve injuries and to assess if composite scales of sensibility correlate with functions.

Data Sources

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched in May 2020, with a supplementary search in July 2020. Reference lists of the included publications were hand searched.

Study Selection

Database search found 2437 records. Eligible studies reported on inferential association between sensibility tests and functions pertaining to adults after upper limb nerve repair. Two reviewers independently assessed eligibility. Fifteen publications were included.

Data Extraction

Extracted data contain patient characteristics, surgical procedure, follow-up duration, sensibility tests, and functional assessments. Two reviewers independently assessed data quality.

Data Synthesis

Fifteen publications involving 849 patients were reviewed. All publications reported on median and/or ulnar nerve injuries. Monofilament tests correlated with Short-Form Health Survey (r=0.548, P<.05), pick-up test (r=0.45, P<.05), and function domain of Patient-Rated Wrist and Hand Evaluation Questionnaire (PRWHE) (r=0.58, P<.05). The 8 studies of static and moving 2-point discrimination provided conflicting correlations with activities of daily living (ADL) and/or the pick-up test. Data for area localization and object/shape identification were equivocal as well. No data were found for Ten test and vibration tests. Rosén score sensory domain correlated with ADL (r=0.59; 95% confidence interval [CI], 0.41-0.72) and PRWHE function domain (r=−0.56, P<.05). Medical Research Council sensory scale was related to pick-up test; return to work status; and Disabilities of the Arm, Shoulder, and Hand questionnaire.

Conclusions

Monofilament tests allow practitioners to gather sensibility data meaningful to patients’ overall recovery of functions after upper limb nerve trauma. For 2-point discrimination and other sensibility tests, practitioners should be aware that improvement in test performance does not necessarily translate to improved hand function. Findings from the composite scales indicate that hand sensibility, in general, is related to functions. Future research on other common sensibility tests is recommended to explore how the test relates to patients’ functions.

Modifiable factors associated with health-related quality of life among lung cancer survivors following curative intent therapy

OBJECTIVE

The number of lung cancer survivors is increasing along with advances in screening, diagnosis, and treatment. Following curative intent therapy, many lung cancer survivors experience significant health-related quality of life (HRQL) impairments. We sought to identify potentially modifiable factors that contribute to the HRQL of these patients.

MATERIALS AND METHODS

In this cross-sectional observational study of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy, we used a conceptual model to examine factors that included behavioral, objective functional and physiologic, self-rated function and symptom burden, specific comorbidities, and non-modifiable demographic and clinical lung cancer-related characteristics. We assessed HRQL using the valid and prognostic European Organization for Research and Treatment of Cancer Quality of Life (QoL) Core 30 global health/QoL subscale. We used univariable and multivariable linear regression modeling with backward elimination of potentially modifiable and non-modifiable factors, and interpreted clinically and statistically significant, consistent, and independent modifiable factors as meaningful.

RESULTS

Among 75 participants at a median of 12 months since treatment completion, the mean (standard deviation) C30 global health/QoL score was 62.7 (23.3) points (0-100 scale range). In multivariable analysis, with and without non-modifiable factors, we identified three clinically and statistically significant, consistent, and independent factors (unstandardized β range) associated with global health/QoL: 1) abnormal exercise-induced dyspnea (-9.23 to -10.0 points); 2) impaired self-rated role function (or inability to perform work or daily activities and pursuing leisure-time activities) (-12.6 to -16.4 points); and 3) abnormal insomnia (or trouble sleeping) (-12.6 to -16.4 points).

CONCLUSION

We identified meaningful modifiable factors associated with the HRQL of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy. Interventions to improve the HRQL of these patients should aim to reduce exercise-induced dyspnea, improve role function - the ability to perform work and other daily including leisure-time activities, and control insomnia.

Sensitive Periods for Recovery from Early Brain Injury

The developing brain is remarkably plastic as it changes in response to a wide range of experiences including sensory and motor experience, psychoactive drugs, peer relationships, parent-infant interactions, gonadal hormones, intestinal flora, diet, and injury. There are sensitive periods for many of these experiences, including cerebral injury. Comparisons across mammalian species (humans, monkeys, cats, rats, mice) show a sensitive period for good outcomes from cerebral injury around the time of intense synaptogenesis. This period is postnatal in humans, cats, and rats, but prenatal in monkeys, reflecting the differences in neuronal development at birth across species. In addition, there appears to be a sensitive period prenatally during the time of maximum cortical neurogenesis and possibly during adolescence as well, although these periods are not as well studied as the period related to synaptogenesis and to date only examined in rats. Here we review the evidence for sensitive periods related to brain injury across species and propose mechanisms that may underlie the plasticity during these periods.

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).

Preoperative Vitamin D Deficiency is Associated with Postoperative Functional Recovery and Complications after Hip Fracture Surgery

Background

Low concentrations of vitamin D are considered one of the risk factors for hip fracture and are associated with worse outcomes. The purpose of this retrospective study was to compare vitamin D deficient group and vitamin D sufficient group and assess the association preoperative vitamin D deficiency and postoperative walking ability after hip fracture surgery.

Methods

Between January 2014 and January 2020, 1,029 elderly patients with hip fracture (243 in men and 785 in women) were measured preoperative serum 25-hydroxy-vitamin D3 levels. Among 1,029 elderly patients, 702 patients were classified as Vitamin D deficient group (<20 ng/mL). Outcome parameters for functional recovery were the length of the hospital stay and KOVAL score, and those for complications were delirium, pneumonia, and thromboembolism.

Results

The mean length of the hospital stay in the vitamin D deficient group was significantly longer than in the vitamin D sufficient group (27.7±17.8 vs. 2.9±11.8 days; odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02–1.05; P=0.001). The mean postoperative KOVAL score in the deficient group was significantly higher than in the sufficient group (4.0±2.1 vs. 3.1±1.9 days; OR, 1.21; 95% CI, 1.11–1.32; P=0.001). Vitamin D deficiency was significantly associated with a higher risk of delirium and pneumonia in deficiency group.

Conclusions

Preoperative vitamin D deficiency in hip fractures patients was associated with prolonged duration of hospital stay and decrease of postoperative ambulatory status, and may increase the risk of delirium and pneumonia. Therefore, it is necessary to evaluate the preoperative vitamin D level and recommend vitamin D supplementation in elderly patients with a high probability of hip fracture.

Post-stroke Hyperglycemia in Non-diabetic Ischemic Stroke is Related With Worse Functional Outcome: A Cohort Study

OBJECTIVE

To investigate long-term and serial functional outcomes in ischemic stroke patients without diabetes with post-stroke hyperglycemia.

METHODS

The Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) is a large, multi-center, prospective cohort study of stroke patients admitted to participating hospitals in nine areas of Korea. From KOSCO, ischemic stroke patients without diabetes were recruited and divided into two groups: patients without diabetes without (n=779) and with post-stroke hyperglycemia (n=223). Post-stroke hyperglycemia was defined as a glucose level >8 mmol/L. Functional assessments were performed 7 days and 3, 6, and 12 months after stroke onset.

RESULTS

There were no significant differences in baseline characteristics between the groups, except in the age of onset and smoking. Analysis of the linear correlation between the initial National Institutes of Health Stroke Scale (NIHSS) score and glucose level showed no significant difference. Among our functional assessments, NIHSS, Fugl-Meyer Assessment (affected side), Functional Ambulatory Category, modified Rankin Scale, and Korean Mini-Mental State Examination (K-MMSE) showed statistically significant improvements in each group. All functional improvements except K-MMSE were significantly higher in patients without post-stroke hyperglycemia at 7 days and 3, 6, and 12 months.

CONCLUSION

The glucose level of ischemic stroke patients without diabetes had no significant correlation with the initial NIHSS score. The long-term effects of stress hyperglycemia showed worse functional outcomes in ischemic stroke patients without diabetes with post-stroke hyperglycemia.

Personality Characteristics and Acute Symptom Response Predict Chronic Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Despite consensus that personality influences mild traumatic brain injury (mTBI) recovery, it has been underexamined. We evaluated the extent to which diverse personality and psychiatric symptom dimensions predict mTBI recovery.

METHODS

This prospective cohort study involved psychological assessments of hospital patients with mTBI (n = 75; median = 2 days post-injury, range = 0-12 days) and orthopedic trauma controls (OTC; n = 79) who were used for comparison in mediation modeling. Chronic symptoms were evaluated at 3 months after mTBI (n = 50) using the Sport Concussion Assessment Tool (SCAT) symptom checklist. Linear regression analyses were used to identify the predominant predictors of chronic symptoms in mTBI. Modern mediation analyses tested the hypothesis that personality traits predict chronic symptoms through acute psychological response to injury.

RESULTS

In mTBI, trait psychoticism directly predicted chronic mTBI symptoms and was the strongest personality predictor overall. Furthermore, an internalizing personality dimension emphasizing negative affect/emotionality and detachment predicted chronic mTBI symptoms indirectly through enhancement of acute somatic complaints. In OTC, internalizing personality acted through the same mediator as in mTBI, whereas the effect of psychoticism was also mediated through acute somatic complaints. There was varying support for a moderated direct effect of personality traits at low levels of positive emotionality across models.

CONCLUSION

These causal models provide novel insights about the role of personality in mTBI symptom recovery, highlighting the complexity of how psychological processes may interact to affect recovery and revealing that some of these processes may be non-specific to brain injury.

Ibrutinib reduces neutrophil infiltration, preserves neural tissue and enhances locomotor recovery in mouse contusion model of spinal cord injury

Following acute spinal cord injury (SCI), excessive recruitment of neutrophils can result in inflammation, neural tissue loss and exacerbation of neurological outcomes. Ibrutinib is a bruton's tyrosine kinase inhibitor in innate immune cells such as the neutrophils that diminishes their activation and influx to the site of injury. The present study evaluated the efficacy of ibrutinib administration in the acute phase of SCI on neural tissue preservation and locomotor recovery. Ibrutinib was delivered intravenously at 3.125 mg/kg either immediately, 12 hours after, or both immediately and 12 hours after SCI induction in adult male C57BL/6 mice. Neutrophil influx into the lesion area was evaluated 24 hours following SCI using light microscopy and immunohistochemistry methods. Animals' body weight changes were recorded, and their functional motor recovery was assessed based on the Basso mouse scale during 28 days after treatment. Finally, spinal cord lesion volume was estimated by an unbiased stereological method. While animals' weight in the control group started to increase one week after injury, it stayed unchanged in treatment groups. However, the double injection of ibrutinib led to a significantly lower body weight compared to the control group at 4 weeks post-injury. Mean neutrophil counts per visual field and the lesion volume were significantly decreased in all ibrutinib-treated groups. In addition, ibrutinib significantly improved locomotor functional recovery in all treated groups, especially in immediate and double-injection groups. Neural tissue protection and locomotor functional recovery suggest ibrutinib treatment as a potent immunotherapeutic intervention for traumatic SCI that warrants clinical testing.

[Reconstruction of defects on the hand]

From a reconstructive viewpoint, injuries of the hand are particularly challenging. They are often associated with exposed tendons, bones, nerves and vessels, whereas little skin and soft tissue reserves are available for coverage. Functional and esthetic requirements necessitate a differentiated approach, depending on the location and extent of the defect. This article gives an overview of reconstruction techniques and flap surgery on the hand for various defect sizes and locations.

Predicting nonrecovery in adults with incident traffic injuries including post-traumatic headache

IMPORTANCE

The management of traffic injuries is challenging for clinicians. Knowledge about predictors of nonrecovery from traffic injuries may help to improve patient care.

OBJECTIVE

To develop a prediction model for self-reported overall nonrecovery from traffic injuries six months post-collision in adults with incident traffic injuries including post-traumatic headache (PTH).

DESIGN

Inception cohort studies of adults with incident traffic injuries (including PTH) injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada; and between January 2004 and January 2005 in Sweden.

METHODS

Prediction model development and geographical external validation.

SETTING

The Saskatchewan cohort (development) was population-based (N = 4,162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20% of cars driven in Sweden in 2004.

PARTICIPANTS

All adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized > 2 days, lost consciousness > 30 min, or reported headache < 3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80%.

PREDICTORS

Baseline sociodemographic, pre-injury, and injury factors.

OUTCOME

Self-reported nonrecovery from all injuries (not "all better (cured)" on the self-perceived recovery scale) six months after traffic collision.

RESULTS

Both cohorts were predominantly female (69.8% in Saskatchewan, 65.2% in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, low back pain, symptoms in arms or hands, hearing problems, sleeping problems, pre-existing headache, and lower recovery expectations. With a positive score (i.e., ≥0.85 probability), the model can rule in the presence of self-reported nonrecovery from all injuries at six months (development: specificity = 91.3%, 95% CI 89.2%-93.0%; sensitivity = 27.8%, 95% CI 26.0%-29.7%; positive likelihood ratio (LR + ) = 3.2, 95% CI 2.5-4.0; negative likelihood ratio (LR-) = 0.79, 95% CI 0.76-0.82; validation: specificity = 72.6%, 95% CI 61.4%-81.5%; sensitivity = 60.5%, 95% CI 53.9%-66.7%); LR+ = 2.2, 95% CI 1.5-3.3; LR- = 0.5, 95% CI 0.4-0.7).

CONCLUSIONS AND RELEVANCE

In adults with incident traffic injuries including PTH, predictors other than those related to baseline head and neck pain drive overall nonrecovery. Developing and testing interventions targeted at the modifiable predictors may help to improve outcomes for adults after traffic collision.

A cortical injury model in a non-human primate to assess execution of reach and grasp actions: implications for recovery after traumatic brain injury

BACKGROUND

Technological advances in developing experimentally controlled models of traumatic brain injury (TBI) are prevalent in rodent models and these models have proven invaluable in characterizing temporal changes in brain and behavior after trauma. To date no long-term studies in non-human primates (NHPs) have been published using an experimentally controlled impact device to follow behavioral performance over time.

NEW METHOD

We have employed a controlled cortical impact (CCI) device to create a focal contusion to the hand area in primary motor cortex (M1) of three New World monkeys to characterize changes in reach and grasp function assessed for 3 months after the injury.

RESULTS

The CCI destroyed most of M1 hand representation reducing grey matter by 9.6 mm³, 12.9 mm³, and 15.5 mm³ and underlying corona radiata by 7.4 mm³, 6.9 mm³, and 5.6 mm³ respectively. Impaired motor function was confined to the hand contralateral to the injury. Gross hand-use was only mildly affected during the first few days of observation after injury while activity requiring skilled use of the hand was impaired over three months.

COMPARISON WITH EXISTING METHOD(S)

This study is unique in establishing a CCI model of TBI in an NHP resulting in persistent impairments in motor function evident in volitional use of the hand.

CONCLUSIONS

Establishing an NHP model of TBI is essential to extend current rodent models to the complex neural architecture of the primate brain. Moving forward this model can be used to investigate novel therapeutic interventions to improve or restore impaired motor function after trauma.

Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities

In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.

Including Distal Motor Function within the NIHSS: Correlation with Motor Arm Function and IV rt-PA Treatment Response

OBJECTIVES

The Distal Motor Function (DMF) sub-score of the NIH Stroke Scale (NIHSS) was measured in the NINDS rt-PA Stroke Trials but is currently not included in the NIHSS. The correlation of DMF with the NIHSS Motor Arm Function (MAF) sub-score, the effect of IV tPA treatment on DMF, and whether adding DMF changes the utility of the NIHSS have not been analyzed.

MATERIALS AND METHODS

MAF and DMF sub-scores were retrieved from the original NINDS rt-PA Stroke Trials for both sides of the body at baseline, 2 hours, 24 hours, 7-10 days, and 3 months after IV tPA treatment. MAF and DMF scores were correlated using Spearman correlation. Clustering of DMF and MAF scores was determined using a Bentler Comparative Fit Index (CFI) to estimate variation in NIHSS when adding DMF. The effect of IV tPA on DMF and MAF was assessed using a linear model comparing changes in scores from baseline to 3 months.

RESULTS

MAF and DMF were highly correlated (p < 0.0001) across all time points for both dichotomous and continuous data on both sides. Intravenous tPA accounted for 21% of the change in DMF (p < 0.014, R² = 0.0157, N = 423) and 39% of the change in MAF (p < 0.093, R² = 0.0125, N = 547) from 0 to 3 months. On adding DMF to NIHSS, CFI decreased from 0.98 to 0.80 and DMF clustered with MAF, indicating that addition of DMF is unlikely to produce any discrepancy to NIHSS.

CONCLUSIONS

Including DMF to the NIHSS does not appear to be of additional value. After IV tPA treatment, proximal and distal motor function in upper extremity strongly correlate over time but greater improvement in MAF is noted. Further research is needed on the role of IV tPA on minor strokes with deficits of DMF.

Outcomes after occupational therapy intervention for traumatic brachial plexus injury: A prospective longitudinal cohort study

STUDY DESIGN

Prospective longitudinal cohort study.

INTRODUCTION

Traumatic brachial plexus injuries (BPIs) can be devastating and negatively impact daily function and quality of life. Occupational therapists play an important role in rehabilitation; however, studies identifying outcomes are lacking.

PURPOSE

This study aims to describe outcomes including motor recovery, upper limb function, participation, pain, and quality of life for people receiving occupational therapy intervention.

METHODS

A convenience sample of English-speaking adults (n = 30) with a traumatic BPI, attending the clinic between December 1, 2014, to November 30, 2016, participated. Participants received occupational therapy focusing on sensorimotor retraining and activity-based rehabilitation. Data on active range of motion (goniometry), strength (Medical Research Council (MRC)), upper-limb function (UEFI15, QuickDASH), participation (PSFS), pain (Brief Pain Inventory), and quality of life (EQ-5D-3L) were collected at baseline, 3, 6, 9, and 12 months.

RESULTS

Elbow flexion strength showed significant improvement at all time-points, average increase 2.17 (MRC) (95% confidence interval: 1.29-3.04; P < .001) and mean final MRC grading 3.86 (standard error: 0.44). Significant improvements at 12 months were seen in: shoulder abduction strength and range, flexion strength and range, external rotation range; elbow extension strength and flexion range; thumb flexion and extension strength. Upper limb function (QuickDASH) showed significant improvement (mean change = 18.85; 95% confidence interval: 4.12-33.59; P = .02). Forearm protonation range and finger flexion strength were significantly worse. Remaining outcomes did not show significant improvement.

CONCLUSIONS

Occupational therapy with surgical intervention can improve strength, range, and upper limb function with people following traumatic BPI. Further investigations into impact on participation, pain, and quality of life are required.

A Population-Based Analysis of Long-Term Outcomes Among Older Adults Requiring Unexpected Intensive Care Unit Admission After Cancer Surgery

BACKGROUND

High-intensity cancer surgery is increasingly common among older adults. However, these patients are at high-risk for unexpected intensive care unit (ICU) admissions after surgery. How these admissions impact older adults' long-term outcomes is unknown.

METHODS

We performed a population-based, cohort study of older adults (age ≥ 70 years) who underwent high-intensity cancer surgery from 2007 to 2017. Analyses were performed to examine time alive and at home following surgery, defined as time from surgery to nursing home admission or death. Patients were followed for up to 5 years. Extended Cox proportional hazards models examined the independent association between unexpected ICU admission (ICU admissions excluding routine postoperative monitoring) and remaining alive and at home. Subgroup analysis stratified patients by duration of mechanical ventilation (MV).

RESULTS

Of 47,367 identified older adults, 7372 (15.6%) had an unexpected ICU admission. Patients with an unexpected ICU admission had a significantly lower probability of being alive and at home at 5 years (26.2%; 95% confidence interval [CI] 25.1-27.2%) compared with those without an unexpected admission (56.8%; 95% CI 56.3-57.4%). After adjusting for baseline characteristics, unexpected ICU admission remained associated with less time alive and at home. The elevated risk of death or nursing home admission persisted for 5 years after surgery (years 2-5: hazard ratio [HR] 1.58, 95% CI 1.50-1.66). Duration of MV was inversely associated with time alive and at home.

CONCLUSIONS

Older adults with an unexpected ICU admission after high-intensity cancer surgery are at increased risk for death or admission to a nursing home for at least 5 years.

Prognostic molecular markers for motor recovery in acute hemorrhagic stroke: A systematic review

BACKGROUND AND AIMS

Molecular biomarkers are associated with poor prognosis in ischemic stroke individuals. However, it might not be generalizable to post-acute hemorrhagic stroke since the underlying mechanisms of this brain damage differ from those found in ischemic stroke. The main purpose of this review was to synthesize the potential predictive molecular biomarkers for motor recovery following acute hemorrhagic stroke.

MATERIALS AND METHODS

An electronic search was conducted by 2 independent reviewers in the following databases: PubMed (Medline), EMBASE, Web of Science, and CINAHL. We included studies that addressed the following: collected blood, urine, or cerebrospinal fluid samples within 72 h after hemorrhagic stroke and that reported the prognostic association with functional motor recovery for each molecular biomarker. Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers.

RESULTS

Twelve thousand, five hundred and sixty-four studies were identified and 218 were considered eligible. Finally, we included 70 studies, with 96 biomarkers analyzed, of which 61 were considered as independent prognostic biomarkers, and 10 presented controversial results.

CONCLUSION

This systematic review shows that motor functional recovery can be predicted by 61 independent prognostic molecular biomarkers assessed in the acute phase after a hemorrhagic stroke.

Predicting successful continuous renal replacement therapy liberation in critically ill patients with acute kidney injury

PURPOSE

No standardized criteria for continuous renal replacement therapy (CRRT) liberation have been established. We sought to develop and internally validate prediction models for successful CRRT liberation in critically ill patients with acute kidney injury (AKI).

MATERIALS AND METHODS

This single-center, retrospective cohort study included adult patients admitted to intensive care units (ICUs) with AKI and treated with CRRT from January 1, 2007, to May 4, 2018, at a tertiary referral hospital. The cohort was randomly divided into derivation and validation sets. The outcomes were successful CRRT liberation, defined as renal replacement therapy (RRT)-free survival within 72 h after the liberation and hospital discharge. Multivariate logistic regression models were developed and internally validated.

RESULTS

Of 1135 AKI patients requiring CRRT, successful CRRT liberation and RRT-free survival at hospital discharge were observed in 228 (20%) and 395 (35%) individuals, respectively. The independent predictors included mean hourly urine output within 12 h before liberation, mean serum creatinine value within 24 h before liberation, cumulative fluid balance from ICU admission to liberation, CRRT duration before liberation, and the requirement of vasoactive agents within 24 h before liberation. The models demonstrated good discrimination (AUROC, 0.76 and 0.78; positive predictive value, 36% and 48%; negative predictive value, 92% and 94%; respectively) and calibration in the validation set.

CONCLUSIONS

These validated models could assist the decision-making related to the CRRT liberation in critically ill patients with AKI.

Association Between Body Mass Index and Functional Outcomes in Elderly Patients with Extra-articular Distal Radius Fracture: A Prospective Observational Study

INTRODUCTION

The association between body mass index (BMI) and functional outcomes is unknown in elderly individuals with distal radius fracture (DRF).

OBJECTIVE

The aim of this study is to evaluate if there is association between BMI and functional outcomes in patients older than 60 years with DRF treated conservatively.

MATERIALS AND METHODS

A prospective observational study was performed. A total of 228 patients with extra-articular DRF were prospectively recruited. All patients were categorized by their BMI as normal, overweight, or obese. Functional outcomes were assessed after cast removal and at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to assess upper limb and wrist/hand function, respectively, while the Jamar Dynamometer was used to assess grip strength.

RESULTS

Of the total number of patients, 184 were female (80.7%), 87 were overweight (38.2%), and 111 were obese (48.7%). After cast removal, the correlations between BMI and functional outcomes were DASH 0.06 (p = 0.578), PRWE 0.04 (p = 0.692), and grip strength - 0.02 (p = 0.763). At 1-year follow-up, the correlations were DASH 0.55 (p = 0.036), PRWE 0.32 (p = 0.041), and grip strength - 0.21 (p = 0.043).

CONCLUSION

This study suggests that at 1-year follow-up, there was a low-to-moderate association between BMI and poor functional outcomes in elderly patients with extra-articular DRF treated conservatively.

LEVEL OF EVIDENCE

Level IV, observational prospective study.

Optimal Ratio of Wnt3a Expression in Human Mesenchymal Stem Cells Promotes Axonal Regeneration in Spinal Cord Injured Rat Model

Objective

Through our previous clinical trials, the demonstrated therapeutic effects of MSC in chronic spinal cord injury (SCI) were found to be not sufficient. Therefore, the need to develop stem cell agent with enhanced efficacy is increased. We transplanted enhanced Wnt3asecreting human mesenchymal stem cells (hMSC) into injured spines at 6 weeks after SCI to improve axonal regeneration in a rat model of chronic SCI. We hypothesized that enhanced Wnt3a protein expression could augment neuro-regeneration after SCI.

Methods

Thirty-six Sprague-Dawley rats were injured using an Infinite Horizon (IH) impactor at the T9-10 vertebrae and separated into five groups : 1) phosphate-buffered saline injection (injury only group, n=7); 2) hMSC transplantation (MSC, n=7); 3) hMSC transfected with pLenti vector (without Wnt3a gene) transplantation (pLenti-MSC, n=7); 4) hMSC transfected with Wnt3a gene transplantation (Wnt3a-MSC, n=7); and 5) hMSC transfected with enhanced Wnt3a gene (1.7 fold Wnt3a mRNA expression) transplantation (1.7 Wnt3a-MSC, n=8). Six weeks after SCI, each 5×105 cells/15 µL at 2 points were injected using stereotactic and microsyringe pump. To evaluate functional recovery from SCI, rats underwent Basso-Beattie-Bresnahan (BBB) locomotor test on the first, second, and third days post-injury and then weekly for 14 weeks. Axonal regeneration was assessed using growth-associated protein 43 (GAP43), microtubule-associated protein 2 (MAP2), and neurofilament (NF) immunostaining.

Results

Fourteen weeks after injury (8 weeks after transplantation), BBB score of the 1.7 Wnt3a-MSC group (15.0±0.28) was significantly higher than that of the injury only (10.0±0.48), MSC (12.57±0.48), pLenti-MSC (12.42±0.48), and Wnt3a-MSC (13.71±0.61) groups (p<0.05). Immunostaining revealed increased expression of axonal regeneration markers GAP43, MAP2, and NF in the Wnt3a-MSC and 1.7 Wnt3a-MSC groups.

Conclusion

Our results showed that enhanced gene expression of Wnt3a in hMSC can potentiate axonal regeneration and improve functional recovery in a rat model of chronic SCI.