Stroke Impact Scale-16: A brief assessment of physical function.

OBJECTIVES: To 1) develop a short instrument (Stroke Impact Scale-16 [SIS-16]) to assess physical function in patients with stroke at approximately 1 to 3 months poststroke using items from the composite physical domain of the Stroke Impact Scale (SIS) version 3.0, and 2) compare the SIS-16 and a commonly used disability measure, the Barthel Index (BI), in terms of their ability to discriminate disability. METHODS: A total of 621 subjects enrolled in the GAIN Americas randomized stroke trial were included in this study. Rasch analysis, which models the probability of a subject's response to an item using both subject ability and item difficulty, was used to construct the SIS-16, describe its properties, and compare its ordering and range of item difficulties to those of the BI. Box plots and analysis of variance were used to examine differences in BI and SIS-16 scores across modified Rankin categories. RESULTS: The study sample had an average age of 68 +/- 12.4 years and 56% were men. Stroke diagnoses were classified as minor in 91 patients (NIH Stroke Scale score [NIHSS] 0 to 5), moderate in 304 (NIHSS 6 to 13), and major in 226 (NIHSS >/= 14). Twelve of the original 28 items in the SIS version 3.0 composite physical domain were eliminated to produce the SIS-16, with a minimal loss of reliability. As compared to the BI, the SIS-16 contains more difficult items that can differentiate patients with less severe limitations, and therefore has less pronounced ceiling effects. SIS-16 scores were significantly different across Rankin levels 0 to 1, 2, 3, 4, and 5, whereas BI was significantly different only across Rankin levels 0 to 2, 3, 4, and 5. CONCLUSION: Compared to the BI, the SIS-16 is an excellent collection of items suitable for assessing a wide range of physical function limitations of patients with stroke at 1 to 3 months poststroke. Because of a less pronounced ceiling effect, the SIS-16 can differentiate lower levels of disability as compared to the BI.

Glycine antagonist in neuroprotection for patients with acute stroke: GAIN Americas: a randomized controlled trial.

CONTEXT: Elucidation of the ischemic cascade has helped stimulate development of neuroprotective drugs aimed at limiting brain injury in the hours following an ischemic stroke. To date, none of these drugs has shown clinical efficacy. OBJECTIVE: To examine the efficacy of gavestinel (GV150526), an antagonist of the glycine site of the N-methyl-D-aspartate receptor, as a neuroprotective therapy for acute ischemic stroke when administered within 6 hours of symptom onset. DESIGN: The Glycine Antagonist in Neuroprotection (GAIN) Americas trial, a randomized, double-blind placebo-controlled trial with enrollment from April 1998 to October 1999. SETTING: One hundred thirty-two hospital centers across the United States and Canada. PATIENTS: The primary efficacy population consisted of 1367 ischemic stroke patients with a predefined level of limb weakness and functional independence prior to stroke, stratified at randomization by age (75 years) and initial stroke severity (National Institutes of Health [NIH] Stroke Scale scores of 2-5, 6-13, or >/=14). INTERVENTION: Patients were randomly assigned to receive an intravenous loading dose (800 mg) plus 5 maintenance doses (200 mg every 12 hours) of gavestinel (n = 701) or placebo (n = 666) for 3 days. MAIN OUTCOME MEASURE: Functional capability at 3 months, measured by the Barthel Index (BI), with scores trichotomized as dead/0-55, 60-90, and 95-100, compared between the gavestinel and placebo groups. RESULTS: Treatment groups were well matched for baseline characteristics. For each group, median NIH Stroke Scale was 12, median age was 72 years, and median time to treatment was 5.2 hours. No statistically significant improvement on the 3-month BI trichotomy was demonstrated for gavestinel (P =.79). The proportion who were functionally independent (BI score = 95-100) was 39% in the gavestinel group and 37% in the placebo group. No statistically significant difference in 3-month survival was observed using Kaplan-Meier curves (P =.11). No other secondary end point suggested an advantage for gavestinel. Among the 333 patients (24%) who received recombinant tissue-type plasminogen activator, there was also no benefit for gavestinel (P =.53). There were no serious safety issues. CONCLUSION: In this study, gavestinel administered up to 6 hours after an acute ischemic stroke did not improve functional outcome at 3 months.

Modulatory impact of acid and pepsin on esophageal hydrophobicity in humans.

OBJECTIVES: The role of hydrophobicity in the pathophysiology of the gastrointestinal tract is well established as a protective mechanism against the impact of lumenal acid and pepsin. Hydrophobic properties of esophageal secretion in humans remain largely unknown. METHODS: We have studied, therefore, hydrophobicity by using fluorescence probe in human esophageal secretion, elaborated under the impact of saline followed by HCl, HCl/pepsin, and final saline. RESULTS: Basal hydrophobicity of human esophageal secretion, elaborated during mucosal exposure to saline, was 237 +/- 32. This value, however, declined 72% during mucosal exposure to HCl (66 +/- 14 vs 237 +/- 32; p < 0.001) and 87% during mucosal exposure to acid supplemented with pepsin (30 +/- 4 vs 237 +/- 32; p < 0.001). Moreover, hydrophobicity upon perfusion with HCl/pepsin was 55% lower than after perfusion with HCl alone (30 +/- 4 vs 66 +/- 14), although the result was insignificant. Substitution of saline for HCl/pepsin solution during the last perfusion period resulted in a partial recovery of hydrophobicity in esophageal secretion (131 +/- 30 vs 30 +/- 4; p < 0.001), although this value was lower than the basal hydrophobicity value (131 +/- 30 vs 237 +/- 32; p = 0.028). In addition, we continuously observed a significant shift in the fluorescence emission maximum from 508 +/- 6.4 to 486 +/- 0.9 (p < 0.001) during perfusion with starting saline, to 492 +/- 1.6 (p < 0.001) during exposure to HCl, to 493 +/- 1.1 (p < 0.001) during perfusion with HCl/pepsin, and to 488 +/- 0.9 (p < 0.001) during infusion of final saline. The maximum emission wavelength after esophageal exposure to initial saline also was significantly lower than the maximum emission upon perfusion with HCl (492 +/- 1.6 vs 486 +/- 0.9; p < 0.05) and HCl/pepsin (493 +/- 1.1 vs 486 +/- 0.9; p < 0.05). Although basal hydrophobicity in males was similar to corresponding values recorded in females, mucosal exposure to HCl (pH 2.1) resulted in an 84% decline in females but only 60% in males. Therefore, the hydrophobicity value in females during the perfusion period with HCl was 52% lower than in males (p = 0.129). CONCLUSIONS: Esophageal secretion exhibits its hydrophobic nature presumably through the presence of mucus components such as mucin and mucin-associated phospholipids. The inhibitory impact of HCl and HCl/pepsin solutions on esophageal hydrophobicity may play a role in the pathogenesis of mucosal damage by gastroesophagel refluxate.

The natural history of idiopathic subfoveal choroidal neovascularization.

PURPOSE: To study the long-term natural history of idiopathic subfoveal choroidal neovascularization (CNV) in young patients. METHODS: A retrospective survey of 19 consecutive patients with idiopathic subfoveal CNV diagnosed in an urban eye hospital and a single practice. RESULTS: Twenty-three (26%) of 87 consecutive patients with idiopathic CNV demonstrated subfoveal CNV. Nineteen patients with subfoveal involvement were followed for a median of 87 months (range, 5-230 months). On initial examination, the median best-corrected Snellen visual acuity was 20/100 (range, 20/40-counting fingers); at final examination, the median visual acuity was 20/70 (range, 20/20-counting fingers). A total of 95% of patients had stable or significantly improved visual acuity, whereas only 5% had significant visual loss. Size of the CNV was the only variable associated with long-term final visual acuity. Lesions 1 disc area or smaller at the time of initial fluorescein angiography were more likely to be associated with a final visual acuity of 20/60 or better and less likely to be associated with a final visual acuity of 20/200 or worse (P = 0.038) as compared with larger lesions. These results were confirmed with multiple logistic regression analysis (P = 0.027). Fellow eyes remained unaffected during the follow-up period. CONCLUSIONS: The natural history of idiopathic subfoveal CNV is not necessarily associated with a profound loss of vision. Therapies for this type of subfoveal lesion must take into consideration the possibility of a favorable natural course.

Risk factors for choroidal neovascularization in young patients: a case-control study.

A pair-matched, case-control design was used to study exposure to Histoplasma capsulatum and other environmental factors, and to determine various host characteristics including human leukocyte antigen (HLA) typings in 94 young patients with macular choroidal neovascularization (CNV) and in 94 controls with other eye diseases. Patients with two types of retinal patterns were studied: Type I, or those with CNV with one or no chorioretinal atrophic spots in the posterior pole or periphery (n = 51), and Type II, or those with CNV and 2 or more chorioretinal atrophic spots (n = 43). Our purpose was to explore whether these two variants of idiopathic CNV have different and distinguishable epidemiologies which may or may not be related to prior exposure to Histoplasma. We found that histoplasmin skin tests were negative in all but two Type I cases. The combination of the HLA-B7 and HLA-DR2 markers (but not either marker alone) was significantly increased in Type I cases. Among Type II cases, HLA-B7, HLA-DR2, HLA-DQ1, a positive histoplasmin skin test, myopic refractive error, prior residence in a histoplasmosis endemic area, occupations involving exposure to animals, and hypertension were all significantly increased. Histoplasmin skin test responses were positive in 18 Type II cases (45%). In the multivariate analysis, only DR2 and the combined presence of DQ1 and a positive histoplasmin skin test remained predictive of Type II disease. Our findings suggest that histoplasmin sensitivity is associated with some, but not all, cases of Type II disease. However, histoplasmin sensitivity appears to have no relationship to Type I disease. HLA factors may play a role in both disease types, possibly by producing a modified immune response to Histoplasma and/or other unidentified agents.

Epstein-Barr virus antibodies in multifocal choroiditis and panuveitis.

Although it has been reported that patients with multifocal choroiditis and panuveitis have serologic evidence of a chronic or persistent Epstein-Barr virus infection, our patients did not seem to have other stigmata of Epstein-Barr virus infection. To reappraise the serologic evidence of chronic Epstein-Barr virus infection, the Epstein-Barr antibody levels in 11 patients with multifocal choroiditis and panuveitis and 11 sex- and age-matched control patients were measured. Neither the antiviral capsid antigen IgG (P = .15) nor the antinuclear antigen (P = .2) antibody titers of the patients with multifocal choroiditis and panuveitis were significantly different than those of the control patients. Neither the patients with multifocal choroiditis and panuveitis nor the control patients had increased antiviral capsid antigen IgM titers. One patient with multifocal choroiditis and panuveitis and three control patients had positive anti-early antigen antibody titers (P = .59). The results of this study do not support the hypothesis that patients with multifocal choroiditis and panuveitis have serologic evidence of chronic or persistent Epstein-Barr virus infection as a characteristic finding.

External cephalic version of term singleton breech presentations with tocolysis: a retrospective study in a community hospital.

External version with the use of tocolysis in low-risk patients has been shown to be relatively safe and effective. A retrospective analysis was undertaken to see if version was practical for a smaller community-based hospital. Thirty-two antepartum external cephalic versions with ritodrine tocolysis during a 4-year period were reviewed. Successful version occurred in 59.4% of attempts. Of patients with a successful version, 68.4% delivered vaginally. One successful version occurred spontaneously with ritodrine tocolysis alone. A stillbirth due to abruptio placentae occurred 20 hours after a failed version attempt.

Lack of the HLA-DR2 specificity in multifocal choroiditis and panuveitis.

The prevalence of the HLA-B7 and HLA-DR2 specificities in 17 unrelated patients with multifocal choroiditis and panuveitis, 11 with and six without subretinal neovascularisation, was evaluated and compared with those of two different groups. The first group was 17 patients with subretinal neovascularisation associated with presumed ocular histoplasmosis syndrome, and the second was a group of 105 eye patients with no retinal disease. HLA-DR2 was not found in any patient with multifocal choroiditis and panuveitis, but it was found in 13 patients with presumed ocular histoplasmosis syndrome (p = 6.72 x 10(-5), comparison of the groups with subretinal neovascularisation). The lack of HLA-DR2 was also significant in comparison with the control group of eye patients (p = 0.041). This study suggests that patients with multifocal choroiditis and panuveitis and presumed ocular histoplasmosis syndrome have differing genetic predispositions, though the fundus pictures in these entities have many similarities.

Radio-frequency heating under ECG electrodes.

ECG electrodes can provide an alternate path for the return of radio-frequency current to an electrosurgical generator. In the process, significant heat rise can take place at the electrode/skin interface. The contribution from the electrode to this heart rise was examined using face-to-face pairs as well as human subject testing. A comparison of various electrode designs revealed a wide range in their RF heating characteristics which affects the probability of burns.