Incidence of nausea/vomiting following propofol sedation with adaptive servo-ventilation for atrial fibrillation ablation.

Background: Postoperative nausea and vomiting (PONV) following atrial fibrillation (AF) ablation can cause considerable distress. Aim: Continuous intravenous propofol sedation with adaptive servo-ventilation (ASV) with or without an analgesic, pentazocine, during AF ablation was studied in 272 consecutive patients with paroxysmal, persistent, and long-standing persistent AF. The study objectives were to determine the incidence of PONV after AF ablation and to assess the predictive value of factors for PONV using the area under the receiver operating characteristic curve (AUC). Results: The present sedation maneuver was successfully accomplished with a low incidence of hypotension and without discontinuation of ablation or switching to general anesthesia, while maintaining an acceptable procedural time (102 ± 32 min). The incidence of PONV was 5.5% (15/272). Nausea occurred in nine patients after an average of 4.6 ± 3.5 h (range: 2-12 h) postablation, and vomiting with nausea occurred in six patients after an average of 4.5 ± 3.1 h (range: 1-9 h) postablation. The postablation interval did not differ significantly between the occurrence of nausea and nausea accompanied by vomiting. AUCs based on various factors, including the Apfel score, ranged from 0.55 to 0.67, indicating low accuracy in predicting PONV occurrence. Conclusions: The incidence of PONV after propofol sedation with ASV was the lowest (5.5%) reported to date. Scoring systems, which included the Apfel score, were ineffective in predicting PONV. The low PONV incidence in addition to the efficacy of propofol sedation with ASV revealed the adequacy of this regimen for AF ablation.

ADL Outcome of Stroke by Stroke Type and Time from Onset to Admission to a Comprehensive Inpatient Rehabilitation Ward.

OBJECTIVE: To examine the effect of onset to admission interval (OAI) and stroke type on activities of daily living (ADL) outcome. MATERIALS AND METHODS: Stroke patients (n=3112) admitted to and discharged from comprehensive inpatient rehabilitation wards at Nanakuri Memorial Hospital were classified into 8 OAI segments and by stroke type [intracerebral hemorrhage (ICH) and cerebral infarction (CI)]. Motor subscore of the Functional Independence Measure (FIM-M) on admission, FIM-M at discharge, FIM-M gain, length of stay (LOS), and FIM-M efficiency in the ICH and CI group matched by OAI segment were compared using the Wilcoxon test. Multiple comparisons using the Steel-Dwass test of FIM-M on admission, FIM-M at discharge, FIM-M gain, LOS, and FIM-M efficiency by OAI segments were performed. RESULTS: FIM-M on admission was lower in the ICH group than the CI group in matched OAI segments. However, FIM-M improvement was greater in the ICH group than the CI group, resulting in no difference in FIM-M between groups at discharge. In both groups, the longer the OAI, the lower the FIM-M on admission and at discharge. The distribution pattern of significant differences among OAI segments differed between the groups. LOS tended to be longer and FIM-M efficiency tended to be higher in the ICH group than in the CI group. CONCLUSIONS: The brain mass effect at the time of admission was larger and took longer to decrease in the ICH group than in the CI group. These results may improve prediction of outcomes in comprehensive inpatient rehabilitation wards.

Predicting walking ability in hemiplegic patients with putaminal hemorrhage: an observational study in a rehabilitation hospital.

BACKGROUND: In stroke rehabilitation, the most important concern of the patients and their families is whether the patients can walk independently and whether they need braces after discharge. AIM: This study aims to investigate the relationship between several types of putaminal hemorrhage and walking independence and orthotic therapy in patients with hemiplegia. DESIGN: Observational study. SETTING: Inpatients rehabilitation department, Fujita Health University Nanakuri Memorial Hospital, Japan. POPULATION: Total 264 patients with putaminal hemorrhage admitted to our hospital. METHODS: Neurological and cognitive functions were examined as per the stroke scale of the National Institutes of Health and the Mini-mental state examination, respectively. The hematomas were classified into five types, and the volume was measured using computed tomography (CT). Walking ability was evaluated by Functional Ambulation Category (FAC), and walking independence was defined as FAC ≥4. The relationship between the types of hematomas and walking independence and orthotic therapy in patients with hemiplegia with putaminal hemorrhage was also analyzed. RESULTS: We observed differences within the hematoma types in volume, neurological symptoms, and cognitive function but not in age, sex, and lesion side aspects of these patients - 143 of whom could walk independently (FAC≥4) and 121 non-independently. Walking independently and the need for orthosis were closely related to the type of hematoma. CONCLUSIONS: CT imaging at stroke onset can provide useful information when examining walking independence and indicate necessity for an orthosis at the time of discharge to the rehabilitation ward. CLINICAL REHABILITATION IMPACT: This study might help to better understand the role of neuroimaging in stroke rehabilitation.

Pattern of item score change in Stroke Impairment Assessment Set in comprehensive inpatient rehabilitation wards.

OBJECTIVES: Although numerous studies have examined activities of daily living (ADL) in stroke rehabilitation, there has been little focus on impairment, despite its close relationship to ADL. Therefore, we evaluated the change in impairment from admission to discharge of patients with stroke in comprehensive inpatient rehabilitation wards using the Stroke Impairment Assessment Set (SIAS). METHODS: Data from 3279 patients with first stroke who were admitted to comprehensive inpatient rehabilitation wards between 2004 and 2016 were analyzed. A scattergram of the items showing the percentage of the highest score on admission and the percentage of patients whose score improved during hospitalization was plotted. The items of the SIAS were grouped by their location on the scattergram. RESULTS: Three clusters could be discriminated on the scattergram. The upper right group, showed an improved score during hospitalization in combination with a high percentage of patients with the highest score on admission. This group consisted of the verticality, unaffected-side quadriceps, visuospatial, and pain items of the SIAS. The upper left group improved during hospitalization, but only contained a small percentage of patients with a high score on admission, and consisted of motor function items. The lower group was characterized by poor improvement during hospitalization and consisted of sensory, tone, range of motion, speech, and grip power items. CONCLUSIONS: Understanding the change in impairment during hospitalization using the three groups described above will facilitate design of a plan for stroke rehabilitation on admission.

Aphasia Following Left Putaminal Hemorrhage at a Rehabilitation Hospital.

OBJECTIVE: We aimed to clarify the relationship between aphasia and hematoma type/volume in patients with left putaminal hemorrhage admitted to a rehabilitation facility. METHODS: We evaluated the relationship between the presence, type, and severity of aphasia and hematoma type/volume in 92 patients with putaminal hemorrhage aged 29-83 years. Hematoma type and volume were evaluated on the basis of CT images obtained at stroke onset. The Standard Language Test for Aphasia was conducted as part of the initial assessment. RESULTS: Aphasia was observed in 79 of 92 patients. A total of 31 patients had fluent aphasia, while 48 had non-fluent aphasia. Non-fluent aphasia often involved hematoma on the anterior limb of the internal capsule, while fluent aphasia often involved hematoma on the posterior limb of internal capsule. When the hematoma volume exceeded 20 mL, patients experienced difficulty in repeating spoken words. When hematoma volume exceeded 40 mL, non-fluent aphasia was observed in all patients. CONCLUSION: Our findings suggest that hematoma type and volume not only influence the development of aphasia following putaminal hemorrhage but also play a major role in determining the patient's fluency and repetition ability.

Factors necessary for independent walking in patients with thalamic hemorrhage.

BACKGROUND: Thalamic hemorrhages cause motor paralysis, sensory impairment, and cognitive dysfunctions, all of which may significantly affect walking independence. We examined the factors related to independent walking in patients with thalamic hemorrhage who were admitted to a rehabilitation hospital. METHODS: We evaluated 128 patients with thalamic hemorrhage (75 men and 53 women; age range, 40-93 years) who were admitted to our rehabilitation hospital. The mean duration from symptom onset to rehabilitation hospital admission was 27.2 ± 10.3 days, and the mean rehabilitation hospital stay was 71.0 ± 31.4 days. Patients' neurological and cognitive functions were examined with the National Institutes of Health Stroke Scale (NIHSS) and Mini-Mental State Examination (MMSE), respectively. The relationship between patients' scores on these scales and their walking ability at discharge from the rehabilitation hospital was analyzed. Additionally, a decision-tree analysis was used to create a model for predicting independent walking upon referral to the rehabilitation hospital. RESULTS: Among the patients, 65 could walk independently and 63 could not. The two patient groups were significantly different in terms of age, duration from symptom onset to rehabilitation hospital admission, hematoma type, hematoma volume, neurological symptoms, and cognitive function. The decision-tree analysis revealed that the patient's age, NIHSS score, MMSE score, hematoma volume, and presence of ventricular bleeding were factors that could predict independent walking. CONCLUSIONS: In patients with thalamic hemorrhage, the neurological symptoms, cognitive function, and neuroimaging factors at onset are useful for predicting independent walking.

Characteristics of patients with hemiparetic stroke who yield highly reliable muscle strength measurements.

[Purpose] Accurate measurement of unaffected lower extremity muscle strength on the unaffected side is useful in patients with hemiparetic stroke; however, muscle strength measurement results in patients with hemiparetic stroke vary greatly compared with those in healthy individuals. The objective of the present study was to determine the characteristics of patients with hemiparetic stroke who yield highly reliable muscle strength measurements. [Subjects and Methods] The subjects were 55 incipient patients with hemiparetic stroke. Muscle strength was measured twice. Based on the measured changes and on error ranges in repeated measurements in previous studies, the subjects were divided into two groups: subjects whose measurement results were within the acceptable range, and those whose measurement results were not within the acceptable range. Logistic regression analysis was performed with this separation of groups as the dependent variable, and demographic data, physical functioning, and functional independence measure (FIM) as independent variables. [Results] From the analysis results, the FIM cognitive subscore was selected as a criterion for patient selection; the cutoff score was 19. [Conclusion] The results of the present study indicated that muscle strength measurements were highly reliable in patients with hemiparetic stroke with an FIM cognitive subscore of ≥19.

Alternating Hemiplegia with Ipsilateral Supranuclear Facial Palsy and Abducens Nerve Palsy Caused by Pontine Infarction.

A 62-year-old right-handed man was diagnosed with a cerebral infarction in the ventromedial region of the left lower pons. He showed left abducens nerve palsy, left-sided supranuclear palsy of the lower part of the face and right hemiparesis. We hypothesized that the mechanism underlying the patient's ipsilateral supranuclear facial palsy involved the corticofacial fibers after they crossed the midline.

Hemorrhagic Transformation in Patients with Cerebral Infarction Referred to a Rehabilitation Hospital.

PURPOSE: The aim of our study was to investigate the presenting conditions of patients with hemorrhagic transformation (HT), the frequency of HT and its treatments at a rehabilitation hospital. SUBJECTS AND METHODS: 165 patients with cerebral infarctions transferred to our rehabilitation hospital during the study period were enrolled. HT was diagnosed by two stroke specialists using computed tomography (CT) at the time of transfer to our rehabilitation hospital and other imaging data from previous consultations. Neurological status, activities of daily living, administered agents, patient age, duration from stroke onset to transfer and length of hospital stay were examined. RESULTS: 30 of the 165 patients (18.2%) were diagnosed with HT. Decreased activities of daily living at admission and discharge as well as longer hospitalization stays were more prevalent in HT patients than in those without HT. We did not change antiplatelet or anticoagulant agents, but continued rehabilitation over a defined period while monitoring blood pressure; we confirmed with CT that the patients' physical conditions did not deteriorate. CONCLUSION: With careful symptom and CT monitoring over a defined period, rehabilitation can be continued in patients who develop HT at the time of transfer to a rehabilitation hospital in the acute phase of cerebral infarction.

Potential factors, including activities of daily living, influencing home discharge for patients with putaminal haemorrhage.

BACKGROUND: Convalescent rehabilitation wards assist stroke patients in acquiring skills for activities of daily living to increase the likelihood of home discharge. However, an improvement in activities of daily living does not necessarily imply that patients are discharged home. We investigated the characteristics of patients with putaminal haemorrhage who are discharged home following convalescence in rehabilitation wards. METHODS: The sample comprised 89 patients (58 men and 31 women) with putaminal haemorrhage hospitalised in the convalescent rehabilitation ward of our hospital between August 2012 and July 2013. Their age ranged from 29 to 88 years (61.9 ± 11.9 years). The lesion occurred on the right side in 48 and on the left in 41 patients. The mean period from onset to hospitalisation in the convalescent rehabilitation ward was 30.8 ± 17.2 days, and the mean hospitalisation period was 70.7 ± 31.8 days. We examined age, sex, haematoma volume, duration from onset to hospitalisation, neurological symptoms, cognitive function, functional independence measure, number of cohabitating family members and whether the patient lived alone before stroke, and the relationship among these factors and discharge destination (home or facility/hospital) was assessed. RESULTS: The discharge destination was home for 71 and a facility or hospital for 18 patients. Differences were observed in age, haematoma volume, neurological symptoms, cognitive function, functional independence measure score on admission and discharge, number of cohabitating family members and whether the patient lived alone before stroke for patients discharged home. Patients who required long-term care and were discharged home were more likely to be living with family members who were present during daytime. Home discharge was possible if functional independence measure score was ≥70 at the time of discharge for motor items and ≥24 for cognitive items, even if a patient lived alone before stroke. CONCLUSIONS: Although the presence of cohabitating family members was important, the factor most strongly influencing home discharge was the patient's activities of daily living status at the time of discharge. For patients who lived alone before stroke, physical and cognitive functions must be maintained for them to be discharged home after rehabilitation.

Dysphagia Following Putaminal Hemorrhage at a Rehabilitation Hospital.

BACKGROUND: Dysphagia occurs frequently during the acute phase of cerebral hemorrhage; however, there are few reports of dysphagia associated with cerebral hemorrhage in the subacute and chronic phase. We focused on putaminal hemorrhage at a rehabilitation hospital and evaluated the relationships between the frequencies of dysphagia, focus, and hematoma volume and type. METHODS: A hundred patients with putaminal hemorrhage referred to our rehabilitation hospital were evaluated. Bedside swallowing assessments (BSAs) were conducted and results were evaluated relative to the information obtained on computed tomography imaging, including hematoma type and volume, and oral intake at the time of admission/discharge from the hospital. RESULTS: A regular diet was provided to 48 patients, dysphagia diet to 44 patients, and enteral feeding to 8 patients. There were significant feeding group differences in age, hematoma volume and type, existence of ventricle rupture, neurological manifestation, cognitive function, existence of unilateral neglect and aphasia, initial BSA, activities of daily living (ADL) score using the Functional Independence Measure at the time of admission/discharge from the hospital, and length of stay. At discharge, we provided a regular diet to 81 patients and dysphagia diet to 19 patients. Age and ADL score had the greatest influence on oral intake at the time of discharge from the hospital. CONCLUSION: The prognosis of dysphagia caused by putaminal hemorrhage is good, with no patient requiring enteral feeding, although putaminal hemorrhage often causes dysphagia. Patient age and ADL score on admission are used to predict the residual factors of dysphagia.

Rehabilitation for a Patient with Hemiplegia, Ataxia, and Cognitive Dysfunction Caused by Pontine Hemorrhage.

Patients with pontine hemorrhage usually experience severe disturbances of consciousness, pupillary abnormalities, quadriparesis, and respiratory failure. However, little is known regarding cognitive dysfunction in patients with pontine hemorrhage. We report the case of a rehabilitation patient presenting with hemiplegia, ataxia, and cognitive dysfunction caused by a pontine hemorrhage. A 55-year-old, right-handed male suffered sudden onset of vertigo, dysarthria, and hemiplegia on the right side. He was diagnosed with brain stem hemorrhage, and conservative treatment was administered. The vertigo improved, but dysarthria, ataxia, hemiplegia, and gait disorder persisted. He was disoriented with respect to time and place and showed a poor attention span, impaired executive function, and reduced volition. A computed tomography revealed hematomas across the pons on both sides, but no lesions were obvious in the cerebellum and cerebrum. Single-photon emission tomography showed decreased perfusion in the brain stem, bilateral basal ganglia, and frontal and parietal lobes in the left hemisphere. The patient received exercise therapy and cognitive rehabilitation, and home modifications were performed to allow him to continue living at home under the supervision of his family. His symptoms improved, along with enhanced regional cerebral blood flow to the frontal and temporal lobes. These findings suggest that the pontine hemorrhage caused diaschisis resulting in secondary reduction of activity in the cerebral hemisphere and the occurrence of cortical symptoms. Therefore, rehabilitation is necessary, along with active instructions for the family members of patients with severe neurological deficits.

A comparison of knee-ankle-foot orthoses with either metal struts or an adjustable posterior strut in hemiplegic stroke patients.

BACKGROUND: We investigated differences in factors affecting judgments regarding the creation of new adjustable posterior strut knee-ankle-foot orthoses (APS-KAFO) and knee-ankle-foot orthoses with metal struts (traditional KAFO) for hemiplegic stroke patients for whom KAFO were created in rehabilitation wards. METHODS: Subjects were 50 patients with hemiplegia due to new-onset stroke (cerebral infarction: n = 25, cerebral hemorrhage: n = 25) who were prescribed KAFO. Patient ages ranged from 36 to 90 years, and the mean duration from stroke onset to hospitalization was 28.8 ± 13.8 days. Neurologic symptoms, cognitive function, activities of daily living, duration from hospitalization to orthosis creation, hospitalization duration, walking ability at discharge, outcome after discharge, and so forth were compared. RESULTS: Fourteen patients were prescribed APS-KAFO, and 36 were prescribed traditional KAFO. Those prescribed APS-KAFO had somewhat milder neurologic symptoms and cognitive dysfunction and a shorter hospitalization duration than those prescribed traditional KAFO. Patients prescribed APS-KAFO also had a higher score and efficiency on functional independence measure at admission and discharge. Walking independence at discharge was seen in 8 of the 14 patients for whom APS-KAFO were created and 8 of the 36 patients for whom traditional KAFO were created. CONCLUSIONS: APS-KAFO was chosen for patients with a high level of activity in the ward and with a higher likelihood of acquiring walking ability using APS-AFO at discharge, whereas traditional KAFO tended to be chosen for patients with relatively severe symptoms who were not expected to acquire practical walking ability.

Changes in serum growth factors in stroke rehabilitation patients and their relation to hemiparesis improvement.

Predicting recovery from hemiparesis after stroke is important for rehabilitation. A few recent studies reported that the levels of some growth factors shortly after stroke were positively correlated with the clinical outcomes during the chronic phase. The aim of this study was to examine the relationships between the serum levels of growth factors (vascular endothelial growth factor [VEGF], insulin-like growth factor-I [IGF-I], and hepatocyte growth factor [HGF]) and improvement in hemiparesis in stroke patients who received rehabilitation in a postacute rehabilitation hospital. Subjects were 32 stroke patients (cerebral infarction: 21 and intracerebral hemorrhage [ICH]: 11). We measured serum levels of VEGF, IGF-I, and HGF and 5 items of the Stroke Impairment Assessment Set (SIAS) for hemiparesis on admission and at discharge. Age-matched healthy subjects (n=15) served as controls. Serum levels of VEGF and HGF in cerebral infarct patients on admission were higher than those in control subjects, and the serum levels of IGF-I in stroke patients were lower than those in controls. The level of HGF in ICH patients on admission was negatively correlated with gains in SIAS, and higher outliers in HGF concentration were correlated with lower gains in SIAS. Focusing on the extremely high levels of these factors may be a predictor of the low recovery from hemiparesis after stroke.

Multi-input/output alarming system for patients with inattention caused by higher cortical function disorder.

BACKGROUND: To apply advanced methods of communication, sensing, and instrumentation technologies to make a system that can help patients suffering from hemispatial neglect caused by higher cortical function disorder. METHOD: By using several sensors and actuators, the objective was to construct a tailor-made system for each patient. The input part of the system consists of sensors, an interface and transmitters. The output part consists of a receiver, logical arithmetic, an output interface and actuators. The information from the input part is sent to the output part in a wireless manner allowing the mobility of the input and output parts. RESULTS: The system and its functionality were realized. Voice alarming and neck muscle stimuli were applied to two patients. We could verify the applicability of the system to remind the patients to put on their wheelchair's brake and raise its footrest before attempting to stand for transferring to their beds. CONCLUSION: The designed and constructed multi-input/output system can be used effectively to alarm the patients.

Change in thigh muscle cross-sectional area through administration of an anabolic steroid during routine stroke rehabilitation in hemiplegic patients.

OBJECTIVE: The aim of this study was to clarify the effect of administration of an anabolic steroid (AS) without the addition of specific training in stroke patients by measuring the cross-sectional area (CSA) of the thigh. DESIGN: Twenty-six hemiplegic stroke patients during subacute rehabilitation were randomly assigned to a metenolone enanthate (ME) administration group or a control group (CT group). In the ME group, ME (100 mg) was injected intramuscularly weekly for 6 wks in the ME group. The CSA of the bilateral thigh muscles was measured using computed tomography. Motor subscore of the Functional Independence Measure (FIM-M) was assessed before the experimental period. RESULTS: At the end of 6 wks, the CSA increase in the ME group (13.4%, affected side; 14.5%, unaffected side) was significantly larger than that in the CT group (3.3%, affected side; 5.2%, unaffected side). Correlation coefficients between the initial FIM-M score and the CSA increase at 6 wks were -0.754 for the affected side and -0.567 for the unaffected side in the ME group and 0.199 for the affected side and 0.431 for the unaffected side in the CT group. CONCLUSIONS: ME administration is effective for improving muscle CSA and, thus, muscle strengthening in stroke rehabilitation. The CSA increase in the ME group was most prominent in patients with a low initial FIM-M score.

Evaluation of use of the Medical Outcome Study 36-Item Short Form Health Survey and cognition in patients with stroke.

The Medical Outcome Study 36-Item Short Form Health Survey (SF-36) is a widely used method to evaluate health-related quality of life and has been applied for patients with stroke. However, because it is a self-assessment tool, there is a risk in using results of the survey because of lack of information on patients who cannot answer the questionnaire. For this report, 38 patients with stroke hospitalized in the rehabilitation department filled out the SF-36 and motor items of the Functional Independence Measure (FIM) and the Stroke Impairment Assessment Set. We then examined characteristics of patients who could not be evaluated by the SF-36. Of the 38 patients, 19 patients could and 19 patients could not be evaluated by the SF-36. There was no remarkable relationship among capacity or incapacity for evaluation by the SF-36, motor subscores on the FIM, and motor items on the Stroke Impairment Assessment Set. All 10 patients having a communication subscore on the FIM of 10 points or less and/or a social cognition subscore on the FIM of 13 points or less could not be evaluated by the SF-36. The remaining unevaluable patients were not cooperative. Studies in which the entry criteria include the ability to answer the SF-36 questionnaire neglect patients with poor cognition. Therefore, when administering the SF-36 for patients with stroke, we recommend using an interview setting.

Reliability and validity of a wheelchair collision test for screening behavioral assessment of unilateral neglect after stroke.

OBJECTIVE: To examine the reliability and validity of a new wheelchair collision test (WCT) for screening behavioral unilateral neglect in people with stroke. DESIGN: A total of 19 patients with left hemiplegia resulting from first-ever stroke (mean +/- SD, 61.9 +/- 25.8 days after onset) were examined with the WCT, whereby the patient was asked to propel a wheelchair to pass four round chairs arranged in two rows. Separate tests were done using two different distances between the chairs: 120 and 140 cm. The number of collisions with the chairs was recorded. The Catherine Bergego Scale was used to evaluate behavioral unilateral neglect. Because unilateral neglect has an unfavorable impact on rehabilitation, the FIMtrade mark instrument was used to determine the function of daily activities. RESULTS: Test-retest reliability ranged from 0.68 to 0.97 in different situations in the WCT. The rate of agreement tested by Kappa statistics between the WCT and Catherine Bergego Scale was higher when the distance between chairs was 120 cm than when the distance was 140 cm (0.68 vs. 0.58). Spearman's rank-correlation coefficient between the WCT and Catherine Bergego Scale was 0.72 (P < 0.001) if the distance between the chairs was 120 cm and 0.75 (P < 0.001) if the distance was 140 cm. The WCT and Catherine Bergego Scale correlated well with the FIM instrument. Spearman's rank-correlation coefficient between the Catherine Bergego Scale and FIM total score was -0.70 (P < 0.001). CONCLUSION: The WCT is a simple screening test with high test-retest reliability and validity to evaluate behavioral unilateral neglect.