Outcomes With Multidisciplinary Cardiac Rehabilitation in Post-acute Systolic Heart Failure Patients-A Retrospective Propensity Score-Matched Study.

Background: Cardiac rehabilitation (CR) is recommended for patients with acute heart failure (HF). However, the results of outcome studies and meta-analyses on CR in post-acute care are varied. We aimed to assess the medium- to long-term impact of CR and ascertain the predictors of successful CR. Methods: In this propensity score-matched retrospective cohort study, records of consecutive patients who survived acute HF (left ventricular ejection fraction <40) and participated in a multidisciplinary HF rehabilitation program post-discharge between May 2014 and July 2019 were reviewed. Patients in the CR group had at least one exercise session within 3 months of discharge; the others were in the non-CR group. After propensity score matching, the primary (all-cause mortality) and secondary (HF readmission and life quality assessment) outcomes were analyzed. Results: Among 792 patients, 142 attended at least one session of phase II CR. After propensity score matching for covariates related to HF prognosis, 518 patients were included in the study (CR group, 137 patients). The all-cause mortality rate was 24.9% and the HF rehospitalization rate was 34.6% in the median 3.04-year follow-up. Cox proportional hazard analysis revealed that the CR group had a significant reduction in all-cause mortality compared to the non-CR group (hazard ratio [HR]: 0.490, 95% confidence interval [CI]: 0.308-0.778). A lower risk of the primary outcome with CR was observed in patients on renin-angiotensin-aldosterone system (RAAS) inhibitors, but was not seen in patients who were not prescribed this class of medications (interaction p = 0.014). Conclusions: Cardiac rehabilitation participation was associated with reduced all-cause mortality after acute systolic heart failure hospital discharge. Our finding that the benefit of CR was decreased in patients not prescribed RAAS inhibitors warrants further evaluation.

Bone infarction of the hip after hand allotransplantation: A case report.

Vascularized composite allotransplantation represents as an emerging field in reconstructive surgery. However, some complications can be associated with the procedure. The authors describe a case of bone infarctions of the bilateral hip joints following the first hand allotransplantation in Taiwan. A 45-year-old man who experienced a traumatic amputation of the distal third of his forearm received a hand transplantation from a brain-dead donor. Immunosuppression included antithymocyte globulins, and bolus methylprednisolone (Solu-Medrol) was used for the induction. The maintenance therapy protocol included systemic tacrolimus, mycophenolate mofetil, and prednisone. The patient discontinued the systemic steroid 15 months after surgery. Two episodes of acute rejections were observed at 105 and 810 days after surgery. These signs disappeared after pulse therapy with Solu-Medrol, titration with tacrolimus, and topical immunosuppressive creams (tacrolimus and clobetasol). However, the patient felt pain in both hips after long periods of standing 30 months after the transplantation. A pelvic radiograph and magnetic resonance imaging revealed avascular necrosis (AVN) in both hip joints. Because of the progressive worsening of the pain, the patient underwent a decompression surgery on the left hip involving a fibula bone graft. The patient underwent a right hip hemi-arthroplasty with a bipolar prosthesis 3 months later. The patient remained in good health without major complications. These findings indicate that systemic steroids and tacrolimus might be the major predisposing factors for the induction of AVN after hand allotransplantation.

The First Hand Allotransplantation in Taiwan: A Report at 9 Months.

PURPOSE: Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. MATERIALS AND METHODS: On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. RESULTS: The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient. CONCLUSIONS: Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.

Hand function measures for burn patients: a literature review.

Hand function is one of the most important goals of burn rehabilitation and is a consensually important functional outcome. The purpose of this article is to review the available hand function measures commonly used for burn patients and to summarize their psychometric properties and clinical utilities to serve as guidelines for clinical practice and research. An online-database search of PubMed, MEDLINE, CINAHL and PsychInfo was performed. One hundred and seventeen articles were found and 23 of them met the inclusion and exclusion criteria. The eight identified measurement instruments were then classified into three categories: traditional component measures, performance measures and patient-reported outcome measures. Each type of hand function measure has its unique characteristics and limitations. Traditional component measures only reflect hand impairments, and may not represent hand function status. Performance measures have not been validated in the burn population and do not correlate well with patient-reported outcomes. Patient-reported outcome measures have not been rigorously validated in the burn population. A discussion of how clinicians choose these measures reflecting the purposes of their measurements and goals of intervention is provided. Moreover, future studies are suggested to develop burn-specific hand function measures.

The effectiveness of interactive computer assisted instruction compared to videotaped instruction for teaching nurses to assess neurological function of stroke patients: a randomized controlled trial.

BACKGROUND: Teaching inexperienced nurses to assess neurologic function of acute ischemic stroke patients poses challenges to educators in Taiwan. OBJECTIVES: The purpose of this study was to examine the effectiveness of two programs that teach nurses the use of the Chinese version of the National Institute of Health Stroke Scale (C-NIHSS), and to evaluate the level of learner satisfaction with these teaching programs. DESIGN: An experimental research design with two groups, one pre-test and two post-tests was utilized. SETTING: Six neurology and neurosurgery wards at two hospitals in southern Taiwan. PARTICIPANTS: Participating nurses were stratified based on their clinical level of experience and prior training on the National Institute of Health Stroke Scale (NIHSS). They were randomly assigned to either the experimental C-NIHSS interactive computer assisted instruction (ICAI) group (n=44) or the Instructor-led videotape learning program (IVLP) group (n=40) to learn the C-NIHSS. METHODS: The measurement tools included the score verification unit (SVU) (score range from 0 to 45, content validity index, CVI=0.96, percentage agreement=84%) and the learner satisfaction scale (CVI=0.92, Cronbach's alpha=0.97). RESULTS: Both groups' scores on the assessment of correctness significantly increased (F=35.50, p=0.00) after intervention. However, there was an insignificant difference between the changes in the two groups (F=0.02, p=0.89). After using one-way ANCOVA analysis, and adjusting for the length of experience in neurological nursing, the results showed that in the second post-test, the ICAI group's score was significantly higher than that of the IVLP group (F=4.81, p=0.03). There was a positive correlation between assessment correctness on the second post-test and length of experience in neurological nursing (r=0.35, p<0.05). It was concluded that nurses with less experience in neurological nursing, who receive ICAI will perform a better assessment of stroke patients than those who received IVLP. CONCLUSION: The C-NIHSS ICAI teaching program contributed to better assessment correctness after adjusting for the length of experience in neurological nursing, and to some extent increased satisfaction for the participating nurses. Therefore it is worth promoting the use of ICAI for in-service education of nurses, especially for nurses with less experience in neurological nursing, in order to enhance long-term effects of learning.

Wisconsin Card Sorting Test performance after putaminal hemorrhagic stroke.

The purpose of this study was to compare the performance differences in the Wisconsin Card Sorting Test (WCST) between 55 patients with putaminal hemorrhage (PH) 3 months after stroke and 69 age-matched normal controls. Impairment on WCST was defined as performance greater than 1.64 standard deviation below the control mean. A multivariate analysis of covariance (MANCOVA) controlling for education yielded a significant main effect for group but not for education and interaction of group x education. Univariate analyses revealed significant between-group differences in five WCST measures, including perseverative errors (PE), perseverative responses (PR), conceptual-level responses (CLR), number of categories completed (NCC), and trials to complete the first category (TCC). For patients with PH, z-scores for two WCST indices were within the impaired range: TCC and PR. A high percentage of patients (40-47%) scored in the designated impaired range on NCC, PR, PE, and TCC. The WCST variables discriminated patients from controls with an overall accurate classification rate of 91.9%. Of these, the variables that contributed most to the differentiation between patients and normal controls were PE, CLR, and total number correct (TNC) (a standardized canonical discriminant function coefficient > 0.40). Finally, no significant hemispheric laterality effects emerged on any of the WCST variables. The results of this study provide further evidence of impaired mental set shifting in stroke patients with PH. The implications for rehabilitation professionals are discussed, and recommendations for further research are made.