Reza Salman Roghani

A Stroke Study of an Urban Area of Iran: Risk Factors, Length of Stay, Case Fatality, and Discharge Destination

BACKGROUND The Iranian population is aging rapidly, which causes huge medical concern for health care of this population. This trend will lead to an increase in stroke incidence in the future. The aim of this study was to investigate the epidemiologic patterns, risk factors, length of hospitalization, hospital discharge destination, and case fatality of patients with ischemic stroke from a city of Iran as well as analyses of interaction of these factors. METHODS A cross-sectional, multihospital-based study was performed on all consecutively discharged and diagnosed patients with ischemic stroke in the city of Qom, Iran, between March 2006 and September 2008. RESULTS A total of 953 patients, 48.9% men and 51.1% women, were included. The mean age was 68+/-13.82 years. Hypertension was found in 64% of patients, followed by diabetes mellitus (36%), heart disease (34%), hypercholesterolemia (32%), and smoking (20%). The average length of stay (LOS) was 7.7 days (95% confidence interval 7.2-8.2). Women had a significantly longer LOS compared with men (8.4 v 7 days, P = .0075) and patients with heart disease had a significantly longer LOS (9 days, 95% confidence interval 7.8-10, P = .004). Overall 1-month fatality rate was 15.3%. CONCLUSION Hypertension and diabetes mellitus are more frequent here than average global findings. One-month case fatality was higher than in European countries but less than in developing countries. The most interesting difference comparing developed countries is the destination, which should be addressed. We strongly recommend establishing a stroke registry, establishing primary prevention, and promoting rehabilitation facilities in Iran.

Stroke epidemiology and one-month fatality among an urban population in Iran

Objective Stroke is one of the most common causes of death and disability in Iran. This study evaluated stroke patient profiles with respect to rate, risk factors, and one-month fatality. Material and method A cross-sectional, hospital-based study on all stroke patients older than 45 years admitted to hospitals in the city of Qom throughout 2001. Results Four hundred and sixty patients older than 45 years were admitted as stroke. The annual stroke rate was estimated to 338/100 000 (95% confidence interval, 300–360) inhabitants older than 45 years. The annual rate of stroke was 384/100 000 (95% confidence interval, 381–386) when adjusted to the European population. Stroke subtypes were; ischaemic infarction 75%, intracranial haemorrhage 20·7%, subarachnoid haemorrhage 3%, and undetermined 1·3%. Main risk factors were hypertension in 74·6% and diabetes in 55·7%. Mortality rate was 24·6% within the first month. Conclusion Stroke incidence was higher than in Western countries. Hypertension and diabetes mellitus were considerably more frequent in our studied stroke patients than in other developing countries. Our findings need to be addressed in future health education programmes in Iran identifying patients at risk and focusing on more aggressive prevention programmes to lower stroke incidence.

The pattern of muscle involvement in ulnar neuropathy at the elbow.

OBJECTIVE To determine the pattern of muscle involvement in patients with ulnar neuropathy at the elbow. MATERIALS AND METHODS This study evaluated all patients referred for upper limb electrodiagnostic study (EDX) during 2007-2011 and included. patients with clinical signs and symptoms of ulnar neuropathy at the elbow. All patients had nerve conduction studies (NCS) for ulnar neuropathy. Needle electromyography (EMG) of four ulnar innervated muscles, flexor carpi ulnaris (FCU), flexor digitrom profoundus (FDP), first dorsal interosseous (FDI) and abductor digiti minimi (ADM)) was evaluated. RESULTS During the study period 34 (23 males and 11 females) patients were diagnosed with ulnar neuropathy at the elbow and three of them had bilateral involvement. Muscle involvement by EMG was as follows: FDI: 91.9%, ADM: 91.3%, FCU: 64.9% and FDP: 56.8%. CONCLUSION In this study, EMG abnormalities of nerve damage were presented more commonly in the FCU muscle than in the FDP in patients with ulnar nerve lesion at the elbow.

Basics of Peripheral Nerve Injury Rehabilitation

The study of peripheral nerve injury, repair & rehabilitation began during the American Civil War and has since expanded to not only include to extensive characterization of the processes and factors that contribute to nerve regeneration and reinnervation, but also to determining therapies that enhance nerve regeneration such as physical modalities, rehabilitation consideration and recently biological conduits and administration of growth promoting molecules.[1] Rehabilitation medicine is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Functional disability due to nerve lesions is completely related to the severity, type and location of nerve lesions. So, before starting any rehabilitation program for patients with nerve injury, deep knowledge of lesion’s type and denervation consequences is necessary.

Sensitivity of high-resolution ultrasonography in clinically diagnosed carpal tunnel syndrome patients with hand pain and normal nerve conduction studies

Background Suspecting carpal tunnel syndrome (CTS) in patients with hand pain is usual. Considering the variable rate of false-negative results in nerve conduction study (NCS), as a frequent reference confirmatory standard test, we aimed to evaluate the diagnostic accuracy of neuromuscular ultrasound in patients with clinical evidence of CTS and normal NCS. Methods It was a diagnostic accuracy study conducted in the outpatient clinic of Rofaydeh Hospital, Tehran, Iran, between July 2012 and December 2016; it recruited clinically diagnosed CTS patients and a control group. All participants underwent comprehensive clinical examination, NCS, and high-resolution ultrasonography of the median nerve. Results Two hundred and fifty patients with clinical evidence of CTS met the inclusion criteria, of whom 103 (27.1%) had normal NCS and underwent an ultrasound examination. A cutoff point of 9.4 mm2 (mean + 2 standard deviation) for median nerve cross-sectional area at the carpal tunnel inlet from the control group was set to detect 73% abnormality in the case group. Conclusion Ultrasonography had a sensitivity rate of 73% in patients with clinical CTS and negative NCS, increasing the overall diagnostic sensitivity for clinically suspected CTS in the electrodiagnostic lab setting to 92%. The study highlights the complementary role of ultraso-nography in diagnosing CTS in conjunction with NCS.

Different doses of steroid injection in elderly patients with carpal tunnel syndrome: a triple-blind, randomized, controlled trial

Background Carpal tunnel syndrome (CTS) is commonly seen in elderly populations, in part due to increased presence of predisposing comorbidities as well as physiological changes. We aimed at comparing the effectiveness of different doses of steroid using the ultrasound-guided hydrodissection method in elderly patients with CTS. Methods We conducted a prospective, triple-blind, randomized, controlled trial in elderly patients with CTS. Patients were allocated to one of three groups by simplified randomization. Groups I–III received 80 mg triamcinolone (2 mL) and 1 mL of 2% lidocaine; 40 mg triamcinolone (1 mL), 1 mL of 2% lidocaine, and 1 mL normal saline; and 1 mL of 2% lidocaine and 2 mL normal saline, respectively to make up to 3 mL volume. A wrist splint was then applied for support. Outcome measures included the visual analog scale (VAS) and the Boston Carpal Tunnel Questionnaire, and median motor and sensory nerve conduction and its sonographic inlet cross-sectional area were used as objective measures. All data were recorded at baseline and 2, 12, and 24 weeks after injection. The investigators, patients, and statistician were blinded to the treatment assignment. Results In total, 161 patients were recruited without statistically significant demographic differences between the three groups. There were no statistically significant differences between groups in any outcome, with the exception of the median distal motor latency, which was greater in Group II at all three follow-up visits, and significant baseline VAS difference between Groups I and III. Conclusion Hydrodissection with lidocaine and normal saline is as effective as hydrodissection with low- and high-dose steroid medication in elderly patients with CTS in this study, but further studies with matched baseline measures and also a sham group are suggested for definitive recommendation.

The diagnostic accuracy of median nerve ultrasonography in elderly patients with carpal tunnel syndrome: sensitivity and specificity assessment

Background Accurate diagnosis of carpal tunnel syndrome (CTS), the most common entrapment neuropathy, and its differentiation from other diseases are essential, especially in older individuals with advanced symptoms and modified electrophysiological abnormalities. The current study was conducted to evaluate the diagnostic accuracy of ultrasonography (US), regarding sensitivity and specificity in the diagnosis of CTS in elderly patients. Methods Individuals with upper limb complaints and reference subjects were recruited from the Rofaydeh Hospital, Tehran, Iran, from June 2013 to October 2014 – (15 months). We evaluate case and control subjects for health status, demographics, clinical characteristics of CTS, median nerve physiology by electrodiagnostic tests, and anatomy by US. Median nerve cross-sectional area (CSA) at precanal, tunnel inlet, midcanal, tunnel outlet, and antecubital levels was measured applying US examination. Results Of the 723 complaining patients, we assessed 380 patients with CTS symptoms. Electrodiagnostic studies (EDX) confirmed the CTS diagnosis in 203 of these clinically diseased patients. A total of 103 patients (of the 113 reference subjects) had normal EDX in the reference group. Comparisons of wrists between the afflicted and reference subjects demonstrated the CSA at precanal, tunnel inlet, midcanal, and tunnel outlet levels being significantly more abundant in the diseased hands than in the nondiseased hands. CSA at the tunnel inlet and the inlet-to-antecubital CSA ratio with a threshold of 8.5 mm2 and 0.65 gave the best diagnostic accuracy with a sensitivity and specificity of 96.9 and 93.6% for the inlet CSA and 99 and 28% for the CSA ratio, respectively. Conclusion The US as a noninvasive diagnostic method may serve for the investigation of CTS in elderly patients with excellent sensitivity and specificity.

Poster 143 Spinal Osteoporosis Rate in Patients With Typical Symptoms of Lumbar Canal Stenosis

Disclosures: A. S. Tenforde, none. Objective: To identify risk factors associated with low bone density in high school female runners. We hypothesized that factors associated with female athlete triad would predict low bone density, and performance would also be associated with injury. Design: Cross-sectional design. Setting: University human performance laboratory, online questionnaire. Participants: Participants in high school distance running (N 87; average age, 15.4 1.1 years old; average body mass index, 20.0 2.4 kg/m). Interventions: Subjects completed a questionnaire regarding risk factors of interest, including amenorrhea, eating disorders, previous running injuries, stress fractures, and best performances in the mile and 5-km distances. The subjects also received a dual-energy x-ray absorptiometry scan that assessed bone mineral density (BMD) z scores at the lumbar spine (LS) and total body. BMD values at the pelvis and femoral neck were collected and adjusted for age, height, and weight. Main Outcome Measures: Association of variables to BMD (B ). Results: Identified risk factors: previous injury (N 74) and stress fracture (N 11), amenorrhea (N 7), and eating disorder (N 5). Lower LS BMD was significantly associated with previous stress fracture (B .555, P .01), improved performances in the mile (B .320, P .01), and 5-km (B .309, P .01), and had a nonsignificant trend with shin splints (B .282, P .10) and amenorrhea (B .190, P .10). An increased number of menstrual periods over the past year was associated with improved LS BMD (B .274, P .05). Lower total body BMD was associated with improved performances in the 5-km and mile (B .313, P .01; B .244, P .05). History of amenorrhea was associated with lower pelvis BMD (B .224, P .05). Stress fracture was not associated with bone density at other regions. No association between eating disorders and bone density was seen. Conclusions: Stress fractures were associated with lower LS BMD. Maintaining normal menses may increase LS BMD and help prevent injury. Higher-performing athletes may be at greater risk for injury due to lower associated bone density. No relationship between eating disorders and bone density was seen: the small sample size may account for this. Consistent with previous studies, lumbar spine BMD appears most variable and significant to optimize bone health in runners.

Poster 141: Spine Bone Density in Elderly Patients With Lumbar Spinal Stenosis

Disclosures: M. A. Reiley, SI-BONE, Inc, Stock options or bond holdings SI-BONE, Inc, Employment. Objective: Over 22% of individuals who presented with lower back complaints actually had problems in their sacroiliac (SI) joint. Despite this large number, most treatment focus centers on the disk. A minimally invasive surgical (MIS) procedure may help to address this significant unmet clinical need. Design: SI joint diagnoses require appropriate interpretation of a patient’s history, clinical examination, and imaging studies (often hip and lumbar pathology coexists with SI joint pathology). CT or fluoroscopic-guided injection provides confirmation of sacroiliac pathology. Setting: MIS procedure is performed with the patient under general in the prone position. Main Outcome Measures: The investigators treated 52 patients included in this report and tested quantitatively for symptoms, preoperatively, at 3, 6, 12, and 24 months. Results: Patients have been able to return to full and unrestricted activity at 3 months and showed significant improvement from before surgery to follow-up. Conclusions: Physiatrists need to have an outlet for unsatisfied SI joint patients. With this new MIS procedure, the surgeon may now be able to successfully treat patients refractory to conservative medical therapy and effectively partner with physiatrists to offer patients new solutions.