Italian translation and cross-cultural validation of an assessment tool for participation in stroke survivors: the Frenchay Activities Index

PURPOSE

Participation needs to be assessed objectively, to state accurate rehabilitation objectives. The Frenchay Activities Index (FAI) is a widely used tool to measure participation in stroke patients. To date, no cross-culturally validated Italian version of FAI is available. This study provides a translation and cross-cultural adaptation of FAI into Italian, assessing its validity and reliability in sub-acute stroke patients.

METHODS

According to international guidelines, a multistep translation and cultural adaptation protocol of forward and backward translations was conducted by qualified linguists and independent native English translators and revised by a healthcare committee. Patients admitted to intensive inpatient rehabilitation after stroke were recruited. Structural validity, reliability (internal consistency, inter- and intra-rater reliability and measurement error), and construct validity were studied.

RESULTS

One hundred and seventy-three patients were included in this study. No significant observations in terms of comprehensibility and conceptual equivalence of the FAI Italian version emerged. The exploratory factorial analysis revealed the presence of two subscales (i.e., domestic chores and work/leisure). The internal consistency resulted good for the first and second subscale (α = 0.821 and 0.716, respectively). Intra- and inter-reliability showed an ICC > 0.90 for both subscales. SEM = 5.75% and 2.33% and MDC = 15.85% and 6.48% were found for the first and second subscale, respectively. Construct validity of first subscale was satisfactory, as 100.0% a priori hypotheses were met, while for the second subscale it was moderate, as 66.6% a priori hypotheses were respected.

CONCLUSION

FAI-I provides a tool for professionals to measure participation in Italian stroke patients in health and social care settings.

Monocarboxylate transporter 1 deficiency impacts CD8+ T lymphocytes proliferation and recruitment to adipose tissue during obesity

Lactate sits at the crossroad of metabolism, immunity, and inflammation. The expression of cellular lactate transporter MCT1 (known as Slc16a1) increases during immune cell activation to cope with the metabolic reprogramming. We investigated the impact of MCT1 deficiency on CD8+ T cell function during obesity-related inflammatory conditions. The absence of MCT1 impaired CD8+ T cell proliferation with a shift of ATP production to mitochondrial oxidative phosphorylation. In Slc16a1 f/f Tcell cre mice fed a high-fat diet, a reduction in the number of CD8+ T cells, which infiltrated epididymal visceral adipose tissue (epiWAT) or subcutaneous adipose tissue, was observed. Adipose tissue weight and adipocyte area were significantly reduced together with downregulation of adipogenic genes only in the epiWAT. Our findings highlight a distinct effect of MCT1 deficiency in CD8+ T cells in the crosstalk with adipocytes and reinforce the concept that targeting immunometabolic reprogramming in lymphocyte could impact the immune-adipose tissue axis in obesity.

Merging Clinical and EEG Biomarkers in an Elastic-Net Regression for Disorder of Consciousness Prognosis Prediction

Patients with Disorder of Consciousness (DoC) entering Intensive Rehabilitation Units after a severe Acquired Brain Injury have a highly variable evolution of the state of consciousness which is a complex aspect to predict. Besides clinical factors, electroencephalography has clearly shown its potential into the identification of prognostic biomarkers of consciousness recovery. In this retrospective study, with a dataset of 271 patients with DoC, we proposed three different Elastic-Net regressors trained on different datasets to predict the Coma Recovery Scale-Revised value at discharge based on data collected at admission. One dataset was completely EEG-based, one solely clinical data-based and the last was composed by the union of the two. Each model was optimized, validated and tested with a robust nested cross-validation pipeline. The best models resulted in a median absolute test error of 4.54 [IQR = 4.56], 3.39 [IQR = 4.36], 3.16 [IQR = 4.13] for respectively the EEG, clinical and hybrid model. Furthermore, the hybrid model for what concerns overcoming an unresponsive wakefulness state and exiting a DoC results in an AUC of 0.91 and 0.88 respectively. Small but useful improvements are added by the EEG dataset to the clinical model for what concerns overcoming an unresponsive wakefulness state. Data-driven techniques and namely, machine learning models are hereby shown to be capable of supporting the complex decision-making process the practitioners must face.

Predictors of Mortality in 433 Nonagenarians Inside the Mugello Study: A 10 Years Follow-Up Study

OBJECTIVE

to identify the predictors of mortality in a cohort of nonagenarians inside the "Mugello study" after 10 years follow-up.

METHODS

Information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 non-selected participants aged 90-99 years, living in the Mugello area (Italy). Participants were followed over 10 years and their dates of death were retrieved from the municipal registers. Cox regression analysis was used to determine significant potential prognostic factors.

RESULTS

The mortality rate was 96.5%. Cox proportional hazards analysis showed that a lower cognitive status was significantly associated with higher mortality as well as a poorer functional status, a higher comorbidity, and a higher number of drugs consumption.

DISCUSSION

Impaired cognitive function, loss of functional independence, higher comorbidity, and higher drugs intake were the stronger predictors of mortality.

Clinical, Neurophysiological, and Genetic Predictors of Recovery in Patients With Severe Acquired Brain Injuries (PRABI): A Study Protocol for a Longitudinal Observational Study

Background

Due to continuous advances in intensive care technology and neurosurgical procedures, the number of survivors from severe acquired brain injuries (sABIs) has increased considerably, raising several delicate ethical issues. The heterogeneity and complex nature of the neurological damage of sABIs make the detection of predictive factors of a better outcome very challenging. Identifying the profile of those patients with better prospects of recovery will facilitate clinical and family choices and allow to personalize rehabilitation. This paper describes a multicenter prospective study protocol, to investigate outcomes and baseline predictors or biomarkers of functional recovery, on a large Italian cohort of sABI survivors undergoing postacute rehabilitation.

Methods

All patients with a diagnosis of sABI admitted to four intensive rehabilitation units (IRUs) within 4 months from the acute event, aged above 18, and providing informed consent, will be enrolled. No additional exclusion criteria will be considered. Measures will be taken at admission (T0), at three (T1) and 6 months (T2) from T0, and follow-up at 12 and 24 months from onset, including clinical and functional data, neurophysiological results, and analysis of neurogenetic biomarkers.

Statistics

Advanced machine learning algorithms will be cross validated to achieve data-driven prediction models. To assess the clinical applicability of the solutions obtained, the prediction of recovery milestones will be compared to the evaluation of a multiprofessional, interdisciplinary rehabilitation team, performed within 2 weeks from admission.

Discussion

Identifying the profiles of patients with a favorable prognosis would allow customization of rehabilitation strategies, to provide accurate information to the caregivers and, possibly, to optimize rehabilitation outcomes.

Conclusions

The application and validation of machine learning algorithms on a comprehensive pool of clinical, genetic, and neurophysiological data can pave the way toward the implementation of tools in support of the clinical prognosis for the rehabilitation pathways of patients after sABI.

12-month survival in nonagenarians inside the Mugello study: on the way to live a century

Background

Life expectancy has increased over the last century and a growing number of people is reaching age 90 years and over. However, data on nonagenarians’ health trends are scarce due to difficulties in investigating this specific population. This study aims to identify risk factors for one-year mortality in nonagenarians using data collected within the “Mugello Study”.

Methods

Complete information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 nonagenarians, as well as information about survival after 1 year from the interview.

Results

The sample included 314 women (72.5%) and 119 men (27.5%) with a median age of 92 years (range 90-99 years). The mortality rate was 20.3% (88 deaths). After adjustment for age and sex, a significantly higher risk of dying within 12 months was observed in individuals with more severe cognitive impairment (HR = 5.011, p < 0.001), more severe disability in basic activities of daily living (HR = 4.193, p < 0.001), sedentary lifestyle (HR = 3.367, p < 0.001), higher number of drugs assumed (HR = 1.118, p = 0.031), and kidney dysfunction (HR = 2.609, p = 0.004). When all the variables were included in the analysis, only older age (HR = 1.079, p = 0.048), lower cognitive function (HR = 2.859, p = 0.015), sedentary lifestyle (HR = 2.030, p = 0.026), and kidney dysfunction (HR = 2.322, p = 0.018) remained significantly associated with reduced survival.

Conclusions

Data from the Mugello study support the hypothesis that survival at 12 months in nonagenarians is not a stochastic process and that older age, reduced cognitive function, sedentary lifestyle, and the presence of kidney dysfunction are associated with mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02908-9.

Synthesis and defect characterization of hybrid ceria nanostructures as a possible novel therapeutic material towards COVID-19 mitigation

This study reports the synthesis of hybrid nanostructures composed of cerium dioxide and microcrystalline cellulose prepared by the microwave-assisted hydrothermal route under distinct temperature and pH values. Their structural, morphological and spectroscopic behaviors were investigated by X-Rays Diffraction, Field Emission Gun Scanning Electron Microscopy, High-Resolution Transmission Electron Microscopy, and Fourier-Transform Infrared, Ultraviolet–Visible, Raman and Positron Annihilation Lifetime spectroscopies to evaluate the presence of structural defects and their correlation with the underlying mechanism regarding the biocide activity of the studied material. The samples showed mean crystallite sizes around 10 nm, characterizing the formation of quantum dots unevenly distributed along the cellulose surface with a certain agglomeration degree. The samples presented the characteristic Ce–O vibration close to 450 cm⁻¹ and a second-order mode around 1050 cm⁻¹, which is indicative of distribution of localized energetic levels originated from defective species, essential in the scavenging of reactive oxygen species. Positron spectroscopic studies showed first and second lifetime components ranging between 202–223 ps and 360–373 ps, respectively, revealing the presence of two distinct defective oxygen species, in addition to an increment in the concentration of Ce³⁺-oxygen vacancy associates as a function of temperature. Therefore, we have successfully synthesized hybrid nanoceria structures with potential multifunctional therapeutic properties to be further evaluated against the COVID-19.

Effects of COVID-19 pandemic on intensive rehabilitation after severe acquired brain injuries

PURPOSE

COVID-19 pandemic has affected most components of health systems including rehabilitation. The study aims to compare demographic and clinical data of patients admitted to an intensive rehabilitation unit (IRU) after severe acquired brain injuries (sABIs), before and during the pandemic.

MATERIALS AND METHODS

In this observational retrospective study, all patients admitted to the IRU between 2017 and 2020 were included. Demographics were collected, as well as data from the clinical and functional assessment at admission and discharge from the IRU. Patients were grouped in years starting from March 2017, and the 2020/21 cohort was compared to those admitted between March 2017/18, 2018/19, and 2019/20. Lastly, the pooled cohort March 2017 to March 2020 was compared with the COVID-19 year alone.

RESULTS

This study included 251 patients (F: 96 (38%): median age 68 years [IQR = 19.25], median time post-onset at admission: 42 days, [IQR = 23]). In comparison with the pre-pandemic years, a significant increase of hemorrhagic strokes (p < 0.001) and a decrease of traumatic brain injuries (p = 0.048), a reduction of the number of patients with a prolonged disorder of consciousness admitted to the IRU (p < 0.001) and a lower length of stay (p < 0.001) were observed in 2020/21.

CONCLUSIONS

These differences in the case mix of sABI patients admitted to IRU may be considered another side-effect of the pandemic. Facing this health emergency, rehabilitation specialists need to adapt readily to the changing clinical and functional needs of patients' addressing the IRUs.

Evaluation of sense of position and agency in children with diplegic cerebral palsy: A pilot study

PURPOSE

This study explores non-motor impairment of the upper dominant limb in children with diplegic cerebral palsy (CP). Specifically, it firstly investigates sense of position without visual control, ability to compare visual and proprioceptive information, and capacity to recognize effects of self-movement. Secondly, it explores the possible association between these items with cognitive function, perceptual disorder (PD), and manual ability (Manual Ability Classification System -MACS).

METHODS

Ten subjects (7 female; 3 male) were tested with three protocols: the first one (A) explored sense of position, the second one (B) collimation between visual and proprioceptive information, and the last one (C) sense of agency with the use of videogames.

RESULTS

All subjects executed Protocol A without making any mistakes, while in Protocol B the median percentage of mistakes was 4.8%. Mistakes were recorded more frequently in positions characterized by wrist extension. Data reported a significant correlation with Processing Speed Index (PSI). Sense of agency was positively associated with cognitive functioning, with a significant correlation with PSI.PD, MACS, and Video-Gaming Experience (VGE) showed no correlation with Protocol C.

CONCLUSION

In the observed sample with diplegic CP, preliminary data support the hypothesis that there is an alteration of both sense of position and sense of agency. They were both associated to PSI, with a positive trend of correlation with cognitive functioning. PD seemed to have no influence. Further studies, with a larger sample size, a control group, and involving children without CP, are required to corroborate the results obtained.

Critical issue on the extinction and inattention subtest of NIHSS scale: an analysis on post-acute stroke patients attending inpatient rehabilitation

Objectives

This study aims to evaluate the diagnostic performance of NIHSS extinction and inattention item, compared to the results of the Oxford Cognitive Screen (OCS) heart subtest. Additionally, the possible role of the NIHSS visual field subtest on the NIHSS extinction and inattention subtest performance is explored and discussed.

Methods

We analysed scores on NIHSS extinction and inattention subtest, NIHSS visual field subtest, and OCS heart subtest on a sample of 118 post-stroke patients.

Results

Compared to OCS heart subtest, the results on NIHSS extinction and inattention subtest showed an accuracy of 72.9% and a moderate agreement level (Cohen’s kappa = 0.404). Furthermore, a decrease in NIHSS accuracy detecting neglect (61.1%) was observed in patients with pathological scores in NIHSS visual field item.

Conclusions

Extreme caution is recommended for the diagnostic performance of extinction and inattention item of NIHSS. Signs of neglect may not be detected by NIHSS, and may be confused with visual field impairment.

Trial registration

This study refers to an observational study protocol submitted to ClinicalTrials.gov with identifier: NCT03968627. The name of the registry is “Development of a National Protocol for Stroke Rehabilitation in a Multicenter Italian Institution” and the date of the registration is the 30th May 2019.

Leukocyte-derived ratios are associated with late-life any type dementia: a cross-sectional analysis of the Mugello study

Immunosenescence, vascular aging, and brain aging, all characterized by elevated levels of inflammatory markers, are thought to share a common pathogenetic pathway: inflamm-aging. Retrospective cross-sectional analysis was conducted using data from the Mugello study (Tuscany, Italy), a representative Italian cohort of free-living nonagenarians. to assess the association between specific peripheral inflammation markers derived from white blood cell counts, and the diagnosis of dementia. All the variables of interest were reported for 411 subjects (110 males and 301 females) out of 475 enrolled in the study. Anamnestic dementia diagnosis was obtained from clinical certificate and confirmed by a General Practitioner, whereas leukocyte ratios were directly calculated from white blood cell counts. Body mass index and comorbidities were considered potential confounders. Diagnosis of any type dementia was certified in 73 cases (17.8%). Subjects affected by dementia were older, more frequently reported a previous stroke, had lower body mass index, and lower Mini-Mental-State-Examination score. Moreover, they had a higher lymphocyte count and lymphocyte-to-monocyte ratio compared to the non-demented nonagenarians. We found that higher levels of lymphocyte counts are cross-sectionally associated with a clinical diagnosis of dementia. Furthermore, lymphocyte-to-monocyte ratio is directly associated with any type of dementia, independently of age, sex, lymphocyte count, and comorbidities. Lymphocyte-to-monocyte ratio may be considered a marker of immunological changes in the brain of dementia patients; moreover, it is low-cost, and easily available, thus enabling comparisons among different studies and populations, although the timeline and the extent of lymphocyte-to-monocyte ratio role in dementia development must be further investigated.

Data-driven prediction of decannulation probability and timing in patients with severe acquired brain injury

BACKGROUND AND OBJECTIVES

From a rehabilitation perspective, removal of tracheostomy in patients with severe acquired brain injuries (sABI) is a crucial step. Predictive parameters for a successful decannulation are currently still a focus of the research for sABI patients, especially for those presenting a disorder of consciousness. For this reason, we adopted a data-driven approach predicting decannulation probability and timing using ensemble learning models in patients in intensive rehabilitation units.

METHODS

327 patients, 186 of which were successfully decannulated during their intensive rehabilitative stay, were recruited in a non-concurrent retrospective study. Decannulation probability and timing were predicted using data available within one week from admission at the rehabilitation unit. Two predictive models were trained and cross-validated independently, with the first being an ensemble of a Support Vector Machine and Random Forests and the second an Adaptive Boosting with a Support Vector Regression as weak learner. Confusion matrix, accuracy and AUC were considered as evaluation metrics for the classifier and median absolute error was considered for the regressor. To quantify the advantages in the clinical practice of using the latter prediction, we compared timing estimation with a timing guess (median) calculated on available data. The comparison was based on a Wilcoxon signed rank test.

RESULTS

Decannulation probability was successfully predicted with an accuracy of 84.8% (AUC = 0.85) and timing with a median absolute error of 25.7 days [IQR = 25.6]. This resulted in a significant improvement with respect to the weaning time guess (p<0.05) with an effect size of 71.7%. Furthermore, dichotomizing the regression prediction with a threshold (3 months from the event), resulted in a prediction accuracy of 77.5% (AUC = 0.82) on the test set.

DISCUSSIONS

A model capable of providing a prediction on decannulation probability and timing was developed and cross-validated, built on data taken at admission to the intensive rehabilitation unit. Translated in clinical practice, this information can support the clinical decision process and provide a mean to improve both in-hospital and domiciliary care organization.

Impact of occupational complexity on cognitive decline in the oldest-old

OBJECTIVES

The theory of "Cognitive Reserve" assumes that premorbid factors such as high educational and occupational attainment may enable a better way of coping with brain damage. It has been suggested that more stimulating lifestyles, including more complex work environments, may provide a buffer against cognitive decline in later life. This study aimed to investigate the association between occupational history and cognitive decline in a large cohort of Italian oldest-old.

METHODS

392 individuals (266 women/126 men, mean age 93 ± 3 years) enrolled in the "Mugello study" provided information about their work history. Jobs were classified in nine categories, according to the level of expertise required to perform them, as suggested by the Italian National Institute for Statistics (ISTAT). In addition, socio-demographic characteristics, comorbidities, level of independence, depression, and cognitive status were assessed. The presence of dementia was established based on cognitive status and independence in performing four selected instrumental activities of daily living (ability to manage telephone, transportation, medications, and budget).

RESULTS

Neither work complexity (p = 0.995) nor work duration (p = 0.701) showed a significant effect on the likelihood of presenting a lower cognitive profile or developing dementia (p = 0.385 and p = 0.096, for work complexity and work duration, respectively).

CONCLUSION

In the observed sample of oldest-old individuals, cognitive decline did not seem to be influenced by cognitive reserve as assessed through the evaluation of cognitive status and level of independence. It is conceivable that in this population, the decline of the brain reserve has a preponderant role in the definition of the cognitive profile.

Diagnostic Validity of the Smart Aging Serious Game: An Innovative Tool for Digital Phenotyping of Mild Neurocognitive Disorder

BACKGROUND

The Smart Aging Serious Game (SASG) is an ecologically-based digital platform used in mild neurocognitive disorders. Considering the higher risk of developing dementia for mild cognitive impairment (MCI) and vascular cognitive impairment (VCI), their digital phenotyping is crucial. A new understanding of MCI and VCI aided by digital phenotyping with SASG will challenge current differential diagnosis and open the perspective of tailoring more personalized interventions.

OBJECTIVE

To confirm the validity of SASG in detecting MCI from healthy controls (HC) and to evaluate its diagnostic validity in differentiating between VCI and HC.

METHODS

161 subjects (74 HC: 37 males, 75.47±2.66 mean age; 60 MCI: 26 males, 74.20±5.02; 27 VCI: 13 males, 74.22±3.43) underwent a SASG session and a neuropsychological assessment (Montreal Cognitive Assessment (MoCA), Free and Cued Selective Reminding Test, Trail Making Test). A multi-modal statistical approach was used: receiver operating characteristic (ROC) curves comparison, random forest (RF), and logistic regression (LR) analysis.

RESULTS

SASG well captured the specific cognitive profiles of MCI and VCI, in line with the standard neuropsychological measures. ROC analyses revealed high diagnostic sensitivity and specificity of SASG and MoCA (AUCs > 0.800) in detecting VCI versus HC and MCI versus HC conditions. An acceptable to excellent classification accuracy was found for MCI and VCI (HC versus VCI; RF: 90%, LR: 91%. HC versus MCI; RF: 75%; LR: 87%).

CONCLUSION

SASG allows the early assessment of cognitive impairment through ecological tasks and potentially in a self-administered way. These features make this platform suitable for being considered a useful digital phenotyping tool, allowing a non-invasive and valid neuropsychological evaluation, with evident implications for future digital-health trails and rehabilitation.

Lipid and metabolite correlation networks specific to clinical and biochemical covariate show differences associated with sexual dimorphism in a cohort of nonagenarians

This study defines and estimates the metabolite-lipidic component association networks constructed from an array of 20 metabolites and 114 lipids identified and quantified via NMR spectroscopy in the serum of a cohort of 355 Italian nonagenarians and ultra-nonagenarian. Metabolite-lipid association networks were built for men and women and related to an array of 101 clinical and biochemical parameters, including the presence of diseases, bio-humoral parameters, familiarity diseases, drugs treatments, and risk factors. Different connectivity patterns were observed in lipids, branched chains amino acids, alanine, and ketone bodies, suggesting their association with the sex-related and sex-clinical condition-related intrinsic metabolic changes. Furthermore, our results demonstrate, using a holistic system biology approach, that the characterization of metabolic structures and their dynamic inter-connections is a promising tool to shed light on the dimorphic pathophysiological mechanisms of aging at the molecular level.

Development and implementation of a stroke rehabilitation integrated care pathway in an Italian no profit institution: an observational study

BACKGROUND

To standardize assessment and coordinate processes in stroke rehabilitation, an integrated care pathway (ICP) was developed in an Italian Rehabilitation and Research Institution by a knowledge-translation interdisciplinary process, from evidence-based guidelines to rehabilitation practice. The ICP was implemented in two pilot Tuscan rehabilitation Centers.

AIM

The purpose of this study was to describe ICP development and assess the ICP effects on postacute stroke inpatient rehabilitation outcomes.

DESIGN

Prospective observational study, before and after comparison.

SETTING

Two Tuscan inpatient rehabilitation centers.

POPULATION

Patients accessing either centers for intensive rehabilitation after acute stroke.

METHODS

Two cohorts were prospectively recruited before (2015-2017) and after (2018) implementation of the pathway. The primary outcome was change in activities of daily living disability, assessed by the modified Barthel Index (mBI) from admission to discharge. Secondary outcomes included length of stay (LOS), adverse outcomes, and changes in communication ability, trunk control, pain, ambulation, bladder catheter (Y/N), bedsores (Y/N).

RESULTS

In 2015-2017, 443 postacute stroke patients (mean age 77±11 years, 47% women), while in 2018, 84 patients (mean age 76±13 years, 61% women) were admitted to the two facilities. Comparing the 2018 vs. the 2015-17 cohort, the mean mBI increase was not substantially different (26 vs. 24 points), nor were LOS (37±18 vs. 36±16 days), adverse outcomes, discharge destination, and improvement of ambulation, pain, and communication (P>0.05). Instead, a significantly higher improvement of trunk control (trunk control test: 69.6±33.2 vs. 79.0±31.3, P=0.019), and a higher percentage of bedsore resolution (13% vs. 5%, P=0.033), and bladder catheter removal (37% vs. 17% P<0.001) were observed in 2018 vs. 2015-2017.

CONCLUSIONS

Compared to prior practice, ICP was associated to improvement of trunk control recovery, bladder catheter removal, and bedsores resolution. Further ICP implementation on a larger scale is needed to verify improvements of stroke inpatient rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An evidence-based stroke rehabilitation ICP was interdisciplinary developed and implemented in two rehabilitation centers of a multicenter Italian health group. ICP implementation as to inpatient intensive postacute stroke rehabilitation was associated to improved trunk control recovery, bladder catheter removal, and bedsore resolution. Further ICP implementation will allow multicenter studies and quality benchmarking.

Predictors of Function, Activity, and Participation of Stroke Patients Undergoing Intensive Rehabilitation: A Multicenter Prospective Observational Study Protocol

Background: The complex nature of stroke sequelae, the heterogeneity in rehabilitation pathways, and the lack of validated prediction models of rehabilitation outcomes challenge stroke rehabilitation quality assessment and clinical research. An integrated care pathway (ICP), defining a reproducible rehabilitation assessment and process, may provide a structured frame within investigated outcomes and individual predictors of response to treatment, including neurophysiological and neurogenetic biomarkers. Predictors may differ for different interventions, suggesting clues to personalize and optimize rehabilitation. To date, a large representative Italian cohort study focusing on individual variability of response to an evidence-based ICP is lacking, and predictors of individual response to rehabilitation are largely unexplored. This paper describes a multicenter study protocol to prospectively investigate outcomes and predictors of response to an evidence-based ICP in a large Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation.

Methods: All patients with diagnosis of ischemic or hemorrhagic stroke confirmed both by clinical and brain imaging evaluation, admitted to four intensive rehabilitation units (adopting the same stroke rehabilitation ICP) within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled (expected sample: 270 patients). Measures will be taken at admission (T0), at discharge (T1), and at follow-up 6 months after a stroke (T2), including clinical data, nutritional, functional, neurological, and neuropsychological measures, electroencephalography and motor evoked potentials, and analysis of neurogenetic biomarkers.

Statistics: In addition to classical multivariate logistic regression analysis, advanced machine learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.

Discussion: By identifying data-driven prognosis prediction models in stroke rehabilitation, this study might contribute to the development of patient-oriented therapy and to optimize rehabilitation outcomes.

Clinical Trial Registration:ClinicalTrials.gov, NCT03968627. https://www.clinicaltrials.gov/ct2/show/NCT03968627?term=Cecchi&cond=Stroke&draw=2&rank=2.

Maternal exposure to air pollutants, PCSK9 levels, fetal growth and gestational age - An Italian cohort

OBJECTIVE

Exposure to airborne pollutants during pregnancy appears to be associated with uterine growth restriction and adverse neonatal outcome. Proprotein convertase subtilisin/kexin type (PCSK9), the key modulator of low-density lipoprotein (LDL) metabolism, increases following particulate matter (PM₁₀) exposure. Because maternal cholesterol is required for fetal growth, PCSK9 levels could be used to evaluate the potential impact of airborne pollutants on fetal growth.

DESIGN

A cohort of 134 healthy women during early pregnancy (11-12 weeks of gestational age) was studied.

RESULTS

A significant association between circulating PCSK9 levels and three tested air pollutants (PM₁₀, PM_2.5, nitric oxide (NO₂)) was found. Of importance, gestational age at birth was reduced by approximately 1 week for each 100 ng/mL rise in circulating PCSK9 levels, an effect that became more significant at the highest quartile of PM_2.5 (with a 1.8 week advance in delivery date for every 100 ng/mL rise in circulating PCSK9; p for interaction = 0.026). This finding was supported by an elevation of the odds ratio for urgent cesarean delivery for each 100 ng/mL rise in PCSK9 (2.99, 95% CI, 1.22-6.57), similar trends being obtained for PM₁₀ and NO₂.

CONCLUSIONS

The association between exposure to air pollutants during pregnancy and elevation in PCSK9 advances our understanding of the unforeseen influences of environmental exposure in terms of pregnancy associated disorders.

Gender differences in post-stroke functional outcome at discharge from an intensive rehabilitation hospital

BACKGROUND

Gender differences in stroke functional recovery after rehabilitation are poorly investigated. Our aim was to compare functional outcomes at discharge from an intensive rehabilitation hospital after stroke in men and women, and to analyze their prognostic factors.

METHODS

Retrospective observational study of consecutive stroke patients discharged from an intensive neurological rehabilitation hospital, from January 2018 to June 2019. Modified Rankin Scale (mRS) at discharge was the main outcome measure.

RESULTS

Among the 208 included patients (mean age 73.4 ± 13.6 years), 105 (50.5%) were women. Women were significantly older (75.3 ± 13.8 vs. 71.4 ± 13.2 years, respectively, p = 0.041), and less often had a history of smoking habit (27% vs. 50%, p < 0.001). No gender differences emerged for vascular risk factors and comorbidities, pre-stroke functional status, length of hospital stay, stroke type, and number of clinical deficits. At admission to the rehabilitation hospital, mRS score distributions were not different (p = 0.795). At discharge, mRS score distributions and destinations did not differ between men and women (p = 0.391, p = 0.785, respectively). A significant interaction between gender and the change in mRS score from admission to discharge was found (F = 6.6, p = 0.011) taking into account age, stroke type, and number of initial clinical deficits. Dividing the cohort according to age, elderly women showed a better functional recovery compared to men.

CONCLUSIONS

At admission to an intensive rehabilitation hospital, men and women presented a similar functional and clinical status and a substantial overlap of functional recovery after stroke. At higher ages, the potential for recovery appeared better in women compared to men.

Comparison between Ischemic and Hemorrhagic Strokes in Functional Outcome at Discharge from an Intensive Rehabilitation Hospital

Comparison studies on recovery outcomes in ischemic (IS) and hemorrhagic strokes (HS) have yielded mixed results. In this retrospective observational study of consecutive IS and HS patients, we aimed at evaluating functional outcomes at discharge from an intensive rehabilitation hospital, comparing IS vs. HS, analyzing possible predictors. Modified Rankin Scale (mRS) at discharge was the main outcome. Out of the 229 patients included (mean age 72.9 ± 13.9 years, 48% males), 81 had HS (35%). Compared with IS (n = 148), HS patients were significantly younger (75 ± 12.5 vs. 68.8 ± 15.4 years, p = 0.002), required longer hospitalizations both in acute (23.9 ± 36.7 vs. 35.2 ± 29.9 days, p = 0.019) and rehabilitation hospitals (41.5 ± 31.8 vs. 77.2 ± 51.6 days, p = 0.001), and had more severe initial clinical deficit (mean number of neurological impairments: 2.0 ± 1.1 vs. 2.6 ± 1.4, p = 0.001) and mRS scores at admission (p = 0.046). At discharge, functional status change, expressed as mRS, was not significantly different between IS and HS (F = 0.01, p = 0.902), nor was the discharge destination (p = 0.428). Age and clinical severity were predictors of functional outcome in both stroke types. On admission in an intensive rehabilitation hospital, HS patients presented a worse functional and clinical status compared to IS. Despite this initial gap, the two stroke types showed an overlapped trajectory of functional recovery, with age and initial stroke severity as the main prognostic factors.

Critical illness polyneuromyopathy: Functional impact after severe acquired brain injuries

OBJECTIVES

Critical illness polyneuropathy and myopathy (CIPNM) frequently affects critical patients and can occur after severe acquired brain injuries (sABI) influencing the functional recovery. We aimed to assess how the concomitance between CIPNM and sABI might influence the rehabilitative outcomes in terms of functional autonomy, oral feeding recovery and endotracheal tube weaning.

MATERIALS AND METHODS

Adult patients with sABI admitted to an intensive rehabilitation unit and underwent an electromyography examination within seven days after admission were included. Assessed rehabilitative outcomes at discharge were decannulation success and its timing, functional autonomy measured by the Functional Independence Measure (FIM) and the Glasgow outcome scale expanded (GOS-E) and oral feeding recovery assessed by the Functional Oral Intake Scale (FOIS) score.

RESULTS

Among the 224 included patients (81 (36%) females, age (median[IQR]): 68.73[21.66] years), 119 (53.1%) presented CIPNM at admission. Albeit the change of rehabilitative outcomes between admission and discharge was significant in all the sABI patients (P < .001 for ΔFOIS, ΔFIM and ΔGOS-E), those with a concomitant CIPNM achieved significantly lower scores as evaluated by Mann-Whitney tests (P < .001 for ΔFIM Δ and GOS-E; P < .005 for ΔFOIS). The CIPNM absence was associated with a higher probability to achieve functional autonomy (GOS-E > 4) (OR:4.57 (1.49/14.06); P < .01) and oral feeding recovery (FOIS ≥ 4) (OR:2.07 (1.07/3.99); P = .03) at discharge. CIPNM presence did not influence decannulation success but a longer time to cannula weaning was required (P < .01 in the log-rank test).

CONCLUSIONS

CIPMN significantly affects the rehabilitative outcomes after a sABI and should be taken into account for better rehabilitative handling.