Infrared Thermography and Vascular Disorders in Diabetic Feet

AIM

Diabetes mellitus (DM) and related foot complications constitute a growing healthcare burden. Diabetes mellitus is associated with lower-limb amputation, but diabetic foot assessment is challenging. Here, we evaluated a novel noninvasive diagnostic method-infrared thermography (IRT) -assessing its diagnostic potential compared to conventional noninvasive measurements.

METHODS

This study included patients with DM (n = 118) and healthy controls (n = 93). All participants underwent ankle brachial index and toe pressure (TP) measurements, and IRT using a standardized protocol with temperature measurement at five foot areas.

RESULTS

Compared to controls, patients with DM generally had warmer feet and exhibited a significantly greater temperature difference between feet (P < .001). Mean temperatures were highest in patients with DM with neuroischemia, followed by neuropathy. Patients with DM with angiopathy showed the lowest mean temperature-similar to controls and noncomplicated diabetics. Mean temperatures at all measurement sites were significantly higher with abnormal TP (<50 mmHg) than normal TP (≥50 mmHg) (P < .001). Infrared thermography revealed differences between angiosome areas, subclinical infections, and plantar high-pressure areas.

CONCLUSION

Infrared thermography revealed local temperature differences in high-risk diabetic feet. Normal skin surface temperature varies between individuals, but in combination with other tools, IRT might be useful in clinical screening.

CLINICALTRIALS ID

14212016.

Peripheral perfusion of lower limb after transcatheter aortic valve implantation (TAVI) in patients with peripheral artery disease

BACKGROUND

In TAVI patients, peripheral arterial disease (PAD) is a common concomitant disease. Given the fact that calcified severe aortic stenosis (AS) limits the blood flow that reaches the periphery, it is conceivable that the treatment of AS may positively influence the peripheral perfusion.

AIM

To evaluate whether, and if so, how the peripheral perfusion changes after TAVI in patients with PAD comparing with patients without PAD.

METHODS

On the basis of objective vascular tests, peripheral perfusion in the lower extremities were studied in 108 TAVI patients with or without concomitant PAD.

RESULTS

108 consecutive patients with a median logistic EuroSCORE of 12.7 (IQR: 8.5 to 22.0) % underwent TAVI with an extensive pre- and post-procedural assessment of the peripheral perfusion. In patients without PAD, the time to peak flow (tPF) did not differ before (6.45 ± 5.24 s) and after (6.45 ± 5.91 s) TAVI (p = 1.000). In PAD patients, however, the tPF was significantly shortened following TAVI (9.51 ± 9.45 s vs. 8.33 ± 8.16 s, p < 0.001), thereby reflecting an improvement in peripheral blood flow. The resting arterial blood flow before and after TAVI showed the highest level at the beginning (0 s) and constantly decreased afterwards. No improvement in the peak flow was achieved.

CONCLUSIONS

In PAD patients, TAVI led to improved peripheral blood flow as reflected by shortened time to peak flow measurements.

Effects of huoxin formula on the arterial functions of patients with coronary heart disease

Context: Huoxin formula is a Traditional Chinese Medicine for coronary heart disease (CHD) treatment. Objective: To explore the therapeutic mechanism of the Huoxin formula on arterial functions in CHD patients. Materials and methods: Fifty-eight CHD patients receiving cardiovascular drugs including β-receptor blocker, statins, and antiplatelet medications or others were randomized into intervention [additionally 13.5 g Huoxin formula granules dissolved in 150 mL warm water per time, twice a day (n = 30)] and control [only cardiovascular drugs (n = 28)] groups. Serum biomarkers (hs-CRP, IL-18, IL-17, TNF-α, MMP-9), and cardiovascular indicators of the common and internal carotid arteries (ICAs) were monitored before and after the treatments. Results: After 3 months of treatment, the increases of intima-media thicknesses (IMT) of the left and right common carotid arteries (CCAs) as well as of the left and right ICAs and the increases of the left and right cardio-ankle vascular index were all significantly (all p < 0.001) less in the intervention than in control group (all p < 0.001). Serum concentrations reductions of hs-CRP, IL-18, IL-17 and MMP9 (all p < 0.001) levels were higher in the intervention compared to the control group, which correlated with the changes of left ICA (hs-CRP: r = 0.581, p = 0.009; IL-18: r = 0.594, p = 0.007; IL-17: r = 0.575, p = 0.006). Discussion and conclusion: Since the Huoxin formula improved arterial functions and reduced inflammatory factor activities in CHD patients, a large-scale clinical trial is warranted.

Clinical examination of peripheral arterial disease and ankle-brachial index in a nationwide cohort of older subjects: practical implications

BACKGROUND

Prevalence of peripheral arterial disease increases with age and is related to increased morbidity and mortality. The clinical diagnosis includes the measurement of ankle-brachial index (ABI).

AIMS

To check the prevalence of abnormal ABI, and the value of physical examination of arterial system in detection of ABI < 0.9.

METHODS

We performed subgroup analysis of patients included in the PolSenior survey. We measured ABI, performed physical examination of arterial system, assessed laboratory and questionnaire factors related to atherosclerosis. Participants were divided according to ABI strata of < 0.9, 0.9-1.4 and > 1.4. Clinical score of abnormalities on physical examination was proposed. Using logistic regression, we obtained areas under the curve (AUC).

RESULTS

The mean age of 844 participants (53.3% men) was 74.7 (10.6) years. ABI < 0.9 was found in 20.3% participants and it was linked to history of myocardial infarction, hypertension and renal failure. In the entire group, 72.4% of subjects declared, that they were able to walk a distance of 200 m without interruption. Higher clinical score was associated with lower ABI. Full physical examination (AUC = 0.67) followed by examination of lower extremities (AUC = 0.65) showed strongest diagnostic value for PAD based on ABI. Neither ABI nor clinical examination was a good predictor of the inability to walk 200 meters without difficulties.

DISCUSSION/CONCLUSIONS

Full clinical examination, only moderately, adds to detection of PAD. The ability to walk 200 m is not a good measure of PAD in older subjects.

Effect of anesthesia on evoked auditory responses in pediatric auditory brainstem implant surgery

OBJECTIVE

Electrically evoked auditory brainstem responses (EABR) guide placement of the multichannel auditory brainstem implant (ABI) array during surgery. EABRs are also recorded under anesthesia in nontumor pediatric ABI recipients prior to device activation to confirm placement and guide device programming. We examine the influence of anesthesia on evoked response morphology in pediatric ABI users by comparing intraoperative with postoperative EABR recordings.

STUDY DESIGN

Retrospective review.

METHODS

Seven children underwent ABI surgery by way of retrosigmoid craniotomy. General anesthesia included inhaled sevoflurane induction and propofol maintenance during which EABRs were recorded to confirm accurate positioning of the ABI. A mean of 7.7 ± 2.8 weeks following surgery, the ABI was activated under general anesthesia or sedation (dexmedetomidine) and EABR recordings were made. A qualitative analysis of intraoperative and postoperative waveform morphology was performed.

RESULTS

Seven subjects (mean age 20.6 months) underwent nine ABI surgeries (seven primary, two revisions) and nine activations. EABRs were observed in eight of nine postoperative recordings. In three cases, intraoperative EABRs during general anesthesia were similar to postoperative EABRs with sedation. In one case, sevoflurane and propofol were used for intra- and postoperative recordings, and waveforms were also similar. In four cases, amplitude and latency changes were observed for intraoperative versus postoperative EABRs.

CONCLUSION

Similarity of EABR morphology in the anesthetized versus sedated condition suggests that anesthesia does not have a large effect on far-field evoked potentials. Changes in EABR waveform morphology observed postoperatively may be influenced by other factors such as movements of the surface array.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:507-513, 2020.

Auditory brainstem stimulation with a conformable microfabricated array elicits responses with tonotopically organized components

Auditory brainstem implants (ABIs) restore hearing to deaf individuals not eligible for cochlear implants. Speech comprehension in ABI users is generally poor compared to that of cochlear implant users, and side effects are common. The poor performance may result from activating broad areas and multiple neuronal populations of the cochlear nucleus, however detailed studies of the responses to surface stimulation of the cochlear nucleus are lacking. A conformable electrode array was microfabricated to fit on the rat's dorsal cochlear nucleus (DCN). It hosts 20 small electrodes (each 100 μm diam.). The array was tested by recording evoked potentials and neural activity along the tonotopic axis of the inferior colliculus (IC). Almost all bipolar electrode pairs elicited responses, in some cases with an even, or relatively constant, pattern of thresholds and supra-threshold measures along the long axis of the array. This pattern suggests that conformable arrays can provide relatively constant excitation along the surface of the DCN and thus might decrease the ABI side effects caused by spread of high current to adjacent structures. We also examined tonotopic patterns of the IC responses. Compared to sound-evoked responses, electrically-evoked response mappings had less tonotopic organization and were broader in width. They became more tonotopic when the evoked activity common to all electrodes and the late phase of response were subtracted out, perhaps because the remaining activity is from tonotopically organized principal cells of the DCN. Responses became less tonotopic when inter-electrode distance was increased from 400 μm to 800 μm but were relatively unaffected by changing to monopolar stimulation. The results illustrate the challenges of using a surface array to present tonotopic cues and improve speech comprehension in humans who use the ABI.

Four-Limb Blood Pressure Measurement with an Oscillometric Device: a Tool for Diagnosing Peripheral Vascular Disease

PURPOSE OF REVIEW

Traditionally, the term peripheral vascular disease (PAD) is restricted to the occlusive arterial disease in the leg, but now, the connotation of PAD is more widespread as it encompasses all extracoronary and extracerebral vascular disease. The incidence of PAD is increasing worldwide; therefore, it is necessary to diagnose PAD at an early stage.

RECENT FINDINGS

Oscillometric BP device is widely used for four-limb measurement in clinical practice and provides several parameters for evaluating inter-limb BP difference, such as ankle-brachial index (OS-ABI), inter-arm BP differences (IAD), and inter-ankle BP difference (IAND). Using angiographic results as reference, the ABI, IAD, and IAND from an oscillometric BP device have been demonstrated having high accuracy for diagnosis of PAD. Meanwhile, combination of these parameters could further improve the accuracy of PAD, including the occlusive artery disease in the arm, leg, and aorta. For example, some patients with severe PAD in the leg have normal ABI; in this situation, an increased sIAND could confirm the diagnosis of PAD in the leg. Because ABI, IAD, and IAND from inter-limb oscillometric BP measurement can also predict adverse prognosis, we encourage the use of an oscillometric device to measure four-limb BP and to evaluate the inter-limb BP difference.

Gender, subclinical organ damage and cardiovascular risk stratification in hypertensive patients

BACKGROUND

The aims of the study were to assess subclinical organ damage in men and women with hypertension and its subsequent effect on cardiovascular risk, and use of new statistical methods for more precise estimation of cardiovascular risk using vascular cardiovascular risk factors: ankle-brachial index (ABI), intima-media thickness (IMT) and pulse wave velocity (PWV).

METHODS

We studied 200 patients: 100 hypertensive and 100 normotensive. The parameters we evaluated included: patient age, ABI, IMT, PWV, serum uric acid and serum C-reactive protein (CRP). In addition, the cardiovascular risk according to the SCORE and Framingham scales was assessed.

RESULTS

In the hypertensive group, there were significant correlations between ABI and the Framingham scale in both sexes. In hypertensive women, there were also significant correlations between IMT and the SCORE scale risk, and IMT and the Framingham scale risk. In normotensive women, there were significant correlations between ABI and the SCORE scale risk, and between ABI and the Framingham scale risk. In normotensive men, there were significant correlations between PWV and the SCORE scale risk, and between PWV and the Framingham scale risk. Lastly, in the group of normotensive men, there were significant correlations between IMT and the SCORE scale risk, and IMT and the Framingham scale risk. The possibility of correctly classifying a patient into the high-risk category by a logistic regression model using synchronous ABI, IMT and PWV was high - 74% for the risk according to the SCORE scale (66% in men, 88% in women), and 98% for the Framingham scale.

CONCLUSIONS

The addition of recognized subclinical target organ damage tests to the estimation of cardiovascular risk can significantly strengthen the prevention of cardiovascular disease. Cardiovascular risk estimation follow-up with ABI, PWV and IMT increased the probability of correctly classifying people, especially women, into an at least high-risk category according to the SCORE scale, which has valuable therapeutic implications.

Long-term effects of air pollution on ankle-brachial index

BACKGROUND

Ankle-brachial index (ABI) has been linked to the risk of cardiovascular events. However, the association between long-term exposure to air pollution and abnormal ABI has not been fully investigated.

METHODS

This cross-sectional study involved 4544 participants from the KORA Study (2004-2008) in the region of Augsburg, Germany. Participants' residential annual mean concentrations of particulate matter (PM) and nitrogen dioxide (NO₂) were predicted with land-use regression models, and the traffic information was collected from geographic information systems. We applied multinomial logistic regression models to assess the effects of air pollution on the prevalence of low and high ABI, and quantile regression models to explore the non-monotonic relationship between air pollution and ABI. We also examined effect modification by individual characteristics.

RESULTS

Long-term exposure to PM with an aerodynamic diameter ≤ 10 μm (PM₁₀) and ≤ 2.5 μm (PM_2.5) was significantly associated with a higher prevalence of low ABI, with the respective odds ratios (ORs) of 1.82 (95%CI: 1.11-2.97) and 1.59 (95%CI: 1.01-2.51) for a 5th to 95th percentile increment in pollutants. Positive associations with the prevalence of high ABI were observed for PM (e.g., PM₁₀: OR = 1.63, 95%CI: 1.07-2.50) and NO₂ (OR = 1.84, 95%CI: 1.15-2.94). Quantile regression analyses revealed similar non-monotonic results. The effects of air pollution on having abnormal ABI were stronger in physically inactive, hypertensive, or non-diabetic participants.

CONCLUSIONS

Long-term exposure to PM and NO₂ was associated with a higher prevalence of both low and high ABI, indicating the adverse effects of air pollution on atherosclerosis and arterial stiffness in the lower extremities.

A high ankle-brachial index is associated with obesity and low serum 25-hydroxyvitamin D in patients with diabetes

Peripheral artery disease (PAD), when present with diabetes, is associated with significant morbidity and mortality. The spectrum of PAD in diabetes includes atherosclerosis with stenotic disease; and diffuse medial calcification with non-compliant arteries, as reflected by high ankle brachial index. The clinical characteristics of a high ABI are less well characterized than that of low ABI.

The aim of this study was to determine the unique clinical phenotype of patients with diabetes who have high ankle brachial index (ABI) reading. We performed a cross sectional observational study including 360 patients. Subjects were grouped according to normal (≥ 0.8 ≤ 1.3), low (<0.8) or high ABI (>1.3) result. Subjects with high ABI were characterised by higher BMI, higher waist/height ratio (WHtR), and lower serum lower vitamin D. Although reduced renal function and neuropathy was present more frequently in those with high ABI, this was also the case in those with low ABI. Similarly to those with low ABI result, a high ABI result was associated with increased risk of diabetic foot complications including amputation. When adjusted for known risk factors for PAD, higher WHtR and lower vitamin D were significant predictors of high ABI. These results suggest an association between increased WHtR and low vitamin D with high ABI; whether there is a causal relationship requires further exploration.

The Relationships of the Fractional Excretion of Uric Acid with Brachial-Ankle Pulse Wave Velocity and Ankle Brachial Index in Chinese Young Adults

BACKGROUND/AIMS

Elevated serum uric acid (UA) was intimately correlated with vascular stiffness and abnormal ankle brachial index (ABI) in various populations. These correlations lost significance after adjustment for estimated glomerular filtration rate (eGFR), indicating that the association of UA and brachial-ankle pulse wave velocity (baPWV) or ABI might be driven by kidney function. UA is predominantly eliminated through the kidneys, and metabolic disorders can influence the clearance of UA. In this study, we aimed to explore the putative correlation between FEUA and baPWV or ABI to determine to what extent the associations with UA were affected by renal function.

METHODS

This cross-sectional study enrolled 2351 participants, who underwent general health screening in Hanzhong people's hospital from March to June of 2017. BaPWV and ABI were measured using a volume-plethysmographic apparatus (BP-203RPEII; Nihon Colin, Tokyo, Japan). FEUA was divided into quartiles: Q1:FEUA≤3.07; Q2: 3.07<FEUA≤5.32; Q3: 5.32<FEUA≤9.19; and Q4: FEUA> 9.19.

RESULTS

Lower FEUA predicted a higher prevalence of high baPWV and low ABI (p for trend <0.001). The respective ORs for high baPWV from the first to the third quartiles of FEUA were 1.777(1.323, 2.387); 1.561(1.158, 2.104); and 1.680 (1.250, 2.259). The prevalence of low ABI was greatly elevated with the decrement of FEUA [ORs for the first to third FEUA quartiles were 6.977(2.062, 23.610); 5.123(1.475, 17.790); and 2.685(0.709, 10.171), respectively]. The association of FEUA and ABI was independent of related confounding factors. However, the association between FEUA and baPWV was greatly influenced by corresponding confounders, especially gender. The efficacy of FEUA in the prediction of low ABI was stronger than that of serum UA. However, serum UA was more powerful in the prediction of high baPWV.

CONCLUSION

Kidney function exerted a profound influence on the relationship between UA and baPWV or ABI, revealing complex interactions among cardiovascular risk factors.

Ankle brachial index and cognitive function among Hispanics/Latinos: Results from the Hispanic Community Health Study/Study of Latinos

BACKGROUND AND AIMS

The Ankle-Brachial index (ABI) is a well-accepted measure of peripheral artery disease (arterial stenosis and stiffness) and has been shown to be associated with cognitive function and disorders; however, these associations have not been examined in Hispanics/Latinos. Therefore, we sought to examine relationships between ABI and cognitive function among diverse middle-age and older Hispanics/Latinos.

METHODS

We used cross-sectional data on n = 7991 participants aged 45-74 years, without stroke or coronary heart disease, from the Hispanic Community Health Study/Study of Latinos. Our primary outcome, global cognition (GC), was a continuous composite score of four cognitive domains (verbal learning and memory, verbal fluency, executive function, and mental status). Secondary outcomes were the individual tests representing these domains. The ABI was analyzed continuously and categorically with standard clinical cut-points. We tested associations using generalized survey regression models incrementally adjusting for confounding factors. Age, sex, hypertension, diabetes, and dyslipidemia moderations were examined through interactions with the primary exposure.

RESULTS

In age, sex, and education adjusted models, continuous ABI had an inverse u-shape association with worse GC. We found similar associations with measures of verbal learning and memory, verbal fluency, executive function, but not with low mental status. The associations were attenuated, but not completely explained, by accounting for the confounders and not modified by age, sex, education, and vascular disease risks.

CONCLUSIONS

In addition to being a robust indicator of arterial compromise, our study suggests that abnormal ABI readings may also be useful for early signaling of subtle cognitive deficits.

The importance of community screening of asymptomatic elderly for peripheral arterial disease by Doppler ultrasound and ankle-brachial index

Background

Peripheral arterial disease is an atherosclerotic disease characterized by an increase in morbidity and mortality. For these reasons early diagnosis of peripheral arterial disease is important. Ankle-brachial systolic pressure index measurement is frequently used in screening studies. Evaluating waveforms of distal lower extremities with Doppler ultrasound can be used as a screening program and provides more accurate information on peripheral arterial disease.

Aim

We investigate the prevalence of peripheral arterial disease, compare the efficacy of Doppler ultrasound evaluation of distal lower extremity waveforms and ankle-brachial systolic pressure index measurement in screening programs, and discuss the importance of early diagnosis of asymptomatic cases.

Material and methods

A total of 457 patients over the age of 65 (between 65 and 94, mean age: 71.4) including 270 males and 187 females were examined with Doppler ultrasound, had ankle-brachial systolic pressure index measurement taken and were screened for peripheral arterial disease. The correlation between Doppler ultrasound findings and ankle-brachial systolic pressure index was examined.

Results

According to the Doppler ultrasound findings, in the aortoiliac (r = 0.648) and femoropopliteal (r = 0.564) area, there is a medium level of correlation between severe stenosis and occlusions and a low ankle-brachial systolic pressure index value, and a low level of correlation between such abnormalities in the tibioperoneal region (r = 0.116) and a low ankle-brachial systolic pressure index value. Therefore, while the sensitivity of ankle-brachial systolic pressure index increases in proximal stenosis, it decreases in distal stenosis.

Conclusion

Despite the fact that ankle-brachial systolic pressure index is a diagnostic test commonly used in screening studies, evaluation of distal arteries by means of Doppler ultrasound provides more accurate information in terms of the identification of peripheral arterial disease.

Evaluation of a computer-based prompting intervention to improve essay writing in undergraduates with cognitive impairment after acquired brain injury

This study evaluated a computer-based prompting intervention for improving expository essay writing after acquired brain injury (ABI). Four undergraduate participants aged 18-21 with mild-moderate ABI and impaired fluid cognition at least 6 months post-injury reported difficulty with the writing process after injury. The study employed a non-concurrent multiple probe across participants, in a single-case design. Outcome measures included essay quality scores and number of revisions to writing counted then coded by type using a revision taxonomy. An inter-scorer agreement procedure was completed for quality scores for 50% of essays, with data indicating that agreement exceeded a goal of 85%. Visual analysis of results showed increased essay quality for all participants in intervention phase compared with baseline, maintained 1 week after. Statistical analyses showed statistically significant results for two of the four participants. The authors discuss external cuing for self-monitoring and tapping of existing writing knowledge as possible explanations for improvement. The study provides preliminary evidence that computer-based prompting has potential to improve writing quality for undergraduates with ABI.

A summary on the effectiveness of the Amsterdam memory and attention training for children (Amat-c) in children with brain injury

OBJECTIVE

To summarise the current research on the effectiveness of the Amsterdam Memory and Attention Training for Children (Amat-c).

METHODS

A literature search was conducted to find articles published about the Amat-c, using PubMed, psychINFO, and PsychBITE databases. Relevant search terms included Amat-c, attention and memory, and childhood ABI.

RESULTS

Our literature search identified 7 articles that described 5 separate studies including 61 children in total (mostly TBI). Only one study had a control group. All results indicated positive effects on memory and attention, although in three of the studies, these results were not statistically tested. Positive results were generally maintained six months follow up.

CONCLUSIONS

This review showed that the Amat-c is effective for treating attention and memory disturbances in children with ABI. However, evidence is limited and training material is outdated. We suggest that the Amat-c should be digitised and implemented in a school setting and further evaluated.

The value of intraoperative EABRs in auditory brainstem implantation

OBJECTIVE

To compare the intraoperative electrically evoked auditory brainstem response (EABR) morphologies between neurofibromatosis II (NF2) adult auditory brainstem implant (ABI) recipients who had auditory percepts post-operatively and those who did not and between NF2 adult ABI recipients and non-NF2 pediatric ABI recipients.

METHODS

This was a retrospective case series at a single tertiary academic referral center examining all ABI recipients from 1994 to 2016, which included 34 NF2 adults and 11 non-NF2 children. The morphologies of intraoperative EABRs were evaluated for the number of waveforms showing a response, the number of positive peaks in those responses, and the latencies of each of these peaks.

RESULTS

27/34 adult NF2 patients and 9/10 children had EABR waveforms. 20/27 (74.0%) of the adult patients and all of the children had ABI devices that stimulated post-operatively. When comparing the waveforms between adults who stimulated and those who did not stimulate, the proportion of total number of intraoperative EABR peaks to total possible peaks was significantly higher for the adults who stimulated than for those who did not (p < 0.05). Children had a significantly higher proportion of total number of peaks to total possible peaks when compared to adults who stimulated (p < 0.02). Additionally, there were more likely to be EABR responses at the initial stimulation than intraoperatively in the pediatric ABI population (p = 0.065).

CONCLUSIONS

The value of intraoperative EABR tracing may lie in its ability to predict post-operative auditory percepts based on the placement of the array providing the highest number of total peaks.

Matrix-assisted laser desorption-ionization-time-of-flight mass spectrometry as a reliable proteomic method for characterization of Escherichia coli and Salmonella isolates

Aim:

Identification of pathogenic clinical bacterial isolates is mainly dependent on phenotypic and genotypic characteristics of the microorganisms. These conventional methods are costive, time-consuming, and need special skills and training. An alternative, mass spectral (proteomics) analysis method for identification of clinical bacterial isolates has been recognized as a rapid, reliable, and economical method for identification. This study was aimed to evaluate and compare the performance, sensitivity and reliability of traditional bacteriology, phenotypic methods and matrix-assisted laser desorption-ionization-time-of-flight mass spectrometry (MALDI-TOF MS) in the identification of clinical Escherichia coli and Salmonella isolates recovered from chickens.

Materials and Methods:

A total of 110 samples (cloacal, liver, spleen, and/or gall bladder) were collected from apparently healthy and diseased chickens showing clinical signs as white chalky diarrhea, pasty vent, and decrease egg production as well as freshly dead chickens which showing postmortem lesions as enlarged liver with congestion and enlarged gall bladder from different poultry farms.

Results:

Depending on colonial characteristics and morphological characteristics, E. coli and Salmonella isolates were recovered and detected in only 42 and 35 samples, respectively. Biochemical identification using API 20E identification system revealed that the suspected E. coli isolates were 33 out of 42 of colonial and morphological identified E. coli isolates where Salmonella isolates were represented by 26 out of 35 of colonial and morphological identified Salmonella isolates. Serological identification of isolates revealed that the most predominant E. coli serotypes were O1 and O78 while the most predominant Salmonella serotype of Salmonella was Salmonella Pullorum. All E. coli and Salmonella isolates were examined using MALDI-TOF MS. In agreement with traditional identification, MADI-TOF MS identified all clinical bacterial samples with valid scores as E. coli and Salmonella isolates except two E. coli isolates recovered from apparently healthy and diseased birds, respectively, with recovery rate of 93.9% and 2 Salmonella isolates recovered from apparently healthy and dead birds, respectively, with recovery rate of 92.3%.

Conclusion:

Our study demonstrated that Bruker MALDI-TOF MS Biotyper is a reliable rapid and economic tool for the identification of Gram-negative bacteria especially E. coli and Salmonella which could be used as an alternative diagnostic tool for routine identification and differentiation of clinical isolates in the bacteriological laboratory. MALDI-TOF MS need more validation and verification and more study on the performance of direct colony and extraction methods to detect the most sensitive one and also need using more samples to detect sensitivity, reliability, and performance of this type of bacterial identification.

The NCK and ABI adaptor genes in catfish and their involvement in ESC disease response

Adaptor proteins non-catalytic region of tyrosine kinase (NCK) and Abelson interactor (ABI) are crucial for disease response. NCK1 was identified to be a candidate gene for enteric septicemia of catfish (ESC) disease resistance, and was speculated to play similar roles during ESC and enteropathogenic Escherichia coli (EPEC) pathogenicity. ABI1 was reported as a positional candidate gene for bacterial cold water disease (BCWD) resistance in rainbow trout. In this study, three NCK genes and six ABI genes were identified in the channel catfish (Ictalurus punctatus) genome and blue catfish (I. furcatus) transcriptome, and annotated by domain structures, phylogenetic and syntenic analyses. Their expression patterns were examined in the intestine and liver of catfish after challenge with Edwardsiella ictaluri. In the intestine, NCK1, ABI2a, ABI2b, ABI3a were differentially expressed after E. ictaluri infection. In the liver, NCK2a, NCK2b, ABI1b, ABI2a, ABI2b were significantly upregulated in ESC susceptible fish. In general, the NCK and ABI genes, with exception of ABI3a gene and NCK1 gene, were expressed at higher levels in susceptible fish after infection than in control fish, but were expressed at lower levels in resistant fish than in the control fish. Taken together, these results support the notion that NCK and ABI genes are involved in disease processes facilitating pathogenesis of the E. ictaluri bacteria.

A study of the VaSera arterial stiffness device in US patients

The cardio-ankle vascular index (CAVI) represents a promising index of arterial stiffness. However, neither the CAVI measure nor its measurement device, the VaSera, have undergone general testing in a North American clinical setting. To begin the process of collecting normal values in the United States, we studied 20 male and 28 female volunteers without reported cardiovascular or renal disease and no history of smoking. Their CAVIs, ankle-brachial indices (ABIs), and four-limb blood pressures were measured in three positions: supine, 7° Trendelenburg, and 7° reverse Trendelenburg. In addition, the ABI function was validated against an established ABI measurement technique. Position was found to affect CAVI and other hemodynamic parameters, indicating that CAVI is not robust to slight positional variations. No differences were found in the blood pressure between arms or legs (interbrachial or interankle), supporting recent findings from meta-analyses and studies but contradicting other work. This study represents an early step in bringing the VaSera device and its CAVI measurement into clinical practice.

Longitudinal recovery of local neuronal activity and consciousness level in acquired brain injury

Decreased brain activity in the default mode network, particularly in the precuneus (PCU), has been consistently shown in acquired brain injury (ABI) patients. However, it is unclear whether resting-state brain activity recovers longitudinally in ABI patients and whether functional activity restoration is associated with improvements in consciousness level. Here, resting-state fMRI data were acquired from 23 ABI patients and 30 age- and gender-matched controls with two longitudinal observations for each participant. The fMRI data were analyzed using amplitude of low-frequency fluctuation (ALFF) to measure the fluctuation strength of local spontaneous activity, and seed-based functional connectivity was used to measure functional relationship with the seed region in the whole brain. The level of consciousness was assessed using the Glasgow Coma Scale (GCS) and Coma Recovery Scale-Revised (CRS-R) on both scanning days of the patients. Interaction effect between the two groups and two scans in ALFF was observed in the PCU, which was driven by restored ALFF in the ABI, while a stable ALFF in the control group. Moreover, restoration of ALFF in the PCU correlated with improvements in both the CRS-R and GCS. Specifically, recovery of ALFF in the PCU primarily reflected the signals of the slow-4 frequency band (0.027-0.073 Hz). Based on the functional connectivity maps of the PCU, we observed a nonsignificant interaction effect or correlation with consciousness level. These findings suggest local activity in the PCU but possibly not its functional connectivity, is related to the longitudinal changes in behavioral responsiveness in ABI. Hum Brain Mapp 38:3579-3591, 2017. © 2017 Wiley Periodicals, Inc.

Correlating the relationship between interarm systolic blood pressure and cardiovascular disease risk factors

Interarm systolic blood pressure difference (IASBPD) can predict cardiovascular disease. To investigate the relationship between IASBPD and cardiovascular disease risk factors, a total of 1426 individuals were studied. Blood pressure was assessed simultaneously and IASBPD was expressed as the absolute difference value (|R-L|). Cardiovascular disease risk factors were compared between the high IASBPD group (IASBPD ≥10 mm Hg) and the normal IASBPD group (IASBPD <10 mm Hg). An increased prevalence of hypertension, body mass index, and systolic and diastolic blood pressure were observed in the high IASBPD group (P<.05), associated with the enhanced mean values of intima-media thickness and maximum intima-media thickness (P<.05). Brachial-ankle pulse wave velocity was increased, while ankle-brachial index was lower in the high IASBPD group (P<.05). Multivariate logistic regression analysis revealed that IASBPD ≥10 mm Hg was positively associated with body mass index (odds ratio, 1.077; P=.002) and systolic blood pressure (odds ratio, 1.032; P<.001), and negatively associated with ankle-brachial index (odds ratio, 0.038; P<.001).

Toe Pressure and Toe Brachial Index are Predictive of Cardiovascular Mortality, Overall Mortality, and Amputation Free Survival in Patients with Peripheral Artery Disease

OBJECTIVE/BACKGROUND

Peripheral haemodynamic parameters are used to assess the presence and severity of peripheral artery disease (PAD). The prognostic value of ankle brachial index (ABI) has been thoroughly delineated. Nonetheless, the relative usefulness of ankle pressure (AP), ABI, toe pressure (TP), and toe brachial index (TBI) in assessing patient outcome has not been investigated in a concurrent study setting. This study aimed to resolve the association of all four non-invasive haemodynamic parameters in clinically symptomatic patients with PAD with cardiovascular mortality, overall mortality, and amputation free survival (AFS).

METHODS

In total, 732 symptomatic patients with PAD admitted to the Department of Vascular Surgery for conventional angiography at Turku University Hospital, Turku, Finland, between January 2009 and August 2011 were reviewed retrospectively. Demographic factors, cardiovascular mortality, all-cause mortality, and above foot level amputations were obtained and assessed in relation to AP, ABI, TP, and TBI by means of Kaplan-Meier life tables and a multivariate Cox regression model.

RESULTS

The haemodynamic parameter that was associated with poor 36 month general outcome was TP < 30 mmHg. Univariate Cox regression analysis of stratified values showed that TP and TBI associated significantly with mortality. In multivariate analysis both TP and TBI were associated with a significant risk of death. For TP < 30 mmHg and TBI < 0.25 the risk of cardiovascular mortality was hazard ratio [HR] 2.84, 95% confidence interval [CI] 1.75-4.61 [p<.001]; HR 3.68, 95% CI 1.48-9.19 [p=.050], respectively; all-cause mortality (HR 2.05, 95% CI 1.44-2.92 [p<.001]; HR 2.53, 95% CI 1.35-4.74 [p=.040], respectively); and amputation or death (HR 2.13, 95% CI 1.52-2.98 [p<.001]; HR 2.46, 95% CI 1.38-4.40 [p=.050], respectively)...

CONCLUSION

Among non-invasive haemodynamic measurements and pressure indices both TP and TBI appear to be associated with cardiovascular and overall mortality and AFS for patients with PAD presenting symptoms of the disease.

Framework for assessment of children's social competence, with particular focus on children with brain injuries

Children's social competence is important for their general wellbeing and life satisfaction. Often it is an area identified as problematic for children brought to the attention of a psychologist, particularly for children with brain injuries. However, it can be difficult to pin down exactly where social difficulties lie, and therefore how best to help. The current article draws together the literature on social competence from brain injury and from more general developmental research. A hierarchical model is presented with three layers: social adjustment, social functioning, and social cognition. Additional factors likely to be relevant for children with brain injuries are noted. This framework can be used to guide psychologists' casework around social competence, aiming to provide a practical and coherent structure for assessment that can then support formulation, person centred planning, and tailored interventions.

Assessing psychosocial functioning following childhood acquired brain injury: The Sydney Psychosocial Reintegration Scale for Children

OBJECTIVE

The Sydney Psychosocial Reintegration Scale for Children (SPRS-C) assesses psychosocial functioning in children with acquired brain injury (ABI). This article aims to: (1) describe normative data for the parent-rated SPRS-C and, (2) evaluate the discriminant validity of the SPRS-C.

METHODS

For Aim 1, participants were parents of typically developing children (TDC) aged 5-14 years (N = 200). For Aim 2, participants with ABI were aged 5-14 years (n = 26). A matched group of TDC was sampled from the larger normative sample to serve as a control group (n = 26).

RESULTS

For Aim 1, SPRS-C scores across the 10 age-bands were in the higher ranges. Correlation coefficients of SPRS-C total score with child's age and parent occupational skill level were not statistically significant. For Aim 2, SPRS-C scores for the ABI group were significantly lower than the control group.

CONCLUSIONS

These data provide a guide for clinical interpretation of the SPRS-C for measuring psychosocial functioning in children with ABI.

Prevalence of abdominal aortic aneurysms and its relation with cardiovascular risk stratification: protocol of the Risk of Cardiovascular diseases and abdominal aortic Aneurysm in Varese (RoCAV) population based study

BACKGROUND

Recent meta-analyses suggested that screening program for abdominal aortic aneurysms (AAA) in 65-year old males is cost-effective at prevalence of about 1%. Since some events occur also in females and among the youngers, screening could be feasible among those at higher risk, such as smokers or individuals with a family history of AAA. The RoCAV (Risk of Cardiovascular diseases and abdominal aortic Aneurysms in Varese) Project is a population-based study aimed to evaluate AAA prevalence in Northern Italy in males over-65 years as well as among females and younger males, and to identify new markers for risk stratification by collecting a large set of CVD risk factors. The aims of the project are: (i) cross-sectional evaluation of AAA prevalence (ii); evaluation of standard CVD risk score as criteria for selecting subgroup at higher risk to be included in a screening program; (iii) identification of new risk markers and risk score algorithm for AAA and CVD risk stratification; (iv) cost-effective evaluation during the follow-up.

METHODS

Males aged 50-75 years and females aged 60-75 years, resident in the city of Varese (Lombardy Region), were randomly selected from the civil registry. Among 5198 successfully invited, 3777 subjects accepted to participate and were finally recruited (participation rate 63.8%) from June 2013 to May 2016. Trained operators administered a computerized anamnestic questionnaire, measured anthropometric parameters (BMI, body circumferences, skinfolds), blood pressure, ankle-brachial index, pulse wave velocity and performed abdominal aortic ultrasound scan, ECG and spirometry. All methods were internationally validated. A blood sample was collected and stored in biobank. A follow-up will be carried out through linkage with electronic records.

DISCUSSION

Participation rate and data quality assessment were as expected and will reasonably allow to reach the project aims. The expected impact in public health of the RoCAV project will be the potential implementation of a AAA screening program to the whole region as well as the formulation of new criteria for risk assessment of AAA and CVD.

Bio-psycho-social effects of a coordinated neurorehabilitation programme: A naturalistic mixed methods study

PURPOSE

Best practice guidelines for neurorehabilitation recommend coordinated rehabilitation programmes to ensure seamless service transitions and comprehensive rehabilitation practices. However, this recommendation for practice and the evidence informing its advancement is based on unexamined assumptions. Therefore, this study investigates bio-psycho-social outcomes and perceptions of a coordinated rehabilitation programme.

METHOD

In a prospective, naturalistic mixed methods study, rehabilitation outcomes for 82 adults (18-66 years) with moderate to severe acquired brain injury were investigated. Clients who received the coordinated rehabilitation programme KORE (n = 27) were compared to clients from the same area who received standard rehabilitation prior to the implementation of the KORE programme (n = 37) and clients who received other coordinated efforts elsewhere (n = 18). The study employed quantitative data from standardized tests (Functional Independence Measure, Major Depression Inventory, Quality of life, and Impact on Participation and Autonomy Questionnaire, as well as information on return to work and qualitative interviews with clients (n = 82) and their relatives (n = 40).

RESULTS

Outcomes did not improve from hospital discharge to two years later. Notably, physiological recovery had probably been achieved to the extent possible, but depression and reduced psychological well-being remained prevalent across groups. Qualitative interviews suggested several barriers to improvement, such as identity dilemmas and unmet needs for psychological support, while rehabilitation services focused on physical and practical training.

CONCLUSION

Coordinated interventions do not guarantee comprehensive rehabilitation and better outcomes for clients with acquired brain injury. Psychological support seems to be important and largely unaddressed.

Clinical usefulness of ankle brachial index and brachial-ankle pulse wave velocity in patients with ischemic stroke

Ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are widely used noninvasive modalities to evaluate atherosclerosis. Recently, evidence has increased supporting the use of ABI and baPWV as markers of cerebrovascular disease. This study sought to examine the relationship between ABI and baPWV with ischemic stroke. This study also aimed to determine which pathogenic mechanism, large artery disease (LAD) or small vessel disease (SVD), is related to ABI or baPWV. Retrospectively, 121 patients with ischemic stroke and 38 subjects with no obvious ischemic stroke history were recruited. First, ABI and baPWV were compared between the groups. Then, within the stroke group, the relevance of ABI and baPWV with regard to SVD and LAD, which were classified by brain magnetic resonance image (MRI) and magnetic resonance angiography (MRA) or computed tomography angiography (CTA) findings, was assessed. The baPWV was higher in the stroke group than non-stroke group (1,944.18±416.6 cm/s vs. 1,749.76±669.6 cm/s, P<0.01). Regarding LAD, we found that mean ABI value was lower in the group with extracranial large artery stenosis (P<0.01), and there was an inverse linear correlation between ABI and the grade of extracranial large artery stenosis (P<0.01). For SVD, there was a significant correlation between SVD and baPWV (2,057.6±456.57 cm/s in the SVD (+) group vs. 1,491±271.62 cm/s in the SVD (-) group; P<0.01). However, the grade of abnormalities detected in SVD did not correlate linearly with baPWV. These findings show that baPWV is a reliable surrogate marker of ischemic stroke. Furthermore, baPWV and ABI can be used to indicate the presence of small vessel disease and large arterial disease, respectively.

Pilot Assessment of the Repeatability of Indocyanine Green Fluorescence Imaging and Correlation with Traditional Foot Perfusion Assessments

BACKGROUND

Ankle brachial index (ABI), toe pressures (TP), and transcutaneous oxygen pressure (TcPO₂) are traditionally used in the assessment of critical limb ischemia (CLI). Indocyanine green (ICG) fluorescence imaging can be used to evaluate local circulation in the foot and to evaluate the severity of ischemia. This prospective study analyzed the suitability of a fluorescence imaging system (photodynamic eye [PDE]) in CLI.

MATERIAL AND METHODS

Forty-one patients with CLI were included. Of the patients, 66% had diabetes and there was an ischemic tissue lesion in 70% of the limbs. ABI, toe pressures, TcPO₂ and ICG-fluorescence imaging (ICG-FI) were measured in each leg. To study the repeatability of the ICG-FI, each patient underwent the study twice. After the procedure, foot circulation was measured using a time-intensity curve, where T1/2 (the time needed to achieve half of the maximum fluorescence intensity) and PDE10 (increase of the intensity during the first 10 s) were determined. A time-intensity curve was plotted using the same areas as for the TcPO₂ probes (n=123).

RESULTS

The mean ABI was 0.43, TP 21 mmHg, TcPO₂ 23 mmHg, T1/2 38 s, and PDE10 19 AU. Time-intensity curves were repeatable. In a Bland-Altman scatter plot, the 95% limits of agreement of PDE10 was 9.9 AU and the corresponding value of T1/2 was 14 s. Correlation between ABI and TP was significant (R=.73, p<.001), and it was weaker in diabetic patients (R=.47, p=.048) compared with non-diabetic patients (R=.89, p=.002). Correlations between ABI and TcPO₂ and TP and TcPO₂ were weak (R=.37, p=.05 and R=.43, p=.037, respectively). Correlation between TcPO₂ and PDE10 was strong in diabetic patients (R=.70, p=.003).

CONCLUSIONS

According to this pilot study, ICG-FI with PDE can be used in the assessment of blood supply in the ischemic foot.

Ankle brachial index most important to identify polyvascular disease in patients with non-ST elevation or ST-elevation myocardial infarction

BACKGROUND

Atherosclerosis is a systemic disease. In patients with acute myocardial infarction (MI) the extent of polyvascular disease (PvD) is largely unknown. In this study we investigate the prevalence and clinical characteristics predictive of PvD in patients with non-ST-elevation (NSTEMI) and ST-elevation (STEMI) MI.

METHOD

375 patients with acute MI included in the REBUS (Relevance of Biomarkers for Future Risk of Thromboembolic Events in Unselected Post-myocardial Infarction Patients) study were examined. Atherosclerotic changes were assessed in three arterial beds by coronary angiography, carotid ultrasound and ankle brachial index (ABI). Results compared findings of atherosclerosis in three arterial beds to fewer than 3 beds. PvD was defined as atherosclerosis in all three arterial beds.

RESULTS

A medical history of MI, peripheral artery disease (PAD) or stroke was reported at admission in 17.9%, 2.1% and 3.7% of the patients, respectively. After evaluation, abnormal ABI was found in 20.3% and carotid artery atherosclerosis in 54.9% of the patients. In the total population, PvD was found in 13.8% of patients with no significant differences observed between NSTEMI and STEMI patients. Age (p<0.001), diabetes (p=0.039), previous PAD (p=0.009) and female gender (p=0.016) were associated with PvD. ABI was the most important predictor of PvD with a positive predictive value of 68.4% (95% CI 57.7-79.2%) and specificity of 92.4% (95% CI 89.5-95.4%).

CONCLUSIONS

PvD is underdiagnosed in patients suffering from MI, both NSTEMI and STEMI. ABI is a useful and simple measurement that appears predictive of widespread atherosclerosis in these patients.

Outcomes following Pediatric Auditory Brainstem Implant Surgery: Early Experiences in a North American Center

There are no approved Food and Drug Administration indications for pediatric auditory brainstem implant (ABI) surgery in the United States. Our prospective case series aims to determine the safety and feasibility of ABI surgery in pediatric patients <5 years old with congenital deafness at a tertiary North American center. The inclusion criterion was pre- or postlinguistic deafness in children not eligible for cochlear implantation. Seventeen candidates were evaluated (mean ± SD: age, 2.52 ± 0.39 years). Four patients underwent ABI surgery (age, 19.2 ± 3.43 months), including 4 primary procedures and 1 revision for device failure. Spontaneous device failure occurred in another subject postoperatively. No major/minor complications occurred, including cerebrospinal fluid leak, facial nerve injury, hematoma, and nonauditory stimulation. All subjects detected sound with environmental awareness, and several demonstrated babbling and mimicry. Poor durability of older implants underscores need for updated technology.

Experiences from Auditory Brainstem Implantation (ABIs) in four paediatric patients

INTRODUCTION

Indications for auditory brainstem implants (ABIs) have been widened from patients with neurofibromatosis type 2 (NF2) to paediatric patients with congenital cochlear malformations, cochlear nerve hypoplasia/aplasia, or cochlear ossification after meningitis. We present four ABI surgeries performed in children at Uppsala University Hospital in Sweden since 2009.

METHODS

Three children were implanted with implants from Cochlear Ltd. (Lane Cove, Australia) and one child with an implant from MedEl GMBH (Innsbruck, Austria). A boy with Goldenhar syndrome was implanted with a Cochlear Nucleus ABI24M at age 2 years (patient 1). Another boy with CHARGE syndrome was implanted with a Cochlear Nucleus ABI541 at age 2.5 years (patient 2). Another boy with post-ossification meningitis was implanted with a Cochlear Nucleus ABI24M at age 4 years (patient 3). A girl with cochlear aplasia was implanted with a MedEl Synchrony ABI at age 3 years (patient 4). In patients 1, 2, and 3, the trans-labyrinthine approach was used, and in patient 4 the retro-sigmoid approach was used.

RESULTS

Three of the four children benefited from their ABIs and use it full time. Two of the full time users had categories of auditory performance (CAP) score of 4 at their last follow up visit (6 and 2.5 years postoperative) which means they can discriminate consistently any combination of two of Ling's sounds. One child has not been fully evaluated yet, but is a full time user and had CAP 2 (responds to speech sounds) after 3 months of ABI use. No severe side or unpleasant stimulation effects have been observed so far. There was one case of immediate electrode migration and one case of implant device failure after 6.5 years.

CONCLUSION

ABI should be considered as an option in the rehabilitation of children with similar diagnoses.

Interarm differences in systolic blood pressure and the risk of dementia and subclinical brain injury

INTRODUCTION

This study examined whether interarm differences in systolic blood pressure (IDSBP) ≥10 mm Hg were associated with the risk of incident dementia and subclinical brain injury.

METHODS

Between 1992 and 1998, 2063 participants of the Framingham Heart Study underwent assessment of IDSBP with results related to the 10-year risk of incident dementia including clinically characterized Alzheimer's disease. Secondary outcomes included markers of subclinical brain injury on magnetic resonance imaging.

RESULTS

High IDSBP were associated with a greater risk of incident dementia (hazard ratio [HR] 1.92; 95% confidence interval [CI], 1.09-3.40) and Alzheimer's disease (HR, 2.32; 95% CI, 1.29-4.18), but only in those who carried an apolipoprotein E (APOE) ε4 allele. IDSBP also predicted lower total brain volumes and more prevalent silent brain infarcts in those who were APOE ε4 positive.

DISCUSSION

High IDSBP were associated with an increased risk of dementia, including clinical Alzheimer's disease, and subclinical brain injury in those who were APOE ε4 positive.

Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults

OBJECTIVE

To clarify the characteristics of ankle-brachial index (ABI), toe-brachial index (TBI), and pulse volume recording (PVR) of the ankle with brachial-ankle pulse wave velocity (baPWV) in healthy young adults.

MATERIAL AND METHODS

We analyzed ABI, TBI, baPWV, and PVR in the ankle of healthy adults aged 20 to 25 years (median, 20 years) using an automatic oscillometric device between 2002 and 2013. The ABI, baPWV, and PVR in 1282 legs of 641 subjects (301 men and 340 women) and the TBI in 474 toes of 237 subjects (117 men and 120 women) were evaluated.

RESULTS

The measured values showed no bilateral differences. ABI and baPWV were higher in men than in women, but TBI was similar in both sexes. ABI <1.0 was observed in 18.1% of the legs in men and in 25.6% in women. TBI <0.7 was observed in 16.2% of the toes in men and 19.1% in women. For ankle PVR, the % mean arterial pressure was higher in women than in men. The upstroke time was <180 ms in most subjects.

CONCLUSIONS

For young people, ABI <1.0 or TBI <0.7 may not always indicate vascular abnormalities. When evaluating circulatory indexes, age and sex should be considered.

Online awareness of functional tasks following ABI: the effect of task experience and associations with underlying mechanisms

BACKGROUND

Self-awareness is a significant predictor of neurorehabilitation process and outcome and encompasses metacognitive knowledge and online awareness. The literature focuses primarily on intellectual awareness and research on online awareness is lacking.

OBJECTIVE

To examine online awareness for functional tasks, how it is affected by task experience and its relationships with neurogenic and psychogenic factors.

METHODS

Thirty six adults with ABI attending neurorehabilitation participated in this study. Online awareness was measured as the discrepancy between subjective ratings of performance and performance on functional tasks, as rated by experienced therapists. Participants' ratings were recorded before and immediately after task experience, as well as following a mediated review of task steps. The Impaired Self-Awareness scale (ISA) and the Denial of Disability scale (DD) rated neurogenic and psychogenic mechanisms of unawareness.

RESULTS

Results indicated significant differences between therapists' and participants' ratings before and after IADL task performance, and following mediation. Participants typically overestimated their functional independence and did not significantly change their ratings after task experience. Significant moderate to strong correlations were found between online awareness measures and both DD and ISA scales.

CONCLUSIONS

Overestimation of functional independence is common in persons with ABI, is related to both neurogenic and psychogenic factors and is not significantly affected by single task experience. Further studies are required to examine the effect of theoretically driven awareness interventions in neurorehabilitation.

Association of fibroblast growth factor-23 with arterial stiffness in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Serum fibroblast growth factor-23 (FGF-23) is associated with cardiovascular disease (CVD), yet the mechanisms remain uncertain. Our objective was to determine whether higher FGF-23 concentrations are associated with arterial stiffness.

METHODS

In this cross-sectional study, serum FGF-23 concentrations were measured in 5977 participants without known CVD in the Multi-Ethnic Study of Atherosclerosis. The primary outcomes of interest were large (LAE) and small artery elasticity (SAE), pulse pressure and ankle-brachial index (ABI) > 1.30. LAE and SAE were measured by pulse contour analysis of the radial artery. Pulse pressure was measured with an automated sphygmomanometer using the average of two resting blood pressure measurements. ABI was calculated as the ratio of the ankle and brachial systolic blood pressures.

RESULTS

Serum FGF-23 concentrations were not significantly associated with LAE [relative difference (RD) per doubling: 0%; 95% confidence interval (CI): -2-1%], SAE (RD per doubling: 0%; 95% CI: -3-2%), pulse pressure (β per doubling: 0.44; 95% CI: -0.31-1.19), or a high ABI (odds ratio per doubling: 1.14; 95% CI: 0.84-1.55). Findings were similar irrespective of chronic kidney disease status.

CONCLUSIONS

Higher serum FGF-23 concentrations are not associated with arterial stiffness, as measured by pulse pressure, LAE, SAE or high ABI, in a community-based population without CVD.

Vascular responsiveness in patients with Chronic Obstructive Pulmonary Disease (COPD)

BACKGROUND

Ischemic heart disease and peripheral vascular diseases are prevalent in COPD and it is estimated that any 10% decrease in forced expiratory volume in 1 second (FEV1) is associated with 30% increased cardiovascular risk of death. Endothelial dysfunction may be one of the mechanistic pathways that link between COPD and cardiovascular mortality. Our aim was to study the vascular reactivity of patients with stable COPD and to try to correlate endothelial dysfunction, vascular reactivity and functional capacity of these patients that eventually may lead to cardiovascular mortality.

METHODS

This was a prospective study. Twenty-three consecutive ambulatory COPD patients were enrolled. All were smoking men, aged 64.4 ± 8.4 years. Twenty-two healthy volunteers aged 44.7 ± 11.7 years, BMI of 25.2 ± 4.2, height of 172 ± 8 cm served as the control group. Vascular studies included endothelial function and ankle brachial index.

RESULTS

Baseline diameter of the brachial artery was larger in COPD patients compared with controls. The absolute change in diameter post hyperemia was significantly less in patients (0.004 ± 0.02 cm vs. 0.05 ± 0.02 cm, p<0.001) and COPD patients responded to hyperemia by constriction instead of dilatation (FMD% was -0.6 ± 6.3% in patients vs. 15.6 ± 7.6% in controls, p<0.001). There was no difference in ABI in patients and controls (0.95 ± 0.26 vs. 1.06 ± 0.16, p=0.07).

DISCUSSION

We found that patients with COPD have dilated arteries, have impaired ability to respond to high shear stress that triggers nitric oxide dependent flow mediated dilatation, and have also impaired ability to function - represented by the poor 6 minute walk test.

Managing driving issues after an acquired brain injury: strategies used by health professionals

BACKGROUND/AIM

The ability to drive safely can be affected by an acquired brain injury. Following acquired brain injury, clients may experience driving disruptions, formal assessment, return to driving or permanent cessation. Health professionals may be involved in formal driving or component skills' assessment and rehabilitation, or interventions for continued community participation. Meeting the needs of clients related to driving remains a challenging area of clinical practice. The aim of this study was to investigate how driving issues are currently managed by acquired brain injury rehabilitation teams.

METHOD

This study utilised a qualitative phenomenological approach to gain insight into the approaches undertaken by four rehabilitation teams working with clients post-acquired brain injury. Semi-structured, audiotaped interviews were conducted with 25 participants who had identified driving as part of their role.

RESULTS

Health professional participants described three major areas of clinical focus, describing strategies and challenges associated with each. These were as follows: 'Integrating driving goals into rehabilitation' which involved optimising timing and acknowledging the clients' focus on driving while enhancing driving and rehabilitation outcomes; 'Managing emotional responses' which required protecting therapeutic relationships and providing information, as well as responding to more extreme responses; and finally 'Managing unlicensed driving and meeting long-term needs', which participants identified as the most challenging aspect. Strategies involved using set procedures, building on knowledge of the client, supporting the family and exploring alternatives.

CONCLUSION

The teams described a range of strategies used to address the challenges related to driving and driving cessation which can be applied to successfully manage this issue in acquired brain injury rehabilitation.

Molecular and bioenergetic differences between cells with African versus European inherited mitochondrial DNA haplogroups: implications for population susceptibility to diseases

The geographic origins of populations can be identified by their maternally inherited mitochondrial DNA (mtDNA) haplogroups. This study compared human cybrids (cytoplasmic hybrids), which are cell lines with identical nuclei but mitochondria from different individuals with mtDNA from either the H haplogroup or L haplogroup backgrounds. The most common European haplogroup is H while individuals of maternal African origin are of the L haplogroup. Despite lower mtDNA copy numbers, L cybrids had higher expression levels for nine mtDNA-encoded respiratory complex genes, decreased ATP (adenosine triphosphate) turnover rates and lower levels of reactive oxygen species production, parameters which are consistent with more efficient oxidative phosphorylation. Surprisingly, GeneChip arrays showed that the L and H cybrids had major differences in expression of genes of the canonical complement system (5 genes), dermatan/chondroitin sulfate biosynthesis (5 genes) and CCR3 (chemokine, CC motif, receptor 3) signaling (9 genes). Quantitative nuclear gene expression studies confirmed that L cybrids had (a) lower expression levels of complement pathway and innate immunity genes and (b) increased levels of inflammation-related signaling genes, which are critical in human diseases. Our data support the hypothesis that mtDNA haplogroups representing populations from different geographic origins may play a role in differential susceptibilities to diseases.

Risk assessment of patients with diabetes for foot ulcers according to risk classification consensus of International Working Group on Diabetic Foot (IWGDF)

Objective: The aim was assessment of diabetic foot ulcer risk factors according to International Working Group on the Diabetic Foot (IWGDF) consensus.

Methodology: All referred patients with diabetes were divided into four groups based on IWGDF criteria (without neuropathy, with neuropathy, neuropathy with deformity or vascular disorders, foot ulcer or amputation history).

Results: Mean age of patients was 53.8±10.7 years. Two hundred and sixty nine patients ​(62/6%) were female and 161(37/4%) were male. Twenty three percent had disturbed sense of vibration, 26% had decreased sensitivity to monofilaments and 17% had decreased pain sensation. Ankle brachial index (ABI) was abnormal in 6%. About 7% had history of prior ulcer. Patients were classified into four risk groups according to IWGDF criteria. Two hundred and seventy seven patients (65%) were in group 0, 75(17%) in group 1, 47 (11%) in group 2 and 31 (7%) in group 3. Patients in higher–risk groups had higher age, longer diabetes duration, higher HbA1C and less training (p=0.0001, 0.001, 0.0001, 0.021 respectively). The risk was higher in the presence of retinopathy (p=0.005). Patient's sex, BMI, smoking and nephropathy did not have significant correlation with risk of diabetic foot ulcer.

Conclusion: This study showed that increase of age, duration of diabetes and HbA1c, lack of training and presence of retinopathy increases the risk of diabetic foot ulcers.

Relation between alcohol consumption and arterial stiffness: A cross-sectional study of middle-aged Japanese women and men

Epidemiological data indicate the existence of a J-shaped association between alcohol consumption and cardiovascular mobility and mortality. However, studies assessing the relationship between alcohol consumption and pulse wave velocity (PWV) as a marker of arterial stiffness have provided inconsistent results. In addition, data regarding the effect of alcohol on arterial stiffness in women has been limited. This study aimed to clarify the relationship between alcohol consumption and PWV among female and male workers in Japan. Study participants were local government employees in Hokkaido, Japan, who underwent annual health check-ups. All data were collected using self-administered questionnaires. The average daily alcohol consumption of the previous month, based on the alcohol concentration of each beverage type (g/day, ethanol equivalent), was estimated according to the frequency and amount of consumption. Data from 3893 participants (812 women and 3081 men) were analyzed. In women, non-drinkers had significantly higher PWV than women who consumed <10 g/day of alcohol. In men, compared with those who reportedly drank 20-39 g/day, non-drinkers and those who drank <20 g/day and ≥60 g/day had significantly higher PWV. Alcohol consumption showed a J-shaped association with PWV in men (p for quadratic term < 0.036) and marginally in women (p < 0.056). The results of stratified analyses by age groups showed a significant J-shaped association, which was most notable for men ≥45 years (p < 0.005). In middle-aged Japanese women and men, light-to-moderate alcohol consumption is associated with lower PWV, which in turn correlates with a reduction in vascular stiffness.

The Effect of Lipid Modification on Peripheral Artery Disease after Endovascular Intervention Trial (ELIMIT)

METHODS

A total of 102 patients were randomized to either mono-therapy with simvastatin (40 mg daily) or triple-therapy with simvastatin (40 mg daily), extended-release niacin (1500 mg daily), and ezetimibe (10 mg daily). MRI was performed at baseline and 6, 12, and 24 months. SFA wall, lumen, and total vessel volumes were quantified. MRI-derived SFA parameters and lipids were analyzed with multilevel models and nonparametric tests, respectively.

RESULTS

Baseline characteristics did not differ between mono and triple-therapy groups, except for ethnicity (p = 0.02). SFA wall, lumen, and total vessel volumes increased non-significantly for both groups between baseline and 24-months. Non-high-density lipoprotein cholesterol was significantly reduced at 12 months with triple-therapy compared with mono-therapy (p = 0.01).

CONCLUSION

No significant differences were observed between mono-therapy using simvastatin and triple-therapy with simvastatin, extended-release niacin, and ezetimibe for 24-month changes in SFA wall, lumen, and total vessel volumes.

CLINICAL TRIAL REGISTRATION INFORMATION

NCT00687076; Link: http://clinicaltrials.gov/ct2/show/NCT00687076.

Studying the effects of polycyclic aromatic hydrocarbons on peripheral arterial disease in the United States

PURPOSE

Polycyclic aromatic hydrocarbons are a group of prevalent pollutants which are produced by incomplete combustion of organic materials such as coal, fuel, tobacco smoking and food cooking. The associations between exposures to polycyclic aromatic hydrocarbons (PAHs) and peripheral arterial disease (PAD) have not been well studied.

METHODS

We used the 2001-2004 National Health and Nutrition Examination Survey (NHANES) to investigate the associations between eight monohydroxy urinary metabolites of four PAHs and PAD.

RESULTS

In a logistic regression model, subjects within the middle and highest tertiles of fluorene metabolites, 2-hydroxyfluorene (2-FLUO) and 3-hydroxyfluorene (3-FLUO), and phenanthrene metabolites, 1-hydroxyphenanthrene (1-PHEN) and 2-hydroxyphenanthrene (2-PHEN), had significantly higher prevalence of PAD as compared to subjects within the lowest tertile after adjusting for cigarette smoking, diabetes mellitus and other covariates (For 2-FLUO, the 3rd tertile: OR=2.22, 95% CI=1.13-4.37, p for trend=0.02; For 3-FLUO, the 3rd tertile: OR=2.36, 95% CI: 1.16-4.77, p for trend=0.02; For 1-PHEN, the 3rd tertile: OR=1.84, 95% CI: 1.01-3.37, p for trend=0.04; For 2-PHEN, the 3rd tertile: OR=1.76, 95% CI: 1.07-2.88, p for trend=0.03).

CONCLUSIONS

Our findings suggest that exposure to PAHs may increase the risk of PAD. Further studies are necessary to explore the associations between PAHs and PAD.

Non-compressible arterial disease and the risk of coronary calcification in type-2 diabetes

OBJECTIVE

Ankle-brachial index (ABI) screening is recommended for the detection of asymptomatic peripheral arterial disease (PAD) in at-risk populations, including diabetics. A low ABI identifies obstructive lower extremity vascular disease and predicts CVD events and increased mortality. A high ABI represents non-compressible arterial disease (NCAD), and is also associated with increased mortality and vascular events. Our objective is to investigate whether low and high ABI have distinct patterns of association with cardiovascular disease (CVD) risk factors and subclinical atherosclerosis in individuals with type-II diabetes mellitus.

METHODS

The Penn Diabetes Heart Study (PDHS) is a prospective observational cohort of diabetic individuals without clinically evident CVD. Multivariate logistic and Tobit linear regression were used to compare CVD risk factors and coronary artery (CAC) among 1863 subjects with PAD (ABI ≤ 0.9), NCAD (ABI ≥ 1.4 or non-compressible) or normal ABI (0.91-1.39).

RESULTS

Compared to those with normal ABI, PAD was associated with smoking, obesity, and lower HDL-c; while diabetes duration and reduced renal function were associated with NCAD. Both PAD and NCAD were independently associated with increased CAC compared to those with normal ABI, and these relationships were not attenuated in multiply adjusted models.

CONCLUSION

NCAD bears a distinct relationship to traditional CVD risk factors among diabetics, though like PAD is independently associated with increased CAC. These findings support the recognition of NCAD as a high-risk phenotype and provide additional relevance to ABI screening in diabetics.

Ankle-brachial index in relation to the natriuretic peptide system polymorphisms and urinary sodium excretion in Chinese

OBJECTIVE

Recent studies have demonstrated that the natriuretic pepetides induce endothelial regeneration and angiogenesis after vascular injury through the autocrine or paracrine action, and might have an inhibitory effect on atherosclerosis. We therefore systematically investigated single nucleotide polymorphisms (SNPs) in the natriuretic peptide system in relation to ankle-brachial index (ABI) in a Chinese population.

METHODS

The study population was recruited from a mountainous area 500 km south of Shanghai from 2003 to 2009. Using the SNapShot method, we first genotyped 951 subjects enrolled in 2005 for 16 SNPs and then the remaining 1355 subjects as validation for 5 SNPs selected from the primary study. ABI and plasma proBNP were measured using the Omron VP-2000/1000 device and the Elecsys proBNP immunoassay, respectively.

RESULTS

Overall, the genetic associations were not significant (P ≥ 0.07). However, in the primary study, there was significant (Pint ≤ 0.045) interaction between 3 SNPs (rs6668352, rs198388, and rs198389) at the NPPA-NPPB locus and urinary sodium excretion in relation to ABI, and the rs6668352 polymorphism had the strongest association (Pint = 0.018). In the primary combined with the validation study populations, the interaction between the rs6668352 polymorphism and urinary sodium excretion in relation to ABI remained statistically significant (Pint = 0.0036). After adjustment for covariates, the rs6668352 A allele carriers, compared with GG homozygotes, had a higher ABI (mean ± standard error, 1.103 ± 0.006 vs. 1.084 ± 0.004, P = 0.009) and lower risk of peripheral arterial disease (PAD, defined as an ABI < 0.90, odds ratio 0.37, 95% confidence interval: 0.14-0.98, P = 0.04) in the subjects of high sodium intake.

CONCLUSION

The minor alleles of 3 SNPs at the NPPA-NPPB locus are associated with a lower risk of PAD, especially in the subjects of high sodium intake.

Novel and recurrent mutations in the TAT gene in Tunisian families affected with Richner-Hanhart syndrome

Tyrosinemia type II, also designated as oculocutaneous tyrosinemia or Richner-Hanhart syndrome (RHS), is a very rare autosomal recessive disorder. In the present study, we report clinical features and molecular genetic investigation of the tyrosine aminotransferase (TAT) gene in two young patients, both born to consanguineous unions between first-degree cousins. These two unrelated families originated from Northern and Southern Tunisia. The clinical diagnosis was based on the observation of several complications related to Richner-Hanhart syndrome: recurrent eye redness, tearing and burning pain, photophobia, bilateral pseudodendritic keratitis, an erythematous and painful focal palmo-plantar hyperkeratosis and a mild delay of mental development. The diagnosis was confirmed by biochemical analysis. Sequencing of the TAT gene revealed the presence of a previously reported missense mutation (c.452G>A, p.Cys151Tyr) in a Tunisian family, and a novel G duplication (c.869dupG, p.Trp291Leufs 6). Early diagnosis of RHS and protein-restricted diet are crucial to reduce the risk and the severity of long-term complications of hypertyrosinemia such as intellectual disability.

Alternative ankle-brachial index method identifies additional at-risk individuals

OBJECTIVES

The aim of this study was to determine whether use of an alternative ankle-brachial index (ABI) calculation method improves mortality risk prediction compared with traditional methods.

BACKGROUND

The ABI is used to diagnose peripheral arterial disease (PAD) and to identify those at risk for cardiovascular events. Traditionally, the ABI is calculated with the higher of the dorsalis pedis and posterior tibial ankle arteries. Studies directly comparing calculation methods are limited.

METHODS

The ABI was calculated at baseline in 1,413 study participants undergoing non-emergent coronary angiography subsequently followed for all-cause and cardiovascular mortality. There were 224 individuals assigned to the traditional-PAD group (ABI <0.90) with the traditional ABI method. Of those remaining, an alternative ABI method using the lower of the 2 ankle pressures assigned 282 patients to the alternative-PAD group. The 862 individuals not assigned to PAD by either method were the no-PAD group.

RESULTS

There were 163 mortalities during a median follow-up of 5.0 years. Adjusted Cox regression models showed that the alternative-PAD group had an increased risk for all-cause (hazard ratio [HR]: 1.49; 95% confidence interval: 1.01 to 2.19) and cardiovascular mortality (HR: 3.21; 95% confidence interval: 1.53 to 6.37) versus the no-PAD group. Additionally, in the no-PAD group, there was an 11% (HR: 1.11; 95% confidence interval: 1.05 to 1.17) increased risk of all-cause mortality/1-mm Hg increased difference between the left and right brachial systolic pressures.

CONCLUSIONS

The implementation of an alternative ABI method and use of the brachial difference identifies individuals at an increased risk for mortality who are currently missed with traditional ABI methods. Current ABI protocols might need to be evaluated.

Altered resting state effective connectivity in long-standing vegetative state patients: an EEG study

OBJECTIVE

Recent evidence mainly based on hemodynamic measures suggests that the impairment of functional connections between different brain areas may help to clarify the neuronal dysfunction occurring in patients with disorders of consciousness (DOC). The aim of this study was to evaluate effective EEG connectivity in a cohort of 18 patients in a chronic vegetative state (VS) observed years after the occurrence of hypoxic (eight) and traumatic or hemorrhagic brain insult.

METHODS

we analysed the EEG signals recorded under resting conditions using a frequency domain linear index of connectivity (partial directed coherence: PDC) estimated from a multivariate autoregressive model. The results were compared with those obtained in ten healthy controls.

RESULTS

Our findings indicated significant connectivity changes in EEG activities in delta and alpha bands. The VS patients showed a significant and widespread decrease in delta band connectivity, whereas the alpha activity was hyper-connected in the central and posterior cortical regions.

CONCLUSION

These changes suggest the occurrence of severe circuitry derangements probably due to the loose control of the subcortical connections. The alpha hyper-synchronisation may be due to simplified networks mainly involving the short-range connections between intrinsically oscillatory cortical neurons that generate aberrant EEG alpha sources. This increased connectivity may be interpreted as a reduction in information capacity, implying an increasing prevalence of stereotypic activity patterns.

SIGNIFICANCE

Our observations suggest a remarkable rearrangement of connectivity in patients with long-standing VS. We hypothesize that in persistent VS, after a first period characterized by a breakdown of cortical connectivity, neurodegenerative processes, largely independent from the type of initial insult, lead to cortex de-afferentation and to a severe reduction of possible cortical activity patterns and states.

Automated, simple, and efficient influenza RNA extraction from clinical respiratory swabs using TruTip and epMotion

BACKGROUND

Rapid, simple and efficient influenza RNA purification from clinical samples is essential for sensitive molecular detection of influenza infection. Automation of the TruTip extraction method can increase sample throughput while maintaining performance.

OBJECTIVES

To automate TruTip influenza RNA extraction using an Eppendorf epMotion robotic liquid handler, and to compare its performance to the bioMerieux easyMAG and Qiagen QIAcube instruments.

STUDY DESIGN

Extraction efficacy and reproducibility of the automated TruTip/epMotion protocol was assessed from influenza-negative respiratory samples spiked with influenza A and B viruses. Clinical extraction performance from 170 influenza A and B-positive respiratory swabs was also evaluated and compared using influenza A and B real-time RT-PCR assays.

RESULTS

TruTip/epMotion extraction efficacy was 100% in influenza virus-spiked samples with at least 745 influenza A and 370 influenza B input gene copies per extraction, and exhibited high reproducibility over four log10 concentrations of virus (<1% CV). RNA yields between the three automated methods differed by less than 0.5 log10 gene copies. 99% of clinical specimens that were PCR-positive after easyMAG or QIAcube extraction were also positive following TruTip extraction. Overall Ct value differences obtained between TruTip/epMotion and easyMAG/QIAcube clinical extracts ranged from 1.24 to 1.91. Pairwise comparisons of Ct values showed a high correlation of the TruTip/epMotion protocol to the other methods (R2>0.90).

CONCLUSION

The automated TruTip/epMotion protocol is a simple and rapid extraction method that reproducibly purifies influenza RNA from respiratory swabs, with comparable efficacy and efficiency to both the easyMAG and QIAcube instruments.

Plasma levels of cathepsins L, K, and V and risks of abdominal aortic aneurysms: a randomized population-based study

BACKGROUND

Cathepsin L (CatL), cathepsin K (CatK), and cathepsin V (CatV) are potent elastases implicated in human arterial wall remodeling. Whether plasma levels of these cathepsins are altered in patients with abdominal aortic aneurysms (AAAs) remains unknown.

METHODS AND RESULTS

Plasma samples were collected from 476 male AAA patients and 200 age-matched male controls to determine CatL, CatK, and CatV levels by ELISA. Student's t-test demonstrated significantly higher plasma CatL levels in AAA patients than in controls (P < 0.0001), whereas CatK and CatV levels were lower in AAA patients than in controls (P = 0.052, P = 0.025). ROC curve analysis confirmed higher plasma CatL levels in AAA patients than in controls (P < 0.001). As potential confounders, current smoking and use of angiotensin-converting enzyme (ACE) inhibitors, aspirin, clopidogrel, and statins associated with significantly increased plasma CatL. Pearson's correlation test demonstrated that plasma CatL associated positively with CatS (r = 0.43, P < 0.0001), body-mass index (BMI) (r = 0.07, P = 0.047) and maximal aortic diameter (r = 0.29, P < 0.001), and negatively with lowest measured ankle-brachial index (ABI) (r = -0.22, P < 0.001). Plasma CatL remained associated positively with CatS (r = 0.43, P < 0.0001) and aortic diameter (r = 0.212, P < 0.001) and negatively with ABI (r = -0.10, P = 0.011) after adjusting for the aforementioned potential confounders in a partial correlation analysis. Multivariate logistic regression analysis indicated that plasma CatL was a risk factor of AAA before (odds ratio [OR] = 3.04, P < 0.001) and after (OR = 2.42, P < 0.001) the same confounder adjustment.

CONCLUSIONS

Correlation of plasma CatL levels with aortic diameter and the lowest ABI suggest that this cysteinyl protease plays a detrimental role in the pathogenesis of human peripheral arterial diseases and AAAs.

Effectiveness of home- and community-based rehabilitation in a large cohort of patients disabled by cerebrovascular accident: evidence of a dose-response relationship

OBJECTIVES

To (1) assess the effectiveness of home- and community-based rehabilitation (HCBR) in a large cohort of individuals with disabilities secondary to cerebrovascular accident (CVA); and (2) evaluate the responsiveness to treatment of the Mayo-Portland Adaptability Inventory (MPAI-4) to changes resulting from HCBR in this patient group.

DESIGN

Retrospective analysis of program evaluation data for treatment completers and noncompleters.

SETTING

HCBR conducted in 7 geographically distinct U.S. cities.

PARTICIPANTS

Individuals with CVA (n=738) who completed the prescribed course of rehabilitation (completed course of treatment [CCT]) compared with 150 individuals who were precipitously discharged (PD) before program completion.

INTERVENTION

HCBR delivered by certified professional staff on an individualized basis.

MAIN OUTCOME MEASURES

Mayo-Portland Adaptability Inventory (MPAI-4) completed by professional consensus on admission and at discharge.

RESULTS

With the use of analysis of covariance, MPAI-4 total scores at discharge for CCT participants were compared with those of PD participants, with admission MPAI-4, age, length of stay, and time since event as covariates. CCT participants showed greater improvement than PD participants (F=99.48, P<.001) with a moderate effect size (partial η(2)=.10). Group differences and effect sizes were similar for the 3 index scores: Ability (F=75.96, P<.001; partial η(2)=.08), Adjustment (F=99.67, P<.001; partial η(2)=.10), and Participation (F=69.15, P<.001; partial η(2)=.07).

CONCLUSIONS

Individuals in the CCT group who received the entire planned course of HCBR showed greater improvement on all MPAI-4 indexes than those in the PD group who were discharged before completing the prescribed program. This dose-response relationship provides evidence of a causal relationship between treatment and outcome.