Brain-computer interface-triggered functional electrical stimulation therapy for rehabilitation of reaching and grasping after spinal cord injury: a feasibility study

STUDY DESIGN

Feasibility and preliminary clinical efficacy analysis in a single-arm interventional study.

OBJECTIVES

We developed a brain-computer interface-triggered functional electrical stimulation therapy (BCI-FEST) system for clinical application and conducted an interventional study to (1) assess its feasibility and (2) understand its potential clinical efficacy for the rehabilitation of reaching and grasping in individuals with sub-acute spinal cord injury (SCI).

SETTING

Spinal cord injury rehabilitation hospital-Toronto Rehabilitation Institute-Lyndhurst Centre.

METHODS

Five participants with sub-acute SCI completed between 12 and 40 1-hour sessions using BCI-FEST, with up to 5 sessions a week. We assessed feasibility by measuring participants' compliance with treatment, the occurrence of adverse events, BCI sensitivity, and BCI setup duration. Clinical efficacy was assessed using Functional Independence Measure (FIM) and Spinal Cord Independence Measure (SCIM), as primary outcomes. In addition, we used two upper-limb function tests as secondary outcomes.

RESULTS

On average, participants completed 29.8 sessions with no adverse events. Only one of the 149 sessions was affected by technical challenges. The BCI sensitivity ranged between 69.5 and 80.2%, and the mean BCI setup duration was ~11 min. In the primary outcomes, three out of five participants showed changes greater than the minimal clinically important differences (MCIDs). Additionally, the mean change in secondary outcome measures met the threshold for detecting MCID as well; four out of five participants achieved MCID.

CONCLUSIONS

The new BCI-FEST intervention is safe, feasible, and promising for the rehabilitation of reaching and grasping after SCI.

Functional electrical stimulation of the facial muscles to improve symptoms in individuals with major depressive disorder: pilot feasibility study

Background

Currently, the mainstay of treatment in patients diagnosed with major depressive disorder (MDD) requiring medical attention is second generation anti-depressants. However, about 40% of patients treated with second-generation anti-depressants do not respond to initial treatment and approximately 70% do not achieve remission during the first-step treatment. There are a few non-pharmacological options available, but none have shown consistently positive results. There is a need for an intervention that is relatively easy to administer, produces consistently positive results and is associated with minimal side effects. In the current study, we assessed the feasibility of using transcutaneous Functional Electrical Stimulation Therapy (FEST) of the facial muscles, as a tool for improving depressive symptoms in individuals with MDD.

Results

Ten (10) individuals with moderate to severe MDD received three FEST sessions/week for a minimum of 10 to a maximum of 40 sessions. All study participants completed the required 10 therapy sessions, and 5 of the 10 participants completed additional 30 (totalling 40) FEST sessions. There were no adverse events or concerns regarding compliance to therapy. We found statistically significant improvements on Hamilton Rating Scale for Depression (HDS) and Inventory of Depressive Symptomatology (IDS) measures. However, no significant improvements were found on Positive and Negative Affect Scale and 10-point Visual Analogue Scale scales. Participants reported improvements in sleeping patterns, and this correlated with statistically significant improvements on sleep parameters of HDS and IDS measures.

Conclusion

This study indicates that facial FEST is an acceptable, practical, and safe treatment in individuals with MDD. We provide preliminary evidence to show improvements in depressive symptoms following a minimum of 10 FEST sessions.

Lessons learned from the pilot study of an orthostatic hypotension intervention in the subacute phase following spinal cord injury

Context: Following spinal cord injury (SCI) at the cervical or upper-thoracic level, orthostatic hypotension (OH) is observed in 13-100% of patients. This study aimed to test the feasibility of conducting a randomized controlled trial combining a dynamic tilt-table (Erigo^®) and functional electrical stimulation (FES) to mitigate OH symptoms in the subacute phase after SCI. Design: Pilot study. Setting: A tertiary rehabilitation hospital. Participants: Inpatients who had a C4-T6 SCI (AIS A-D) less than 12 weeks before recruitment, and reported symptoms of OH in their medical chart. Interventions: Screening sit-up test to determine eligibility, then 1 assessment session and 3 intervention sessions with Erigo^® and FES for eligible participants. Outcome measures: Recruitment rate, duration of assessment and interventions, resources used, blood pressure, and Calgary Presyncope Form (OH symptoms). Results: Amongst the 232 admissions, 148 inpatient charts were reviewed, 11 inpatients met all inclusion criteria, 7 participated in a screening sit-up test, and 2 exhibited OH. Neither of the two participants recruited in the pilot study was able to fully complete the assessment and intervention sessions due to scheduling issues (i.e. limited available time). Conclusion: This pilot study evidenced the non-feasibility of the clinical trial as originally designed, due to the low recruitment rate and the lack of available time for research in participant's weekday schedule. OH in the subacute phase after SCI was less prevalent and less incapacitating than expected. Conventional management and spontaneous resolution of symptoms appeared sufficient to mitigate OH in most patients with subacute SCI.

Cation exchange capacity of biochar: An urgent method modification

Biochar, produced through pyrolysis of organic matter, is negatively charged, thus contributing to electrostatic adsorption of cations. However, due to its porous structure and contents of alkaline ashes, the determination of the cation exchange capacity (CEC) is challenging. Literature values for the CEC of biochar are surprisingly variable and are often poorly reproducible, suggesting methodological problems. Here, we modify and critically assess different steps in the existing ammonium acetate (NH₄OAc) method (pH 7), where ammonium (NH₄⁺) is displaced by potassium chloride (KCl), following removal of excess NH₄OAc with isopropanol, in batch mode. We used pigeon pea biochar to develop the method and conducted a test on three additional biochars with different acid neutralizing capacity. A pretreatment step of biochar was introduced, using diluted hydrochloric acid, to decrease biochar pH to near neutral, so that 1 M NH₄OAc effectively buffers the biochar suspension pH at 7. This allows the CEC of all biochars to be determined at pH 7, which is crucial for biochar comparison. The dissolution of ashes may cause relatively large weight losses (e.g. for cacao shell biochar), which need to be accounted for when computing the CEC of raw biochar. The sum of NH₄OAC-extractable base cations provided a smaller and better estimate of the CEC than KCl-extractable NH₄⁺. We hypothesize that the overestimation of the CEC based on KCl-extractable NH₄⁺ is due to the ineffectiveness of the relatively large isopropanol molecules to remove excess NH₄OAc in biochars rich in micro-pores, due to size exclusion. The amount of base cations removed in the pretreatment was about three (rice husk biochar) to ten times (pigeon pea biochar) greater than the amount of exchangeable cations. The CEC values of biochar increased from 10.8 cmol/Kg carbon to 119.6 cmol/Kg carbon. These values are smaller than reported CEC values of soil organic carbon.

Functional electrical stimulation therapy for severe hemiplegia: Randomized control trial revisited

Background.

Stroke is the leading cause of long-term disability. Stroke survivors seldom improve their upper-limb function when their deficit is severe, despite recently developed therapies.

Purpose.

This study aims to assess the efficacy of functional electrical stimulation therapy in improving voluntary reaching and grasping after severe hemiplegia.

Method.

A post hoc analysis of a previously completed randomized control trial ( clinicaltrials.gov , No. NCT00221078) was carried out involving 21 participants with severe upper-limb hemiplegia (i.e., Fugl-Meyer Assessment–Upper Extremity [FMA-UE] ≤ 15) resulting from stroke.

Findings.

Functional Independence Measure Self-Care subscores increased 22.8 (±6.7) points in the intervention group and 9 (±6.5) in the control group, following 40 hr of equal-intensity therapy. FMA-UE score changes were 27.2 (±13.5) and 5.3 (±11.0) for the intervention and control groups, respectively.

Implications.

The results may represent the largest upper-limb function improvements in any stroke population to date, especially in those with severe upper-limb deficit.

Restoration of Upper Limb Function in an Individual with Cervical Spondylotic Myelopathy using Functional Electrical Stimulation Therapy: A Case Study

Non-traumatic spinal cord pathology is responsible for 25–52% of all spinal cord lesions. Studies have revealed that spinal stenosis accounts for 16–21% of spinal cord injury (SCI) admissions. Impaired grips as well as slow unskilled hand and finger movements are the most common complaints in patients with spinal cord disorders, such as myelopathy secondary to cervical spondylosis. In the past, our team carried out couple of successful clinical trials, including two randomized control trials, showing that functional electrical stimulation therapy (FEST) can restore voluntary reaching and/or grasping function, in people with stroke and traumatic SCI. Motivated by this success, we decided to examine changes in the upper limb function following FEST in a patient who suffered loss of hand function due to myelopathy secondary to cervical spondylosis. The participant was a 61-year-old male who had C3–C7 posterior laminectomy and instrumented fusion for cervical myelopathy. The participant presented with progressive right hand weakness that resulted in his inability to voluntarily open and close the hand and to manipulate objects unilaterally with his right hand. The participant was enrolled in the study ~22 months following initial surgical intervention. Participant was assessed using Toronto Rehabilitation Institute’s Hand Function Test (TRI-HFT), Action Research Arm Test (ARAT), Functional Independence Measure (FIM), and Spinal Cord Independence Measure (SCIM). The pre–post differences in scores on all measures clearly demonstrated improvement in voluntary hand function following 15 1-h FEST sessions. The changes observed were meaningful and have resulted in substantial improvement in performance of activities of daily living. These results provide preliminary evidence that FEST has a potential to improve upper limb function in patients with non-traumatic SCI, such as myelopathy secondary to cervical spondylosis.

Functional electrical stimulation therapy for recovery of reaching and grasping in severe chronic pediatric stroke patients

Stroke affects 2.7 children per 100,000 annually, leaving many of them with lifelong residual impairments despite intensive rehabilitation. In the present study the authors evaluated the effectiveness of 48 hours of transcutaneous functional electrical stimulation therapy for retraining voluntary reaching and grasping in 4 severe chronic pediatric stroke participants. Participants were assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, and Assisting Hand Assessment. All participants improved on all measures. The average change scores on selected Rehabilitation Engineering Laboratory Hand Function Test components were 14.5 for object manipulation (P = .042), 0.78 Nm for instrumented cylinder (P = .068), and 14 for wooden blocks (P = .068) and on the grasp component of Quality of Upper Extremity Skills Test was 25.93 (P = .068). These results provide preliminary evidence that functional electrical stimulation therapy has the potential to improve upper limb function in severe chronic pediatric stroke patients.

Effect of intensive functional electrical stimulation therapy on upper-limb motor recovery after stroke: case study of a patient with chronic stroke

PURPOSE

Motivated by a prior successful randomized controlled trial showing that functional electrical stimulation (FES) therapy can restore voluntary arm and hand function in people with severe stroke, this study was designed to examine neuromuscular changes in the upper limb following intensive FES therapy, consisting of task-specific upper-limb movements with a combination of preprogrammed FES and manual assisted motion.

METHODS

The patient was a 22-year-old woman who had suffered a haemorrhagic stroke 2 years earlier. FES therapy was administered for 1 hour twice daily for 12 weeks, for a total of 108 treatment sessions.

RESULTS

While maximal voluntary contraction level of the upper-limb muscles did not show significant improvement, the ability to initiate and stop the muscle contraction voluntarily was regained in several upper-limb muscles (approx. 5%-15% of the maximum voluntary contraction of the same muscle in the less-affected arm). A reduction in arm spasticity was also observed, as indicated by the reduction of H-reflex in the wrist flexor muscle (82.1% to 45.0% in Hmax/Mmax) and decreased Modified Ashworth Scale scores (from 3 to 2 for the hand and 4 to 3 for the arm). Coordination between shoulder and elbow joints during the circle-drawing test improved considerably over the course of FES therapy: the patient was unable to draw a circle at all at baseline but was able to do so proficiently at discharge.

CONCLUSION

Improvements in upper-limb function observed in people with severe stroke following intensive FES therapy can be attributed to (a) regained ability to voluntarily contract muscles of the affected arm, (b) reduced spasticity and improved muscle tone in the same muscles, and (c) increased range of motion of all joints.

Restoring voluntary grasping function in individuals with incomplete chronic spinal cord injury: pilot study

BACKGROUND

Functional electrical stimulation (FES) therapy has been shown to be one of the most promising approaches for improving voluntary grasping function in individuals with subacute cervical spinal cord injury (SCI).

OBJECTIVE

To determine the effectiveness of FES therapy, as compared to conventional occupational therapy (COT), in improving voluntary hand function in individuals with chronic (≥24 months post injury), incomplete (American Spinal Injury Association Impairment Scale [AIS] B-D), C4 to C7 SCI.

METHODS

Eight participants were randomized to the intervention group (FES therapy; n = 5) or the control group (COT; n = 3). Both groups received 39 hours of therapy over 13 to 16 weeks. The primary outcome measure was the Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT), and the secondary outcome measures were Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), Functional Independence Measure (FIM) self-care subscore, and Spinal Cord Independence Measure (SCIM) self-care subscore. Outcome assessments were performed at baseline, after 39 sessions of therapy, and at 6 months following the baseline assessment.

RESULTS

After 39 sessions of therapy, the intervention group improved by 5.8 points on the TRI-HFT's Object Manipulation Task, whereas the control group changed by only 1.17 points. Similarly, after 39 sessions of therapy, the intervention group improved by 4.6 points on the FIM self-care subscore, whereas the control group did not change at all.

CONCLUSION

The results of the pilot data justify a clinical trial to compare FES therapy and COT alone to improve voluntary hand function in individuals with chronic incomplete tetraplegia.

Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population

Robotic rehabilitation devices have been suggested as a tool to increase the amount of rehabilitation delivered after a neurological injury. Clinical robotic rehabilitation studies of the upper extremity have generally focused on stroke survivors. We present the results of a multi-center pilot study where an upper-limb robotic rehabilitation device (Armeo Spring®, Hocoma AG) was incorporated into the rehabilitation program of 12 subjects with sub-acute cervical spinal cord injury (motor level C4-C6, AIS A-D). Outcomes were measured using two tests of upper extremity function: ARAT and GRASSP. The change in scores for the arm receiving the Armeo training were not statistically significant when compared to the arm not receiving the Armeo training at discharge from therapy and over follow up assessments (8.7 +/- 2.9 compared to 7.4 +/- 2.5 for ARAT at discharge, p = 0.98, and 13.0 +/- 3.2 compared to 13.3 +/- 3.3 for GRASSP at discharge, p = 0.69). Nevertheless, subjects with some minimal (partial) hand function at baseline had a significantly larger increase in GRASSP scores than subjects with no minimal hand function preserved at baseline (19.3 +/- 2.4 compared to 6.6 +/- 4.7, p = 0.02). This suggests that the initial functional capabilities of patients can influence the benefits measured after robotic rehabilitation training and heterogeneous subject populations should be avoided in early phase studies.

Local control of glomus tumors of the head & neck by radiation therapy and surgery

PURPOSE

Glomus tumors are rare tumors, highly vascular and typically radiosensitive. Therapeutic options include surgery, radiation therapy (RT), embolisation or any combination of them, but the appropriate treatment still remains a challenge. The purpose of this study was to report the results of local control of 7 patients with glomus tumors treated with surgery and external beam RT (EBRT).

METHODS

All of the patients underwent primary surgery and then postoperative EBRT. Follow-up was calculated from the date of initiation of EBRT and ranged from 3 to 15 years (mean 7.14, median 6.2). The likelihood of local control was analysed using the Kaplan-Meier product limit method. We also analysed the average duration of response between two groups of patients with different doses of EBRT as well as the presence of acute and late EBRT complications.

RESULTS

Local control was obtained in 6/7 (85.7%) patients. Moreover, local control was achieved in 3/4 (75%) patients with recurrent glomus tumors, while in patients with postoperative residual disease local control was obtained in 3/3 (100%) of them. Patients who received <50 Gy (n=2) had shorter average duration of response compared to patients who received >50 Gy (n=5; p=0.248). There were no severe treatment complications.

CONCLUSION

Surgery and RT represent an appropriate treatment approach for advanced glomus tumors with acceptable complications.

Toronto rehabilitation institute-hand function test: assessment of gross motor function in individuals with spinal cord injury

PURPOSE

The objective of this study was to evaluate the interrater reliability, construct validity, and sensitivity of Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT), within an interventional randomized control trial.

METHOD

Twenty-one participants with subacute C4 to C7 spinal cord injury (SCI) were recruited. Based on randomization, participants were allocated to either the functional electrical stimulation therapy group or the conventional occupational therapy group. Baseline and follow-up assessments of participants were videotaped. For testing interrater reliability, videotaped images were transferred to DVDs that were later observed by 2 observers. Construct validity was determined by comparing total scores on TRI-HFT to self-care subscore components of the Spinal Cord Independence Measure (SCIM) and FIM. To establish sensitivity of TRI-HFT, we compared pre- and posttreatment scores on all 3 measures (ie, TRI-HFT, FIM, and SCIM).

RESULTS

TRI-HFT was found to have high interrater reliability with an intercorrelation coefficient (ICC) of 0.98. Moderate to strong correlations were found between TRI-HFT total scores and self-care components of FIM and SCIM for both hands individually post therapy. Due to a floor effect of the FIM and SCIM, there was weak correlation between pretherapy scores of the said measures and TRI-HFT. TRI-HFT was found to be highly sensitive in determining difference in function pre and post therapy.

CONCLUSIONS

This study demonstrated that the TRI-HFT is a reliable and sensitive measure to assess unilateral hand gross motor function in persons with tetraplegia, with moderate to strong construct validity.

Functional electrical stimulation therapy of voluntary grasping versus only conventional rehabilitation for patients with subacute incomplete tetraplegia: a randomized clinical trial

BACKGROUND

Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI).

OBJECTIVE

This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping.

METHODS

Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up.

RESULTS

At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 (P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible.

CONCLUSION

FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

Rehabilitation of reaching and grasping function in severe hemiplegic patients using functional electrical stimulation therapy

OBJECTIVE

The aim of this study was to establish the efficacy of a therapeutic intervention based on functional electrical stimulation (FES) therapy to improve reaching and grasping function after severe hemiplegia due to stroke.

METHODS

A total of 21 subjects with acute stroke were randomized into 2 groups, FES plus conventional occupational and physiotherapy (FES group) or only conventional therapy (control group) 5 days a week for 12 to 16 weeks. A third group of 7 subjects with chronic hemiplegia (at least 5 months poststroke) received only FES therapy (chronic group) and pre-post training changes were compared. FES was applied to proximal and then distal muscle groups during specific motor tasks. At baseline and at the end of treatment, grasping function was assessed using the Rehabilitation Engineering Laboratory Hand Function Test, along with more standard measures of rehabilitation outcome.

RESULTS

The FES group improved significantly more than the control group in terms of object manipulation, palmar grip torque, pinch grip pulling force, Barthel Index, Upper Extremity Fugl-Meyer scores, and Upper Extremity Chedoke-McMaster Stages of Motor Recovery. The chronic stroke subjects demonstrated improvements in most categories, but the changes were not statistically significant.

CONCLUSIONS

FES therapy with upper extremity training may be an efficacious intervention in the rehabilitation of reaching and grasping function during acute stroke rehabilitation.

Functional electrical therapy: retraining grasping in spinal cord injury

OBJECTIVE

To determine the clinical efficacy of functional electrical therapy in the rehabilitation of grasping function for quadriplegics.

STUDY DESIGN

Randomized intervention-versus-control trial.

SETTING

Rehabilitation hospital for spinal cord injury in Toronto, Canada.

METHODS

A total of 21 people with new spinal cord injuries ranging from C3 to C7 were randomly assigned to two groups: Control (N=9) and Intervention (N=12). The intervention was functional electrical therapy, which consisted of repetitive grasping exercises using a neuroprosthesis that applied surface electrical stimulation to the arm to generate and/or assist grasping movements. It was applied by registered Occupational Therapists in a clinical setting. Main outcome measures were: Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM), and the Rehabilitation Engineering Laboratory Hand Function Test. Consumer perceptions of functional electrical therapy were assessed via qualitative interviews.

RESULTS

Differences between the Control and Intervention groups could be observed although they are not significant due to an insufficient number of participants. Consumer perceptions were positive, including improved Activities of Daily Living and self-satisfaction.

CONCLUSION

Functional electrical therapy has the potential to be an effective treatment modality to restore grasping function in quadriplegia. It can be implemented by occupational therapists in a clinical setting. Further research is required to establish suitable indications for participant selection. In addition, a larger number of participants is needed to demonstrate statistical significance of the Functional Electrical Therapy.

Cheyne-Stokes respiration in stroke: relationship to hypocapnia and occult cardiac dysfunction

BACKGROUND

Central sleep apnea (CSA) and Cheyne-Stokes respiration have been reported in association with stroke, but their pathophysiologic correlates have not been well described.

OBJECTIVE

To test the hypotheses that (1) CSA in patients with stroke is associated with nocturnal hypocapnia and (2) in those stroke patients with CSA and with left ventricular (LV) systolic dysfunction, periodic breathing (PB) will have a Cheyne-Stokes respiration pattern in which cycle duration is greater than in those without LV systolic dysfunction.

METHODS

We prospectively performed polysomnography and echocardiography in 93 patients with stroke. CSA was defined as central apneas and hypopneas occurring at a rate of 10 or more per hour of sleep. In patients with CSA, we compared PB cycle duration between those with normal and impaired LV systolic function (LV ejection fraction [LVEF] > 40% and < or = 40%, respectively).

RESULTS

CSA was found in 19% of subjects who had lower nocturnal transcutaneous PCO2 (39.3 +/- 0.9 vs. 42.8 +/- 0.8 mmHg, p = 0.015) and a higher prevalence of LVEF of 40% or less (22 vs. 5%, p = 0.043) than stroke patients without CSA. There was no significant difference in stroke location or type between the two groups. In patients with CSA, those with LVEF of 40% or less had a longer PB cycle than those with an LVEF of more than 40% (66.6 +/- 5.6 vs. 46.6 +/- 2.9 seconds, p = 0.006), but had no symptoms of heart failure.

CONCLUSION

In patients with stroke, CSA is associated with hypocapnia and occult LV systolic dysfunction but is not related to the location or type of stroke. The presence of LV systolic dysfunction is associated with a Cheyne-Stokes pattern of hyperpnea.

The basis for splenic segmental dearterialization: a post-mortem study

The anatomical features of splenic segmental vessels in 102 human spleen autopsy specimens were analyzed. Methods applied were corrosion casting and post-mortem arteriography. The superior terminal splenic branch divided extracapsularly into 2.8+/-0.9 (range 2-5) and the inferior terminal splenic branch into 2.3+/-0.75 (range 2-5) branches per sample. The extracapsular lengths of the segmental branches ranged from 4.0 to 16.7 mm and the calibers from 0.4 to 2.2 mm. Superior polar arteries occurred in 31.3% and inferior polar arteries in 20.6% of cases. Their average extracapsular lengths were 39 mm and 31 mm, respectively. In conclusion, segmental splenic arteries have an extrasplenic origin and course, with an average length and caliber that allow surgical access and ligation, in order to achieve segmental dearterialization for hemostasis purposes and splenic preservation.

Relationship of sleep apnea to functional capacity and length of hospitalization following stroke

STUDY OBJECTIVES

Recent evidence indicates that sleep apnea is common in patients with stroke. We hypothesized that the presence of sleep apnea among stroke patients would be associated with a greater degree of functional disability and longer hospitalization following stroke.

DESIGN

Prospective study.

SETTING AND PATIENTS

Sixty-one stroke patients admitted to a stroke rehabilitation unit.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Sleep studies were performed on all patients, and sleep apnea was defined as an apnea-hypopnea index of 10 or more per hour of sleep. Patients underwent functional assessments, including the Functional Independence Measure. Sleep apnea was found in 72% of patients; 60% had predominantly obstructive sleep apnea, while 12% had predominantly central sleep apnea. Although the severity of stroke was similar in the 2 groups, compared to patients without sleep apnea, those with sleep apnea had lower functional capacity [Functional Independence Measure score (mean +/- SEM) 80.2 +/- 3.6 versus 94.7 +/- 4.3, p < 0.05 at admission, and 101.5 +/- 2.8 versus 112.9 +/- 2.7, p < 0.05 at discharge] and spent significantly more days in rehabilitation (45.5 +/- 2.3 versus 32.1 +/- 2.7 days, p < 0.005). In addition, multiple regression analysis showed that obstructive sleep apnea was significantly and independently related to functional impairment and length of hospitalization.

CONCLUSIONS

Sleep apnea is very common among stroke patients undergoing rehabilitation, and its presence is associated with worse functional impairment and a longer period of hospitalization and rehabilitation. These data suggest that sleep apnea may be contributing to functional impairment and prolonged hospitalization following stroke.

Is splenic lobe/segment dearterialization feasible for inferior pole trauma during left hemicolectomy?

We discuss splenic salvage by lobe/segment dearterialization, without resection, after intraoperative trauma, and present two cases. We performed a retrospective analysis of 163 patients in whom the colon splenic flexure was mobilized. Patients with ileo-rectal anastomosis or urgent cases were excluded. Surgical operations included left hemicolectomy and anterior resection of the rectum. Splenic procedures were splenorrhaphy, dearterialization and splenectomy. Spleen lesions occurred in 4 (2.45%) cases. One capsular tear was managed with splenorrhaphy. Three mechanical lesions to capsula and tissue of the inferior pole were managed by either splenectomy (the first case) or dearterialization. Overall mortality in the series was 4.3%. Among the patients with splenic procedures, the splenectomized patient died due to pulmonary embolism. The two cases treated by inferior splenic branch and inferior polar artery ligature are presented. In operative trauma to the inferior splenic pole, bleeding can be controlled by lobe/segment dearterialization and by methods of local hemostasis in most cases.

Herpes simplex virus infection in women with previous spontaneous abortion

We have carried out a retrospective clinical investigation of 45 women in the first and second trimester of pregnancy aiming to demonstrate the role of genital HSV infection in the genesis of spontaneous abortion (miscarriage). Latent HSV infection was diagnosed using the microneutralization test; asymptomatic HSV vaginal or cervical shedding was diagnosed with indirect immunofluorescence and cytological-Papanicolau staining. The results showed that the highest incidence of latent HSV type 2 infection (64%) occurred in women who had one or more spontaneous abortions, whereas this type of infection was found in only 5% of pregnant women of the control group. The incidence of asymptomatic cervical HSV type 2 infection was also considerably higher in patients with a history of spontaneous abortions. Our results indicate a possible aetiological connection between HSV and spontaneous abortion.