A Patient with Permanent Cardiac Pacemaker, History of Stroke Presents for an Extraction of Mandibular Molar Tooth

Poor oral health and/or dental disease are highly prevalent among stroke survivors. Muscle weakness and loss of dexterity can decrease the patient's ability to provide effective oral hygiene post-stroke. Modifications to dental treatment should be based on the degree of neurologic sequelae, including scheduling needs. Special considerations must be taken with individuals who have permanent cardiac pacemakers.

Reliability of IMU-based balance assessment in clinical stroke rehabilitation

BACKGROUND

Balance is often affected after stroke, severely impacting activities of daily life. Conventional testing methods to assess balance provide limited information, as they are subjected to floor and ceiling effects. Instrumented tests, for instance using inertial measurement units, offer a feasible and promising alternative.

RESEARCH QUESTION

We examined whether postural sway can reliably be measured in sitting and standing balance in people after stroke in clinical rehabilitation using a single inertial measurement unit. Additionally, we assessed to what extent averaging two measurements would improve test-retest reliability compared to a single measurement, and if sway features can potentially be used to monitor progression.

METHOD

Forty participants performed two assessments with a test-retest interval of 24 h. Each assessment consisted of one sitting and four standing balance conditions (eyes open, feet together, eyes closed and foam). The standing balance conditions were performed twice during both assessments. In total, 35 sway features were calculated for each condition. For the standing balance conditions, these were calculated for both single test-retest measurement and the average of the two test and retest measurements. We determined the reliability using the intraclass correlation coefficient for both single and averaged measurements. Additionally, the minimal detectable change and the relative minimal detectable change were computed.

RESULTS

The single and averaged measurements resulted in 22 sitting, 30 & 32 eyes open, 27 & 22 feet together, 28 & 33 eyes closed and 23 & 13 foam sway features with good-excellent reliability. Overall, the difference between intraclass correlation coefficient values of the single and averaged measurements was small and inconsistent. The relative minimal detectable change ranged between 0.5 and 1.5 standard deviation.

SIGNIFICANCE

Sitting and standing balance can reliably be assessed in people after stroke in clinical rehabilitation with a single measurement using one inertial measurement unit.

The association between obstructive sleep apnea and stroke in sickle-cell disease children

INTRODUCTION

The prevalence of stroke in SCD patients was reported to be around 4%; however, the pediatric category was among the higher risk group for stroke compared to young and middle age adults. Furthermore, the risk of OSA increases in SCD children. The objective of this study is to calculate the prevalence of stroke in children with SCD with and without obstructive sleep apnea.

METHOD

This is a cross-sectional study held at two major tertiary hospitals in Jeddah, Saudi Arabia. Inclusion criteria included patients aged between 2 and 18 at the time of enrollment with confirmed SCD. The primary outcome of the study was at least one documented episode of stroke over the last 3 years. OSA was assessed using PSQ.

RESULTS

A total of 150 children with SCD were included in the study. The mean age was 9.6 (±4.3). Most of the sample (85.3%) were sickle-cell anemia with HbSS. Children who were positive for OSA were at higher odds of having a stroke [OR 2.97; 95% CI 1.13-7.75 (P = 0.02)]. The relationship between OSA and stroke was not significant in the multivariant analysis.

CONCLUSION

Patients who had OSA had a higher prevalence of stroke compared to non-OSA patients by 16% with almost three times higher odds. The difference was statistically significant in bivariant but not multivariant analysis. The rate of hospitalization, emergency visit, and blood transfusion were not affected by OSA status. Screening for OSA in high-risk patients such as SCD children and early management could prevent the risk of SCD complications.

Role of neuronal nitric oxide synthase on cardiovascular functions in physiological and pathophysiological states

This review describes and summarizes the role of neuronal nitric oxide synthase (nNOS) on the central nervous system, particularly on brain regions such as the ventrolateral medulla (VLM) and the periaqueductal gray matter (PAG), and on blood vessels and the heart that are involved in the regulation and control of the cardiovascular system (CVS). Furthermore, we shall also review the functional aspects of nNOS during several physiological, pathophysiological, and clinical conditions such as exercise, pain, cerebral vascular accidents or stroke and hypertension. For example, during stroke, a cascade of molecular, neurochemical, and cellular changes occur that affect the nervous system as elicited by generation of free radicals and nitric oxide (NO) from vulnerable neurons, peroxide formation, superoxides, apoptosis, and the differential activation of three isoforms of nitric oxide synthases (NOSs), and can exert profound effects on the CVS. Neuronal NOS is one of the three isoforms of NOSs, the others being endothelial (eNOS) and inducible (iNOS) enzymes. Neuronal NOS is a critical homeostatic component of the CVS and plays an important role in regulation of different systems and disease process including nociception. The functional and physiological roles of NO and nNOS are described at the beginning of this review. We also elaborate the structure, gene, domain, and regulation of the nNOS protein. Both inhibitory and excitatory role of nNOS on the sympathetic autonomic nervous system (SANS) and parasympathetic autonomic nervous system (PANS) as mediated via different neurotransmitters/signal transduction processes will be explored, particularly its effects on the CVS. Because the VLM plays a crucial function in cardiovascular homeostatic mechanisms, the neuroanatomy and cardiovascular regulation of the VLM will be discussed in conjunction with the actions of nNOS. Thereafter, we shall discuss the up-to-date developments that are related to the interaction between nNOS and cardiovascular diseases such as hypertension and stroke. Finally, we shall focus on the role of nNOS, particularly within the PAG in cardiovascular regulation and neurotransmission during different types of pain stimulus. Overall, this review focuses on our current understanding of the nNOS protein, and provides further insights on how nNOS modulates, regulates, and controls cardiovascular function during both physiological activity such as exercise, and pathophysiological conditions such as stroke and hypertension.

Early postoperative heparinization reduce hemolysis in patients with HeartMate II devices

Hemolysis is closely related with pump thrombosis and thromboembolic events in patients with continuous flow left ventricular assist devices. We retrospectively investigated the impact of early postoperative heparinization on hemolysis in patients with HeartMate II devices. From April 2013 to August 2017, 83 patients (age 45 ± 12 years; 20 females; body surface area 1.6 ± 0.2 m²) underwent HeartMate II implantation. Postoperative heparinization was started when hemostasis was achieved and continued until full warfarinization. Hemolysis was defined in accordance with the Interagency Registry for Mechanically Assisted Circulatory Support definitions. The average support period was 22 ± 14 months. The 6-, 12-, and 24-month freedoms from hemolysis were 72%, 70%, and 67%, respectively. Pump thrombosis developed in five (6%) patients and four (5%) required pump exchanges. Heparin start time was significantly later in patients with hemolysis (43 ± 23 h after implantation) versus those without (29 ± 14 h after implantation; p = 0.01). Receiver operating characteristic analysis determined the cut-off point of heparin start time as 29 h. The patients were divided into the early group (heparin start time < 29 h; n = 29), and the late group (heparin start time > 29 h; n = 54). The respective 6-, 12-, and 24-month freedoms from hemolysis for the early group (86%, 86%, and 86%, respectively) were significantly higher than those for the late group (49%, 47%, and 44%, respectively; p = 0.002). Being in the late group was an independent risk factor for hemolysis (hazard ratio 4.09). Early postoperative heparinization (within 29 h after implantation) reduces hemolysis in patients with HeartMate II devices.

Dueling Myxomas: A Rare Finding

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Multiple cardiac myxomas are rare, most commonly seen in the left atrium.

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Myxomas are most commonly attached on the left atrial side of the interatrial septum.

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Echocardiography is key in acute CVA to identify cardioembolic sources.

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TEE can provide definitive diagnosis and location of multiple cardiac myxomas.

Acute Pancreatitis Masquerading as Inferior Wall Myocardial Infarction: A Review

A rare presentation of acute pancreatitis is with electrocardiographic (ECG) changes that mimic myocardial ischemia. We present a report of a patient that presented with hemodynamic instability and new ECG changes of ST segment elevations in contiguous leads II, III, and aVF mimicking an inferior wall myocardial infarction. Emergent coronary angiography showed no significant coronary obstruction, but it was followed by a left-sided hemiplegia with radiographic evidence of diffuse embolic stroke. The patient was later found to have an underlying diagnosis of pancreatitis. Additional history that later became available indicated a history of severe acute pancreatitis treated elsewhere a few months prior to the current admission. We present the first comprehensive review of the literature comprising 36 total cases with pancreatitis masquerading as acute myocardial infarction, with inferior wall STEMI pattern being the most frequent. We present this case to highlight the diagnostic dilemma posed by this masquerade of a high acuity myocardial infarction and to highlight alternative diagnoses to be considered in such clinical circumstances.

An articulated ankle-foot orthosis with adjustable plantarflexion resistance, dorsiflexion resistance and alignment: A pilot study on mechanical properties and effects on stroke hemiparetic gait

Mechanical properties of an articulated ankle-foot orthosis (AFO) are closely related to gait performance in individuals post-stroke. This paper presents a pilot study on the mechanical properties of a novel articulated AFO with adjustable plantarflexion resistance, dorsiflexion resistance and alignment, and its effect on ankle and knee joint kinematics and kinetics in an individual post-stroke during gait. The mechanical properties of the AFO were quantified. Gait analysis was performed using a 3D motion capture system with a split-belt instrumented treadmill under 12 different settings of the mechanical properties of the AFO [i.e. 4 plantarflexion resistances (P1<P4), 4 dorsiflexion resistances (D1<D4), 4 initial alignments (A1<A4)]. The AFO demonstrated systematic changes in moment-angle relationship in response to changes in AFO joint settings. The gait analysis demonstrated that the ankle and knee angle and moment were responsive to changes in the AFO joint settings. Mean ankle angle at initial contact changed from -0.86° (P1) to 0.91° (P4) and from -1.48° (A1) to 4.45° (A4), while mean peak dorsiflexion angle changed from 12.01° (D1) to 6.40° (D4) at mid-stance. The novel articulated AFO appeared effective in influencing lower-limb joint kinematics and kinetics of gait in the individual post-stroke.

Methods for an International Randomized Clinical Trial to Investigate the Effect of Gsk249320 on Motor Cortex Neurophysiology using Transcranial Magnetic Stimulation in Survivors of Stroke

Introduction

Transcranial Magnetic Stimulation (TMS) is a neurophysiological tool capable of assessing the motor nervous system and its change over time. In multi-site clinical trials, this technique has some advantages over other neuroimaging methods owing to its relatively low cost, low personnel and equipment infrastructure requirements, and greater ease in consistently applying technology to collect and analyze data. Limited published details exist regarding methods to deliver TMS and analyze data in a standardized and consistent manner as part of an international, multicenter, clinical trial.

Purpose

The objective of this paper is to describe standardized methods of applying TMS motor cortex assessments in an international clinical trial of a pharmacological intervention for stroke patients, which was conducted at 15 centers in three countries.

Materials and methods

A standardization process was developed to ensure TMS protocol adherence and data quality, and each clinical site was required to successfully complete standardization procedures prior to collecting patient data. Key elements of standardization included internet-based training, pilot subject data collection, common TMS equipment across sites, and corrective feedback provided by a standardization administrator. Subsequently, TMS assessments of motor hot spot location, motor threshold, and recruitment curve were conducted in stroke patients on post-stroke Days 5, 30, and 112. Ongoing standardization was maintained by regular review of patient data and communication between the clinical site and standardization administrator.

Conclusion

Although TMS methodological approaches vary, a protocol with standardized procedures was successfully developed and implemented. Using this protocol, centers were formally certified to perform TMS-based neurophysiological measures in this clinical trial of stroke patients. The methodology described is potentially valuable to investigators who might construct future multi-site clinical trials using TMS.

The effects of core stability strength exercise on muscle activity and trunk impairment scale in stroke patients

The purpose of this study was to examine the effects of core stability-enhancing exercises on the lower trunk and muscle activity of stroke patients. The control group (n = 10) underwent standard exercise therapy, while the experiment group (n =10) underwent both the core stability-enhancing exercise and standard exercise therapy simultaneously. The standard exercise therapy applied to the two groups included weight bearing and weight shifts and joint movements to improve flexibility and the range of motion. The core stability-enhancing exercise was performed 5 times a week for 30 min over a period of 4 weeks in the room where the patients were treated. For all 20 subject, the items measured before the exercise were measured after the therapeutic intervention, and changes in muscle activity of the lower trunk were evaluated. The activity and stability of the core muscles were measured using surface electromyography and the trunk impairment scale (TIS). The mean TIS score and muscle activity of the lower trunk increased in the experiment group significantly after performing the core stability-enhancing exercise (P<0.05). The results of this study show that the core stability-enhancing exercise is effective in improving muscle activity of the lower trunk, which is affected by hemiplegia.