The Influence of Flush Methods on Transfemoral Catheter Cerebral Angiography: Continuous Flush versus Intermittent Flush.

PURPOSE: To evaluate the influence of different flush methods on transfemoral cerebral angiography (TFCA). MATERIALS AND METHODS: This single-blind randomized controlled trial included 50 patients who had undergone TFCA. Balanced block randomization was used to allocate participants into intermittent-flush (n = 25) and continuous-flush (n = 25) groups. Differences in procedure duration, amounts of contrast medium and heparinized saline used, heparin dose, blood loss, fluoroscopy time, radiation dose, and occurrence of new embolic signal (NES) on diffusion-weighted imaging (DWI) were compared between the two groups. RESULTS: The procedure duration was shorter in the continuous-flush group (mean 26.5 min ± 3.7) than in the intermittent-flush group (mean 29.6 min ± 2.8) (P = .004). Amounts of injected contrast medium (mean 20.2 mL ± 4.4 vs 57.1 mL ± 9.0), wasted heparinized saline (mean 19.8 mL ± 9.6 vs 92.3 mL ± 16.7), and aspirated blood (mean 4.7 mL ± 1.3 vs 13.2 mL ± 2.9) were lower in the continuous-flush group than in the intermittent-flush group (P < .001). The amount of injected (or infused) heparinized saline, heparin dose, fluoroscopy time, radiation dose, and occurrence of NES on DWI did not differ between the groups (P > .05). CONCLUSIONS: The use of continuous flushing during TFCA reduced the procedure time, amount of contrast medium needed, amount of wasted heparinized saline, and blood loss, but no difference in the occurrence of NES on DWI was noted between the groups.

Are plasma homocysteine levels related to neurological severity and functional outcome after ischemic stroke in the Korean population?

Hyperhomocysteinemia is known to be an independent risk factor for arteriosclerosis. However, the prognosis of functional disability in cerebrovascular disease has not been well established. Therefore, we conducted this study to determine the prognostic significance of plasma homocysteine (Hcy) levels in Asian patients with functional disabilities after acute ischemic stroke. A total of 267 patients were examined within 24 h after symptom onset. Hcy was measured at admission. The correlations between plasma Hcy concentration and functional disability at 1-month, 3-months, 6-months, and 12-months after stroke onset were analyzed. In addition, the associations between each risk factor for stroke or neurological severity and plasma Hcy level were evaluated. The results of the present study showed that there was no significant correlation between Hcy level on admission and modified Rankin Scale score obtained at 1-month, 3-months, 6-months, and 12-months after stroke onset. There was also no association between plasma Hcy level and neurological severity after stroke or stroke subtype. This study showed that there is no association between Hcy levels and functional outcome after stroke. Therefore, we cautiously assert that plasma Hcy levels have no value as predictors of functional disability in Asian patients with stroke.

The relationship between low bone mineral density and Parkinson's disease in a Korean population.

There have been few studies concerning osteoporosis in patients with Parkinson's disease (PD), even though patients with PD have a high incidence of falls. Using a Korean population, we investigated the association between bone mineral density (BMD) and PD. A total of 107 patients with PD were compared with age-matched and sex-matched normal controls. Using the Hoehn & Yahr staging system, we classified the patients with PD into three subgroups. Parts II and III of the Unified Parkinson's Disease Rating Scale were administered to evaluate the relationship between the severity of PD and BMD. In conclusion, in the PD population we found that decreased BMD was related to the severity of immobility of patients, and that BMD changes were greater at the femoral neck than the spine area. Therefore, we assert that clinicians should consider administering screening tests to elderly patients with PD and provide appropriate primary or secondary prophylactic treatment for osteoporosis.

See-Through Type 3D Head-Mounted Display-Based Surgical Microscope System for Microsurgery: A Feasibility Study.

BACKGROUND: The surgical microscope is used primarily for microsurgeries, which are more complicated than other surgical procedures and require delicate tasks for a long time. Therefore, during these surgical procedures, surgeons experience back and neck pain. To solve this problem, new technology, such as wearable displays, is required to help surgeons maintain comfortable postures and enjoy advanced functionality during microsurgery. OBJECTIVE: The objective of this study was to develop a surgical microscope system that would work with wearable devices. It would include a head-mounted display (HMD) that can offer 3D surgical images and allow a flexible and comfortable posture instead of fixed eyepieces of surgical microscope and can also provide peripheral visual field with its optical see-through function. METHODS: We designed and fabricated a surgical microscope system that incorporates a see-through type 3D HMD, and we developed an image processing software to provide better image quality. The usability of the proposed system was confirmed with preclinical examination. Seven ENT (ear, nose, and throat) surgical specialists and 8 residents performed a mock surgery-axillary lymph node dissection on a rat. They alternated between looking through the eyepieces of the surgical microscope and viewing a 3D HMD screen connected to the surgical microscope. We examined the success of the surgery and asked the specialists and residents to grade eye fatigue on a scale of 0 (none) to 6 (severe) and posture discomfort on a scale of 1 (none) to 5 (severe). Furthermore, a statistical comparison was performed using 2-tailed paired t test, and P=.00083 was considered significant. RESULTS: Although 3D HMD case showed a slightly better result regarding visual discomfort (P=.097), the average eye fatigue was not significantly different between eyepiece and 3D HMD cases (P=.79). However, the average posture discomfort, especially in neck and shoulder, was lower with 3D HMD display use than with eyepiece use (P=.00083). CONCLUSIONS: We developed a see-through type 3D HMD-based surgical microscope system and showed through preclinical testing that the system could help reduce posture discomfort. The proposed system, with its advanced functions, could be a promising new technique for microsurgery.

Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis.

OBJECTIVE: To quantify the adherence of patients to drug therapy for osteoporosis in real-world settings via a systematic review and meta-analysis of observational studies. METHODS: The PubMed and Cochrane databases were searched for English-language observational studies published from January 1, 1990, to February 15, 2006, that assessed patient adherence to drug therapy for osteoporosis using the following medical subject headings and keywords: drug therapy, medication adherence, medication persistence, medication possession ratio, patient compliance, and osteoporosis. Studies were stratified into 3 groups: persistence (how long a patient continues therapy), compliance (how correctly, in terms of dose and frequency, a patient takes the medication), and adherence (a combination of persistence and compliance). A random-effects model was used to pool results from the selected studies. RESULTS: Twenty-four studies were included in the meta-analysis. The pooled database-derived persistence rate was 52% (95% confidence interval [CI], 44%-59%) for treatment lasting 1 to 6 months, 50% (95% CI, 37%-63%) for treatment lasting 7 to 12 months, 42% (95% CI, 20%-68%) for treatment lasting 13 to 24 months, returning to 52% (95% CI, 45%-58%) for treatment lasting more than 24 months. Pooled adherence rates decreased from 53% (95% CI, 52%-54%) for treatment lasting 1 to 6 months to 43% for treatment lasting 7 to 12 months (95% CI, 38%-49%) or 13 to 24 months (43%; 95% CI, 32%-54%). The pooled refill compliance estimate was 68% (95% CI, 63%-72%) for treatment lasting 7 to 12 months and 68% (95% CI, 67%-69%) for treatment lasting 13 to 24 months. The pooled self-reported compliance rate was 62% (95% CI, 48%-75%) for treatment lasting 1 to 6 months and 66% (95% CI, 45%-81%) for treatment lasting 7 to 12 months. CONCLUSION: One-third to half of patients do not take their medication as directed. Nonadherence occurs shortly after treatment initiation. Terms and definitions need to be standardized to permit comparability of technologies designed to improve patient adherence. Prospective trials are needed to assess the relationship between adherence and patient outcomes.

Evaluating Adherence to Dilated Eye Examination Recommendations Among Patients with Diabetes, Combined with Patient and Provider Perspectives.

BACKGROUND: Diabetes mellitus remains the leading cause of new cases of blindness among US adults. Routine dilated eye examinations can facilitate early detection and intervention for diabetes-related eye disease, providing an opportunity to reduce the risk for diabetes-related blindness in working-aged Americans. The Healthcare Effectiveness Data and Information Set (HEDIS) established criteria for performing dilated eye examination in patients with diabetes. OBJECTIVES: To obtain information about adherence and nonadherence to diabetic eye examinations among insured patients to understand the barriers to routine dilated eye examinations, and to identify ways to improve the quality of care for these patients. METHODS: This retrospective claims analysis is based on administrative claims from the HealthCore Integrated Research Database, a broad database representing claims from a large commercially insured population. Patients with diabetes and who had ≥1 dilated eye examinations between August 1, 2011, and July 31, 2013, were defined as adherent to the HEDIS recommendations. The analysis was augmented with findings from focus groups. The patient focus groups included adherent and nonadherent patients. The provider focus group participants were general practice or internal medicine physicians and ophthalmologists who provided medical care for the study population. For the administrative claims analysis, comparisons between the adherent and nonadherent patients were performed using t-tests for continuous data and chi-square tests for categorical data. RESULTS: Of 339,646 patients with diabetes identified in a claims data set, 43% were adherent and 57% were nonadherent to the HEDIS eye examination performance measure. The common barriers to routine eye examination cited by 29 patients across 4 focus groups included a lack of understanding of insurance benefits (N = 15), a lack of awareness of the importance of dilated eye examinations (N = 12), and time constraints (N = 12). The common barriers cited by 18 providers included the patient's level of education (N = 13), eye examinations as a lower priority than the management of other diabetes-related health issues (N = 12), and a lack of symptoms (N = 11). CONCLUSION: Several reasons for patient nonadherence to routine eye examination were identified, including a lack of understanding of insurance benefits, a lack of awareness or low prioritization of having an examination, patient education level, time constraints, and a lack of symptoms. These may be considered by providers and payers when developing programs to increase the rates of eye examinations and improve outcomes among patients with diabetes.

Health care resource utilization and the impact of anemia management in patients with chronic kidney disease.

BACKGROUND: Limited information exists on resource utilization patterns and overall patient management of chronic kidney disease (CKD) before the initiation of dialysis therapy. METHODS: A retrospective claims analysis from January 1997 to December 1999 was conducted using a managed care database on 1,936 incident dialysis patients, examining the 12 months preceding dialysis initiation to evaluate whether managed care patients with CKD are receiving expected interventions and appropriate management of CKD. RESULTS: Mean age was 66.8 years, 46% were women, 91.2% had claims for facility services, 97.6% had claims for professional services, and 95.7% had claims for outpatient pharmacy, with mean costs per patient of $26,204, $9,623, and $1,503, respectively. Sixty-two percent of patients were hospitalized, averaging 1.3 admissions annually ($14,818/admission; average, 7.8 d/admission). Despite high overall resource use, treatments for preparation for dialysis therapy, appropriate tests, and nutritional supplements (eg, phosphate binders, B-complex combinations, and vitamins with iron) were administered infrequently. Comorbid conditions, such as anemia (47.4%) and diabetes (53%), were appropriately addressed with erythropoietin (10.5%) and angiotensin-converting enzyme inhibitors (38%) in only a minority of cases. In preparation for dialysis therapy, only 20.8% underwent a vascular access procedure. CONCLUSION: Although patients consumed significant amounts of resources during the 12 months before dialysis initiation, many were not using expected resources for the appropriate management of CKD. A number of opportunities exist to improve predialysis care through better management of these conditions.

Physician-pharmacist comanagement of hypertension: a randomized, comparative trial.

OBJECTIVE: To compare the effectiveness of an evidence-based, systematic approach to hypertension care involving comanagement of patients by primary care physicians and clinical pharmacists versus usual care in reducing blood pressure in patients with uncontrolled hypertension. METHODS: Patients in a staff model medical group with uncontrolled hypertension were randomized to either a usual care (UC) or a physician-pharmacist comanagement (PPCM) group. All physicians in the study received both group and individual education and participated in the development of an evidence-based hypertension treatment algorithm. Physicians were then given the names of their patients whose medical records documented elevated blood pressures (defined as systolic > or = 140 mm Hg and/or diastolic > or = 90 mm Hg for patients aged < 65 yrs, and systolic > or = 160 mm Hg and/or diastolic > or = 90 mm Hg for those aged > or = 65 yrs). Patients randomized to the UC group were managed by primary care physicians alone. Those randomized to the PPCM group were comanaged by their primary care physician and a clinical pharmacist, who provided patient education, made treatment recommendations, and provided follow-up. Blood pressure measurements, antihypertensive drugs, and visit costs/patient were obtained from medical records. RESULTS: One hundred ninety-seven patients with uncontrolled hypertension participated in the study. Both PPCM and UC groups experienced significant reductions in blood pressure (systolic -22 and -11 mm Hg, respectively, p < 0.01; diastolic -7 and -8 mm Hg, respectively, p < 0.01). The reduction in systolic blood pressure was greater in the PPCM group after adjusting for differences in baseline blood pressure between the groups (p < 0.01). More patients achieved blood pressure control in the PPCM than in the UC group (60% vs 43%, p = 0.02). Average provider visit costs/patient were higher in the UC than the PPCM group ($195 vs $160, p = 0.02). CONCLUSIONS: An evidence-based, systematic approach using physician-pharmacist comanagement for patients with uncontrolled hypertension resulted in improved blood pressure control and reduced average visit costs/patient.

Low bone mineral density is associated with poor clinical outcome in acute ischemic stroke.

BACKGROUND: Chronic low bone mineral density is associated with an increased risk of stroke. However, little is known about the influence of bone mineral density at the time of stroke on clinical outcome. We investigated the association between bone mineral density and functional disability at three-months in patients with acute ischemic stroke. METHODS: We retrospectively examined consecutive acute ischemic stroke patients who underwent bone densitometry tests within seven-days of stroke symptom onset. Patient demographics, risk factors, and initial National Institute of Health Stroke Scale scores were assessed. Bone mineral density was measured at the lumbar spine and bilateral femoral necks. Osteoporosis was defined as bone mineral density ≤-2·5 T-scores at each site. The primary outcome was modified Rankin Scale at 90 days poststroke. A favorable outcome was defined as modified Rankin Scale 0-1 and poor outcome as modified Rankin Scale 2-6. RESULTS: Of the 191 patients included, 61 (31·9%) were men. Mean age (±standard deviation) was 69·8 ± 11·1 years. Patients with osteoporosis of the right femoral neck were more likely to have poor outcome (25/82; 30·5%) than those without (12/109; 11·0%, P = 0·001). After adjustment for age, sex, and initial National Institute of Health Stroke Scale score, osteoporosis of the right femoral neck was significantly associated with poor outcome (odds ratio, 2·97; 95% confidence interval 1·21 to 7·32, P = 0·018). CONCLUSIONS: Low bone mineral density of the right femur in the acute poststroke period is associated with poor outcome at three-months. Assessment of bone mineral density in acute stroke patients may be a useful prognosticator and facilitate early intervention.

Acetazolamide-challenged perfusion magnetic resonance imaging for assessment of cerebrovascular reserve capacity in patients with symptomatic middle cerebral artery stenosis: comparison with technetium-99m-hexamethylpropyleneamine oxime single-photon emission computed tomography.

OBJECTIVES: Acetazolamide-challenged perfusion magnetic resonance imaging (MRI) has been shown as a method for assessment of cerebrovascular reserve (CVR) capacity in patients with atherosclerotic steno-occlusive disease of internal carotid artery. We have assessed the feasibility of the acetazolamide-challenged perfusion MRI for evaluating CVR in symptomatic patients with severe middle cerebral artery (MCA) stenosis (≥70%) by comparison with the acetazolamide-challenged technetium-99m-hexamethylpropyleneamine oxime (HMPAO) single-photon emission computed tomography (SPECT). METHODS: Seventeen prospectively enrolled patients with symptomatic unilateral MCA stenosis underwent technetium-99m-hexamethylpropyleneamine oxime SPECT and perfusion MRI without and with acetazolamide challenge, respectively. Acetazolamide-challenged SPECT and perfusion MRI were compared quantitatively by Region of interest (ROI) analysis. RESULTS: At all ROIs, there were no significant differences in percent change between SPECT and perfusion MRI. Patients with impaired CVR showed significant decreases in the percent changes of respective cerebral blood flow (P=.016) and respective cerebral blood volume (P=.029). CONCLUSION: Acetazolamide-challenged perfusion MRI is feasible for evaluating CVR in symptomatic patients with severe MCA stenosis quantitatively.

Measurement of precuneal and hippocampal volumes using magnetic resonance volumetry in Alzheimer's disease.

BACKGROUND AND PURPOSE: Alzheimer's disease (AD) is associated with structural alterations in the medial temporal lobe (MTL) and functional alterations in the posterior cortical region, especially in the early stages. However, it is unclear what mechanisms underlie these regional discrepancies or whether the posterior cortical hypometabolism reflects disconnection from the MTL lesion or is the result of local pathology. The precuneus, an area of the posteromedial cortex that is involved in the early stages of AD, has recently received a great deal of attention in functional neuroimaging studies. To assess the relationship between the precuneus and hippocampus in AD, we investigated the volumes of these two areas using a magnetic resonance volumetric method. METHODS: Twenty-three subjects with AD and 14 healthy age-matched controls underwent T1-weighted three-dimensional volumetric brain magnetic resonance imaging. Volumetric measurements were performed in the precuneus and hippocampus. RESULTS: Compared to controls, AD patients exhibited a significant reduction in total precuneal volume, which was more prominent on the right side, and significant bilateral reductions in hippocampal volume. No correlation was found between the total volumes of the precuneus and hippocampus in the AD group. CONCLUSIONS: These results suggest that volumetric measurements of both the precuneus and hippocampus are useful radiological indices for the diagnosis of AD. Furthermore, the lack of correlation is attributable to local pathology rather than being a secondary consequence of MTL pathology.

Pure sensory deficit at the t4 sensory level as an isolated manifestation of lateral medullary infarction.

In rare cases restricted sensory deficits along the somatotopic topography of the spinothalamic tract can develop from a lateral medullary infarction. To our knowledge, isolated dermatomal sensory deficit as a single manifestation of a lateral medullary infarction has not been reported previously. A 58-year-old man presenting with sudden left-sided paresthesia complained of sensory deficit of pain and temperature below the left T4 sensory level without other neurologic deficits. Diffuse- and T2-weighted magnetic resonance imaging (MRI) of the brain showed high signal intensities in the right lower medulla oblongata, whereas thoracic-spine MRI and somatosensory evoked potentials produced normal findings.