Anthony C. Leonard

Mental Practice in Chronic Stroke: Results of a Randomized, Placebo-Controlled Trial

Background and Purpose— Mental practice (MP) of a particular motor skill has repeatedly been shown to activate the same musculature and neural areas as physical practice of the skill. Pilot study results suggest that a rehabilitation program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to increase affected arm use and function. This Phase 2 study compared efficacy of a rehabilitation program incorporating MP of specific arm movements to a placebo condition using randomized controlled methods and an appropriate sample size. Method— Thirty-two chronic stroke patients (mean=3.6 years) with moderate motor deficits received 30-minute therapy sessions occurring 2 days/week for 6 weeks, and emphasizing activities of daily living. Subjects randomly assigned to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of the activities of daily living; subjects assigned to the control group received the same amount of therapist interaction as the experimental group, and a sham intervention directly after therapy, consisting of relaxation. Outcomes were evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer Assessment. Results— No pre-existing group differences were found on any demographic variable or movement scale. Subjects receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function (both at the P<0.0001 level). Only patients in the group receiving MP exhibited new ability to perform valued activities. Conclusions— The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm motor function in patients with chronic stroke. These changes are clinically significant.

Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample

Research has indicated significant comorbid psychopathology with chronic posttraumatic stress disorder (PTSD) in samples of war veterans. The present paper examines the issue of comorbidity in a disaster sample to learn whether findings from veterans generalized to this event. A total of 193 subjects exposed to the Buffalo Creek dam collapse of 1972 were examined 14 years later using diagnoses derived from the Structured Clinical Interview for DSM-III (SCID). Past and present PTSD was found in a significant portion of the sample. Major depression was the next most common diagnosis and was highly related to PTSD. Anxiety disorders were also common. The overlap with other diagnoses was quite similar to that found in a sample of Vietnam veterans we studied earlier, except that the disaster sample had fewer dysthymic disorders, substance abusers, and antisocial personality disorders. Possible explanations for comorbidity in chronic PTSD were discussed and it was suggested that the morphology of PTSD may be quite stable in at least some other nonveteran trauma populations.

Spirituality and Religion in Patients with HIV/AIDS

BackgroundSpirituality and religion are often central issues for patients dealing with chronic illness. The purpose of this study is to characterize spirituality/religion in a large and diverse sample of patients with HIV/AIDS by using several measures of spirituality/religion, to examine associations between spirituality/religion and a number of demographic, clinical, and psychosocial variables, and to assess changes in levels of spirituality over 12 to 18 months.MethodsWe interviewed 450 patients from 4 clinical sites. Spirituality/religion was assessed by using 8 measures: the Functional Assessment of Chronic Illness Therapy—Spirituality-Expanded scale (meaning/peace, faith, and overall spirituality); the Duke Religion Index (organized and nonorganized religious activities, and intrinsic religiosity); and the Brief RCOPE scale (positive and negative religious coping). Covariates included demographics and clinical characteristics, HIV symptoms, health status, social support, self-esteem, optimism, and depressive symptoms.ResultsThe patients’ mean (SD) age was 43.3 (8.4) years; 387 (86%) were male; 246 (55%) were minorities; and 358 (80%) indicated a specific religious preference. Ninety-five (23%) participants attended religious services weekly, and 143 (32%) engaged in prayer or meditation at last daily. Three hundred thirty-nine (75%) patients said that their illness had strengthened their faith at least a little, and patients used positive religious coping strategies (e.g., sought God’s love and care) more often than negative ones (e.g., wondered whether God has abandoned me; P<.0001). In 8 multivariable models, factors associated with most facets of spirituality/religion included ethnic and racial minority status, greater optimism, less alcohol use, having a religion, greater self-esteem, greater life satisfaction, and lower overall functioning (R2=.16 to .74). Mean levels of spirituality did not change significantly over 12 to 18 months.ConclusionsMost patients with HIV/AIDS belonged to an organized religion and use their religion to cope with their illness. Patients with greater optimism, greater self-esteem, greater life satisfaction, minorities, and patients who drink less alcohol tend to be both more spiritual and religious. Spirituality levels remain stable over 12 to 18 months.

Acute Kidney Injury Episodes and Chronic Kidney Disease Risk in Diabetes Mellitus

BACKGROUND AND OBJECTIVES Prior studies have examined long-term outcomes of a single acute kidney injury (AKI) event in hospitalized patients. We examined the effects of AKI episodes during multiple hospitalizations on the risk of chronic kidney disease (CKD) in a cohort with diabetes mellitus (DM). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 4082 diabetics were followed from January 1999 until December 2008. The primary outcome was reaching stage 4 CKD (GFR of <30 ml/min per 1.73 m(2)). AKI during hospitalization was defined as >0.3 mg/dl or a 1.5-fold increase in creatinine relative to admission. Cox survival models examined the effect of first AKI episode and up to three episodes as time-dependent covariates, on the risk of stage 4 CKD. Covariates included demographic variables, baseline creatinine, and diagnoses of comorbidities including proteinuria. RESULTS Of the 3679 patients who met eligibility criteria (mean age = 61.7 years [SD, 11.2]; mean baseline creatinine = 1.10 mg/dl [SD, 0.3]), 1822 required at least one hospitalization during the time under observation (mean = 61.2 months [SD, 25]). Five hundred thirty of 1822 patients experienced one AKI episode; 157 of 530 experienced ≥2 AKI episodes. In multivariable Cox proportional hazards models, any AKI versus no AKI was a risk factor for stage 4 CKD (hazard ratio [HR], 3.56; 95% confidence interval [CI], 2.76, 4.61); each AKI episode doubled that risk (HR, 2.02; 95% CI, 1.78, 2.30). CONCLUSIONS AKI episodes are associated with a cumulative risk for developing advanced CKD in diabetes mellitus, independent of other major risk factors of progression.

Modified constraint-induced therapy in acute stroke: a randomized controlled pilot study.

To determine modified constraint-induced therapy (mCIT) feasibility and compare its efficacy to traditional rehabilitation (TR) in acute stroke patients exhibiting upper limb hemiparesis. Method. Before-after, multiple baseline, randomized controlled pilot study. Setting. Rehabilitation hospital. Patients. Ten stroke patients < 14 d poststroke and exhibiting upper limb hemiparesis and affected limb nonuse. Interventions. Five patients were administered mCIT, consisting of structured therapy emphasizing more affected arm use in valued activities 3 d/week for 10 weeks and less affected arm restraint 5 d/week for 5 h. Five other patients received 1/2 sessions of traditional motor rehabilitation for the affected arm, which included affected limb manual dexterity exercises and stretching, as well as compensatory strategies with the unaffected limb. The TR regimens occurred 3 d/week for 10 weeks. Main Outcome Measures. The Fugl-Meyer Assessment of Motor Recovery (Fugl-Meyer), Action Research Arm Test (ARA), and Motor Activity Log (MAL). Results. Before intervention, all patients exhibited stable motor deficits and more affected arm nonuse. After intervention, mCIT patients displayed increased affected arm use (+ 2.43 on the MAL amount of use scale), uniformly exhibited increases on the Fugl-Meyer and ARA (mean change scores = + 18.7 and + 21.7, respectively), and were able to again perform valued activities. TR patients exhibited nominal change in affected limb use (+ 0.07 on the MAL amount of use scale) and modest changes on the Fugl-Meyer and ARA (+ 4.4 and + 4.8, respectively). Fugl-Meyer and ARA changes were significant for the mCIT group only (P < 0.01). Conclusions. mCIT is a promising regimen for improving more affected limb use and function in acute cerebrovascular accident. However, larger confirmatory studies need to be performed.

Modified Constraint-Induced Therapy in Chronic Stroke: Results of a Single-Blinded Randomized Controlled Trial

Background and Purpose: This single-blinded randomized controlled trial compared the efficacy of a reimbursable, outpatient, modified constraint-induced therapy (mCIT) protocol (half-hour therapy sessions occurring 3 days per week in which subjects used the more affected arm combined with less affected arm restriction 5 days per week for 5 hours; both of these regimens were administered during a 10-week period) with that of a time-matched exercise program for the more affected arm or a no-treatment control regimen. Subjects: Thirty-five subjects with chronic stroke participated in the study. Methods: The Action Research Arm Test (ARAT), Fugl-Meyer Assessment of Motor Recovery After Stroke (FM), and Motor Activity Log (MAL) were administered to the subjects. Results: After intervention, significant differences were observed on the ARAT and MAL Amount of Use and Quality of Movement scales, all in favor of the mCIT group. Discussion and Conclusion: The data affirm previous findings suggesting that this reimbursable, outpatient protocol increases more affected arm use and function. Magnitude of changes was consistent with those reported in more intense protocols, such as constraint-induced therapy.

Religious Coping and Physiological, Psychological, Social, and Spiritual Outcomes in Patients with HIV/AIDS: Cross-sectional and Longitudinal Findings

The present study investigated the relationships between positive religious coping (e.g., seeking spiritual support) and spiritual struggle (e.g., anger at God) versus viral load, CD4 count, quality of life, HIV symptoms, depression, self-esteem, social support, and spiritual well-being in 429 patients with HIV/AIDS. Data were collected through patient interview and chart review at baseline and 12–18 months later from four clinical sites. At baseline, positive religious coping was associated with positive outcomes while spiritual struggle was associated with negative outcomes. In addition, high levels of positive religious coping and low levels of spiritual struggle were associated with small but significant improvements over time. These results have implications for assessing religious coping and designing interventions targeting spiritual struggle in patients with HIV/AIDS.

Prediction of Hypertension Improvement After Stenting of Renal Artery Stenosis: Comparative Accuracy of Translesional Pressure Gradients, Intravascular Ultrasound, and Angiography

OBJECTIVES We investigated the comparative accuracy of renal translesional pressure gradients (TPG), intravascular ultrasound (IVUS), and angiographic parameters in predicting hypertension improvement after stenting of renal artery stenosis (RAS). BACKGROUND The degree of RAS that justifies stenting is unknown. METHODS In 62 patients with RAS, TPG (resting and hyperemic systolic gradient [HSG], fractional flow reserve, and mean gradient) were measured by a pressure guidewire; IVUS and angiographic parameters (minimum lumen area and diameter, area stenosis, and diameter stenosis) were measured by quantitative analyses. RESULTS The HSG had a larger area under the curve than most other parameters and an HSG >or=21 mm Hg had the highest sensitivity, specificity, and accuracy (82%, 84%, and 84%, respectively) in predicting hypertension improvement after stenting of RAS. The average IVUS area stenosis was markedly greater in RAS with an HSG >or=21 mm Hg versus <21 mm Hg (78% vs. 38%, respectively; p < 0.001). After stenting, hypertension improved in 84% of patients with an HSG >or=21 mm Hg (n = 36) versus 36% of patients with an HSG <21 mm Hg (n = 26) at 12 months, p < 0.01; the number of antihypertensive medications was significantly lower in patients with an HSG >or=21 mm Hg versus <21 mm Hg (2.30 +/- 0.90 vs. 3.40 +/- 0.50, respectively; p < 0.01). By multivariable analysis, HSG was the only independent predictor of hypertension improvement (odds ratio: 1.39; 95% confidence interval: 1.05 to 1.65; p = 0.013). CONCLUSIONS An HSG >or=21 mm Hg provided the highest accuracy in predicting hypertension improvement after stenting of RAS, suggesting that an HSG >or=21 mm Hg is indicative of significant RAS.

Adherence to the HPV Vaccine Dosing Intervals and Factors Associated With Completion of 3 Doses

OBJECTIVE: The objectives of this study were to determine (1) adherence to the immunization schedule for the human papillomavirus quadrivalent vaccine and (2) factors associated with completion of the 3-dose series. METHODS: This was a retrospective review of health information records from an academic medical center. The sample included all 9- to 26-year-old female patients who initiated vaccination within 2 years after quadrivalent vaccine availability. Multivariable logistic regression models were estimated to determine associations with completion of the 3-dose series within 7 and 12 months. RESULTS: Among the 3297 female patients who initiated vaccination with human papillomavirus quadrivalent vaccine, 67% self-identified as black and 29% self-identified as white. Fewer than 3% of vaccine doses were received earlier than recommended, but >50% of doses were received late. Completion rates were 14% by 7 months and 28% by 12 months. Independent predictors of completion by 7 months included white versus black race (odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.64–2.56]; P < .001), use of contraception that required intramuscular injections every 3 months (OR: 1.53 [95% CI: 1.12–1.95]; P < .001), and private versus public insurance (OR: 1.31 [95% CI: 1.06–1.63]; P < .05). Age and clinic type were not independent predictors of completion. CONCLUSIONS: Adherence to recommended intervals and completion of the vaccine series were low. Lower rates of completion in black patients compared with white patients raises concern that disparities in vaccine completion could exacerbate existing disparities in cervical cancer.

Acute Kidney Injury after Gastric Bypass Surgery

Gastric bypass surgery is a common treatment for morbid obesity. The presence of comorbid conditions and drugs that are used to treat them can adversely influence kidney function. Risk factors and outcomes of acute kidney injury (AKI) after gastric bypass surgery are not well understood, however. A total of 504 patients underwent gastric bypass between January 2003 and 2005. Primary outcome was AKI, defined as a > or =50% increase in serum creatinine relative to baseline or requirement of dialysis. Secondary outcomes were duration of hospitalization, all-cause hospital mortality, and readmissions within 30 d after surgery. Demographic, comorbid, and laboratory variables and preoperative medication use were examined as potential risk factors for AKI. A total of 42 (8.5%) patients developed postoperative AKI. Hyperlipidemia, preoperative use of angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB), intraoperative hypotension, and higher body mass index were associated with increased frequency of AKI. By multivariable analyses, the independent risk factors for AKI were body mass index (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.00 to 1.06), hyperlipidemia (OR 2.53; 95% CI 1.21 to 5.28), and preoperative use of ACE-I or ARB (OR 2.06; 95% CI 1.05 to 4.04). The postoperative mortality was 0.45% (n = 2), both of whom had AKI. Duration of hospitalization was greater in patients with AKI versus no AKI (4.0 versus 2.7 d; P = 0.0003). Postoperative AKI is not infrequent after gastric bypass surgery. Certain comorbid conditions and their commonly prescribed treatments, ACE-I or ARB, are independently associated with increased risk for postoperative AKI.