The comparative efficacy of theta burst stimulation or functional electrical stimulation when combined with physical therapy after stroke: a randomized controlled trial.

OBJECTIVE:: To study the long-term effectiveness of Theta Burst Stimulation (TBS) or Functional Electrical Stimulation (FES) combined with Physical therapy (PT) as compared to PT alone for improving arm functions in patients with acute stroke. DESIGN:: Single blind randomized controlled trial. SETTING:: Outpatient clinics and inpatient wards at tertiary care neurology center. SUBJECTS:: Adult patients with acute middle cerebral artery territory ischemic stroke. INTERVENTIONS:: 60 patients were randomized into three groups of 20 each: TBS+PT; FES+PT; and PT alone. TBS group received intermittent TBS of ipsilesional hemisphere and continuous TBS of contralesional hemisphere while FES group received FES of paretic limb, both for four weeks. All groups received supervised physical therapy for four weeks followed by home physiotherapy for one year. OUTCOME MEASURES:: Fugl Meyer Assessment upper limb score (FMA-UL) was primary outcome measure. Patients were evaluated at baseline and subsequently at one, three and six months and one year. RESULTS:: Compared to PT group, mean FMA-UL scores were higher in TBS and FES groups at all follow-ups ( P < 0.001). From baseline to one year, mean (SD) FMA-UL scores increased from 14.9(2.1) to 55.55(2.46) in TBS group, 15.5(1.99) to 55.85(2.46) in FES group, and 14.3(2.2) to 43.3(4.22) in PT group indicating an increase of 273%, 260%, and 203% respectively. There was no difference between FES and TBS groups. CONCLUSION:: A four-week intervention with TBS or FES combined with PT produces better long-term arm functions as compared to PT alone in patients with acute stroke.

Characteristics of the post-surgical decrease in platelet counts in orthopedic surgery patients, observations and insights.

INTRODUCTION: A reduced platelet count (PLT) is a frequent post-operative finding in orthopedic surgery patients. Despite its prevalence, the characteristics of post-surgical thrombocytopenia have not been well described. METHODS: A retrospective chart review was conducted on patients who underwent a knee or hip replacement from 2012 to 2015. Patients who received heparin were excluded. RESULTS: A total of 56 patients were analyzed on post-operative days 0 to 4. By day 1, 90.9% of the patients experienced a reduction in their platelet counts. The lowest mean platelet count (nadir) occurred on day 2 (201.3 × 109/L). The average decrease in the platelet count from the baseline was 24% (95%CI: 20.6 - 27.2). The change in the platelet count from the baseline ranged from a 49.6% drop to a 14.2% increase. A substantial portion of patients experienced thrombocytopenia, with 28% occurring on day 2. Platelet counts less than 100 × 109/L occurred only once. The percent decrease in the platelet count from the baseline to any other time point was significantly larger in patients aged > 65 years, compared to patients aged ≤ 65 years (p = 0.007). Specifically, the average drop in the platelet count at the nadir (day 2) relative to the baseline was 27.8% in patients aged > 65 years, compared to 19.5% in patients aged ≤ 65 years. CONCLUSIONS: A reduction in the platelet count is a frequent post-operative finding in orthopedic surgery patients, even after removing confounding factors, such as heparin exposure, but clinical thrombocytopenia is uncommon. Alternative etiologies should be considered when the platelet count is less than 100 × 109/L. Vigilance should also be considered regarding elderly patients.

The contribution of competing mechanisms in stroke despite anticoagulation in patients with atrial fibrillation.

BACKGROUND: For reasons poorly understood, strokes frequently occur in patients with atrial fibrillation (AF) despite oral anticoagulation. Better data are needed to inform randomised trials (RCTs) of new strategies to prevent recurrence in these patients. We investigate the relative contribution of competing stroke mechanisms in patients with AF who have stroke despite anticoagulation (OAC+) compared with those who are anticoagulant naïve (OAC-) at the time of their event. PATIENTS AND METHODS: We performed a cross-sectional study leveraging data from a prospective stroke registry (2015-2022). Eligible patients had ischemic stroke and AF. Stroke classification was performed by a single stroke-specialist blinded to OAC status using TOAST criteria. The presence of atherosclerotic plaque was determined using duplex ultrasonography, computerised tomography (CT) or magnetic resonance (MR) angiography. Imaging was reviewed by a single reader. Logistic regression was used to identify independent predictors of stroke despite anticoagulation. RESULTS: Of 596 patients included, 198 (33.2%) were in the OAC+ group. A competing cause for stroke was more frequent in patients with OAC+ versus OAC- (69/198 (34.8%)) versus 77/398 (19.3%), p < 0.001). After adjustment, both small vessel occlusion (odds ratio (OR): 2.46, 95% CI: 1.20-5.06) and arterial atheroma (⩾50% stenosis) (OR: 1.78, 95% CI: 1.07-2.94) were independently associated with stroke despite anticoagulation. DISCUSSION AND CONCLUSION: Patients with AF-associated stroke despite OAC are much more likely than patients who are OAC-naïve to have competing stroke mechanisms. Rigorous investigation for alternative stroke causes in stroke despite OAC has a high diagnostic yield. These data should be used to guide patient selection for future RCTs in this population.

An uncommon complication of acute stroke thrombolysis.

Thrombolysis with tissue plasminogen activator is a well-established treatment for acute ischaemic stroke. We report a case of an 87-year-old woman who developed an acute ischaemic limb, on the background of stroke thrombolysis, and underwent an embolectomy. A rare but serious complication, there are few reports of similar thromboembolic events, particularly in patients with known atrial fibrillation as presented in this case. Early recognition of this rare complication may prevent long-term, and at times fatal, complications.

The incidence and prevalance of idiopathic intracranial hypertension in south Sharaqiah region, Oman.

BACKGROUND: To determine the incidence and demographic features of idiopathic intracranial hypertension (IIH) in south Sharqiyah, Sultanate of Oman. MATERIALS AND METHODS: A retrospective review of Omani patients diagnosed as IIH in Sur Regional Hospital from January 2001 to December 2011 was carried out. All patients fulfilled the modified Dandy criteria for IIH. Data collected included age and sex of patients, age of onset of the disease, body mass index (BMI), presence of comorbid conditions, and medication use. Findings of ophthalmic examination, neuroimaging, and neurological assessment were recorded. Total number of new outpatients in the study period and the 2010 south Sharqiyah mid-population statistics were also collected. RESULTS: Forty patients were diagnosed as IIH during a period of 11 years from January 2001 to December 2011 in Sur Regional Hospital. The female to male ratio was 3:1; of the 40 patients; 30 (75%) females and 10 (25%) males. Thirteen patients (32.5%) were children below 15 years. Of females in the child bearing age (15-44 years), 60% were obese. As per 2010 census, the Omani population in south Sharqiyah region was 166,318. The calculated annual incidence per 100,000 persons of general population was 2.18. Annual incidence in women of all ages per 100,000 persons was 3.25 and in women of child bearing age was 4.14. In children below 15 years, the incidence was 1.9 per 100,000 children; it was 2.96 per 100,000 for female children. CONCLUSION: This study shows that the incidence in south Sharqiyah is comparable to that of other countries. Females and obese patients are at a higher risk of developing IIH. Obesity is not a risk factor in males and children. Nearly 60% of the females in the child bearing age were obese.

A retrospective study of fungal corneal ulcers in the South sharqiyah region in oman.

OBJECTIVES: To study the incidence, identify the risk factors and determine the predominant microorganisms and treatment regimen of fungal corneal ulcers. METHODS: This was a retrospective analysis of corneal ulcers treated in the Ophthalmology Department of Sur Hospital, Oman, undertaken from January 2004 to December 2007. Medical and microbiology records of thirty two culture proven cases of fungal keratitis were reviewed for risk factors, laboratory findings and response to treatment. RESULTS: Out of the total 242 corneal ulcers, 13.22 % were fungal. Among the 102 culture positive cases, 31.38 % were fungal isolates. Fusarium spp (50%) and Aspergillus spp (34.4%) predominated in the hyaline fungal spectrum. The important risk factors were topical steroid usage in 31.25 % of cases and ocular injury in 25 %. The majority of cases (90.62%) responded to 2% ketoconazole alone or in combination with 0.15% amphotericin B. CONCLUSION: Fungal ulcer remains one of the leading causes of visual disability. Indiscriminate use of topical steroids and ocular trauma are the most important risk factors. Filamentous fungi are common aetiological agents in this region. Topical ketoconazole and amphotericin B were very effective for most of the cases.

Tear film status in patients attending the eye clinic in South sharqiya region.

OBJECTIVE: To study the tear film profile of patients attending the eye clinic of Sur hospital of South Sharqiya region of Oman and to study the epidemiology of patients having abnormal tear film profile. METHOD: Patients attending the eye clinic of Sur hospital and B. Ali eye clinic were asked about the clinical symptoms relevant to dry eye and subjected to tear film tests namely TBUT (Tear Break up Time) and Schirmer's 1 to assess tear film profile. Patients with irregular corneas were excluded from the study. Overall 127 patients were included in the study. RESULTS: 42.5% (95% CI: 33.9% to 51.1%) of patients examined had abnormal tear film profile with patients >30 years 56.75% (95% CI: 45.4% to 68%) showing abnormality more often and females 40.3% (95% CI: 29.3% to 51.2%) outnumbered males. Burning was the main symptom in patients with abnormal tear film profile. CONCLUSION: We infer that a large number of patients had abnormal tear film profile most of them were asymptomatic and trachoma figured prominently amongst the diseases in cases with abnormal tear film profile.