Nur Turhan

Predictors of functional outcome in first-ever ischemic stroke: A special interest to ischemic subtypes, comorbidity and age

OBJECTIVES Most cardiovascular abnormalities are associated not only with increased risk of certain ischemic stroke subtypes but also with markedly greater disability in stroke patients. We aimed to investigate the associations between age, comorbidity, cardiovascular problems, site and size of ischemic lesions and functional outcome in inpatient first-ever ischemic stroke patients. SUBJECTS A total of 129 first-ever ischemic stroke admissions to a university affiliated rehabilitation centre were involved. METHODS Demographic data, brain computerized tomography or magnetic resonance imaging reports of the patients were recorded. Cardiovascular parameters consisted of electrocardiographic, echocardiographic and carotid Doppler ultrasonographic findings. Location and size of ischemic lesions was determined by using the Oxfordshire Community Stroke Project classification. Charlson Comorbidity index adjusted for ischemic stroke was used to assess associated health problems. Functional recovery was defined as the improvements made on Functional Independence Measure. RESULTS Our data indicated that the presence of chronic atrial fibrillation and carotid stenosis had significant associations with total anterior circulation infarcts. Multivariate analyses revealed that age, Charlson Comorbidity index adjusted for ischemic stroke, total anterior circulation infarcts, Functional Independence Measure on admission were associated with rehabilitation outcomes. CONCLUSIONS Advanced age, high comorbidity, large anterior circulation infarcts and poor functional level on admission were independent indicators of unfavorable functional outcome. Hemodynamic comorbidities had significant impact on localization and extend of ischemic lesions.

Ergonomic Risk Factors for Cumulative Trauma Disorders in VDU Operators

The objectives of this study were to investigate the rate of cumulative trauma disorders (CTDs) in the upper body and to describe the associations of such disorders with ergonomic parameters in a group of data entry operators. A total of 173 data entry operators volunteered to take part in the study. Questionnaires were used to investigate their medical history. Diagnoses of CTDs were made with clinical tests. A visual posture analysis of the workers and an ergonomic analysis of workstations and workload were used to reveal risk factors. Neck and shoulder pain, extensor tendonitis of the wrists and De Quervain’s disease were common in the study population. An assessment of risk factors showed that leaning wrists on the keyboard, hard keystrokes, extreme wrist joint and thumb positions and working in poor ergonomic design were correlated to pain and development of CTDs.

Post injection sciatic neuropathy in adults.

There were no clonic convulsions. Postictally, he was unresponsive for 10 more seconds and complete amnesia for the accident was evident. According to its semiology, the seizure was classified a right versive seizure initiated by an epigastric aura (Lüders et al., 1998). The presence of an epigastric aura suggests origination of the seizure within the mesial temporal lobe (Henkel et al., 2002). A right versive seizure with tonic head rotation suggests involvement of the left frontal eye field (Lüders et al., 1998). Blood glucose testing was normal. Electroencephalography was unremarkable. At follow-up 3 days, 1 week and 4 weeks later the neurological examination was normal. The incident was formally reported to the local Ethics Committee. Given the risk of seizure induction, rTMS should in general be administered only under the supervision of a physician experienced with the technique, the management of potential side-effects and fully trained in neurology, psychiatry or another appropriate speciality (Belmaker et al., 2003). Expert medical assistance should be immediately available in any rTMS session and therefore, rTMS should be performed in a medical setting with appropriate facilities to manage seizures and their consequences. It is recommended that any TMS laboratory should establish a plan with procedures for screening subjects for risk factors prior to rTMS, assessing individual risks and potential benefits in patients, guaranteeing the informed consent process with information about the risk of seizure and its consequences, setting of rTMS stimulation parameters and monitoring of subjects during and after rTMS (Belmaker et al., 2003). The dosage of rTMS should be limited by published safety guidelines (Wassermann, 1998). We extended our study protocol by electroencephalography recording, including provocation maneuvers, such as hyperventilation and photostimulation, prior to participation. The number of reported seizures following rTMS is considerably low regarding the widespread use of rTMS in an increasing number of centers all over the world (Wassermann, 2002). The majority of seizures occurred under stimulation parameters beyond the published safety levels regarding stimulation intensity, frequency and intertrain interval (Wassermann, 1998, 2002). In particular, the majority of rTMS induced seizures in healthy subjects occurred following rTMS at high frequencies, while 1 Hz rTMS is generally considered to be safe. The current safety guidelines on the use of rTMS are based on motor cortex stimulation. However, the susceptibility of non-motor cortical areas to rTMS associated seizure induction could be different. Importantly, the present case illustrates that rTMS may induce topic seizures at the site of brain stimulation with TMS parameters set within the limits that have been proven to be safe in an increasing amount of studies over the past decade. We feel that reporting such rare events is urgently needed to allow correct judgment upon the incidence of side-effects associated with this novel technique. References

Can High-Sensitivity C-Reactive Protein and Ferritin Predict Functional Outcome in Acute Ischemic Stroke? A Prospective Study

Abstract Background: Inflammation may not only be the consequence of brain infarction but it may also contribute to ischemic damage. However, the role of inflammatory markers in predicting functional outcome in stroke remains controversial. Objective: This study was conducted to evaluate the predictive value of admission high-sensitivity C-reactive protein (hs-CRP) and ferritin levels for functional disability in patients with acute ischemic stroke at 3-month follow-up and investigate the relationship between inflammatory markers and subtypes, severity, and risk factors of ischemic stroke. Methods: Sixty-two patients were examined prospectively within 48 hours after onset of ischemic stroke. Plasma hs-CRP and ferritin measurements were obtained from patients within 48 hours after onset and at 3-month follow-up. Patients were divided into 2 groups based on the level of hs-CRP: elevated (serum hs-CRP ≥0.5 mg/dL) and normal (serum hs-CRP<0.5 mg/dL) hs-CRP groups. Stroke severity was analyzed by the National Institutes of Health Stroke Scale (NIHSS) and functional disability was assessed by the Functional Independence Measure (FIM) and Functional Ambulation Scale (FAS). Stroke subtypes were classified according to the Oxfordshire Community Stroke Project. Results: Except for the correlation between hs-CRP levels and FIM scores on admission, no significant correlation was found between laboratory markers and FIM, FAS, and NIHSS scores and stroke subtypes on admission and at 3-month follow-up (P > .05). Conclusion: This study revealed that neither hs-CRP nor ferritin levels could predict functional disability 3 months after stroke onset. FIM, FAS, and NIHSS scores were more useful in predicting functional outcome 3 months after stroke onset than the laboratory markers evaluated in this study.

Association of ideomotor apraxia with lesion site, etiology, neglect, and functional independence in patients with first ever stroke.

Abstract Background: Ideomotor apraxia (IMA) is characterized by the inability to correctly imitate hand gestures and voluntarily pantomime tool use. The relationship between IMA and characteristics of stroke has not been totally elucidated. Objective: This study aimed to find out associations between presence of IMA and stroke etiology, site of the lesions, neglect, and temporal and functional parameters of stroke in patients with first ever stroke. Methods: Thirty-nine patients with first ever stroke were included. Patients with severe cognitive deficits were excluded. Assessment tools included Ideomotor Apraxia Test, Functional Independence Measure (FIM), Brunnstrom recovery stages, Mini Mental Test (MMT), and star cancellation test. Etiology (hemorrhagic or ischemic) and site of stroke was assessed through brain imaging methods. Location and size of ischemic lesion was determined by using the Oxfordshire Community Stroke Project system. Results: IMA was identified in 35.9% of the patients. Patients with IMA had significantly lower FIM scores both on admission and discharge (P = 0.001, P = 0.001). Presence of IMA was significantly associated with the presence of neglect (P = 0.004), total anterior circulation ischemia (TACI) (P < 0.001), and lower MMT scores (P < 0.001). Lesion site, patient age, time since onset, and stroke etiology had no impact on the presence of IMA. Conclusion: IMA was in concordance with poor cognitive and functional state and was not limited to left hemisphere lesions. The study revealed strong associations between IMA, neglect, and TACI. Every patient with stroke should be evaluated for the presence of IMA on admission to rehabilitation unit.

Predictors of mobility in medically unstable elderly patients with hip fractures: a preliminary study in a geriatric ward.

ACKNOWLEDGMENTS All authors are members of interRAI, a nonprofit organization that provides royalty-free licenses for governments or caregivers to use its assessment instruments. The University of Michigan Committee on Conflict of Interest has ruled that Dr. Fries’ involvement in research is not in conflict with his role as President of interRAI. All the authors have contributed to this letter, and the sponsors took no role in any aspect of it.

Significance of poststroke urinary incontinence as a negative predictor of functional recovery on the basis of aging

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Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation

[Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management.

Treatment of immobilization hypercalciuria using weekly alendronate in two quadriplegic patients

Metabolic and urinary problems encountered in spinal cord injury patients are multifaced. We report two patients with high-level spinal cord injuries who have developed hypercalciuria after admission to the rehabilitation unit. To establish a clean intermittent self-catheterization programme, the hypercalciuria was treated successfully with alendronate. Twenty-four-hour urinary calcium excretion decreased significantly after medical treatment for hypercalciuria. Since high-level quadriplegic patients may not be mobilized in the acute phase of the rehabilitation, use of alendronate for preventing hypercalciuria and maintaining a successful clean intermittent self-catheterization programme can be considered as a supportive/complementary measure.