Dexterity in the Acute Phase of Stroke: Impairments and Neural Substrates.

BACKGROUND: Stroke can impair manual dexterity, leading to loss of independence following incomplete recovery. Enhancing our understanding of dexterity impairment may improve neurorehabilitation. OBJECTIVES: The study aimed to measure dexterity components in acute stroke patients with and without hand motor deficits, compare them to those of healthy controls (HC), and to explore the neural substrates involved in specific components of dexterity. METHODS: We used the Dextrain Manipulandum to quantify fine finger force control, finger selection accuracy, coactivation, and reaction time (RT). Dexterity was evaluated twice (2 days apart) in 74 patients and 14 HC. Voxel-Lesion-Symptom-Mapping (VLSM) was used to analyze the relationship between tissue damage and dexterity. Results. Due to severe paresis or fatigue, 24 patients could not perform these tasks. In 50 patients (included 4.6 ± 3.3 days post-stroke), finger force control improved (P < .001), as it did in HC (P = .03) who performed better than patients on both evaluations. Accuracy of finger selection did not improve significantly in any group, but the HC performed better on both evaluations. Unexpectedly, coactivation was better in patients than in HC at D3 (P = .03). There were no between-group differences in RT. VLSM showed that damage to the superior temporal gyrus (STG) impaired finger force control while damage to the posterior limb of the internal capsule (PLIC) impaired finger selectivity. CONCLUSIONS: Acute stroke affecting the STG or PLIC impaired selective components of dexterity. Patients with mild to moderate impairment showed better finger force control and accuracy selection within 48 hours, suggesting the feasibility of detecting early dexterity improvements.

Abstinence is associated with better outcomes in patients with alcohol-related hepatocellular carcinoma: Results of an observational study.

BACKGROUND: Patients with alcohol-related cirrhosis and hepatocellular carcinoma (HCC) may have reduced survival compared to those with HCC related to other causes. The impact of abstinence in alcohol-related HCC is unknown. We compared access to curative treatment and the prognosis of patients with HCC according to the cause of cirrhosis and evaluated the impact of abstinence on the prognosis of patients with alcohol-related HCC. PATIENTS AND METHODS: Data for patients with cirrhosis and HCC were prospectively collected in a single center. A logistic regression model was used to identify factors associated with access to curative treatment. Multivariate Fine and Gray proportional hazards models were used to identify factors associated with 5-year survival after adjustment for lead-time bias. RESULTS: Two hundred patients were included, 114 (57 %) with non-alcohol-related HCC and 86 (43 %) with alcohol-related HCC (35 abstainers, 51 consumers). During follow-up, 21 patients were transplanted and 156 died. The proportion of patients who had access to curative treatment was 65 % in abstainers, 44 % in consumers, and 57 % in patients with non-alcohol-related cirrhosis (p = 0.06). In multivariate analyses, abstinence was not associated with better access to curative treatment. After adjustment for lead-time bias, the 5-year cumulative incidence of overall death was significantly lower in abstainers than in consumers and in patients with non-alcohol-related cirrhosis (52 % vs. 78 % vs. 81 %, respectively, p = 0.04). In multivariate analyses, abstainers had lower risk of death than consumers (SHR: 0.47, 95 % CI: 0.28-0.80, p = 0.005). CONCLUSION: Abstinence improves the outcome of patients with alcohol-related cirrhosis once HCC has occurred.

CPAP adherence after ambulatory and in-hospital management in patients aged 65 years and older.

OBJECTIVES: The aims of this study are to evaluate the early adherence to CPAP treatment in patients aged 65 years and older and to compare ambulatory (ACPAP) and in-hospital (HCPAP) management in starting CPAP treatment. METHODS: Adherence to CPAP therapy at 3 months was retrospectively studied in patients on whom CPAP therapy was initiated between 1 January 2020 and 31 December 2021. Patients in the ACPAP group were selected based on the current Belgian reimbursement criteria (OAHI ≥30/h and few comorbidities). RESULTS: 146 patients were studied (median OAHI 43.35/h [32.02; 57.40]; median age 69 [67.0; 73.0]): 116 (79.5%) patients in the HCPAP and 30 (20.5%) in the ACPAP group. Based on an adherence threshold of average CPAP use of ≥ 4 hours per day, 120 (82%) patients were adherent to the treatment; 94 (81%) patients in the HCPAP and 26 (86.7%) in the ACPAP group. The median CPAP use for the total population was 6.4 h/day [4.89; 7.34], reaching 6.3 h/d [4.79; 7.15] for the HCPAP group and 6.8 h/d [6.21; 8.06] for the ACPAP group (p = 0.019). Insomnia was a significant risk factor for non-adherence (OR 5.16 [1.64; 16.08], p = 0.0043) but the ACPAP method was not (OR 0.66 [0.18; 1.91], p = 0.4748). CONCLUSION: Early CPAP adherence in patients ≥ 65 years old was good in terms of average use per day and proportion of adherent patients. ACPAP method was not a risk factor for lower CPAP adherence in patients presenting severe OSAS (OAHI ≥30/h) and few comorbidities.

Treatment and Prognosis of Patients with Lung Cancer and Combined Interstitial Lung Disease.

BACKGROUND: Interstitial lung disease (ILD) is associated with a higher lung cancer (LC) risk and may impact cancer's clinical characteristics, treatment strategies, and outcomes. This impact's extent is unclear, particularly in Caucasians. METHODS: In this retrospective observational study, we reviewed the files of all LC patients diagnosed in a 38-month period. Expert radiologists reviewed the computed tomography scans performed at diagnosis. Patients with LC and ILD (n = 29, 7%) were compared to those without ILD (n = 363, 93%) for population and cancer characteristics, treatments, and clinical outcomes. RESULTS: Patients with LC and ILD were older (73 ± 8 vs. 65 ± 11 years; p < 0.001). There was no significant difference in LC histology, localization, stage, or treatment modalities. The respiratory complication rate after cancer treatment was significantly higher in the ILD group (39% vs. 6%; p < 0.01). Overall survival rates were similar at 12 (52% vs. 59%; p = 0.48) and 24 months (41% vs. 45%; p = 0.64) but poorer in the ILD group at 36 months, although not statistically significant (9% vs. 39%; p = 0.06). The ILD group had a higher probability of death (hazard ratio (HR) = 1.49 [0.96;2.27]), but this was not statistically significant (p = 0.06). In a Cox regression model, patients with ILD treated surgically had a significantly higher mortality risk (HR = 2.37 [1.1;5.09]; p = 0.03). CONCLUSIONS: Patients with combined LC and ILD have worse clinical outcomes even when similar treatment modalities are offered.

Bimanual motor skill learning after stroke: Combining robotics and anodal tDCS over the undamaged hemisphere: An exploratory study.

Background: Since a stroke can impair bimanual activities, enhancing bimanual cooperation through motor skill learning may improve neurorehabilitation. Therefore, robotics and neuromodulation with transcranial direct current stimulation (tDCS) are promising approaches. To date, tDCS has failed to enhance bimanual motor control after stroke possibly because it was not integrating the hypothesis that the undamaged hemisphere becomes the major poststroke hub for bimanual control. Objective: We tested the following hypotheses: (I) In patients with chronic hemiparetic stroke training on a robotic device, anodal tDCS applied over the primary motor cortex of the undamaged hemisphere enhances bimanual motor skill learning compared to sham tDCS. (II) The severity of impairment correlates with the effect of tDCS on bimanual motor skill learning. (III) Bimanual motor skill learning is less efficient in patients than in healthy individuals (HI). Methods: A total of 17 patients with chronic hemiparetic stroke and 7 healthy individuals learned a complex bimanual cooperation skill on the REAplan® neurorehabilitation robot. The bimanual speed/accuracy trade-off (biSAT), bimanual coordination (biCo), and bimanual force (biFOP) scores were computed for each performance. In patients, real/sham tDCS was applied in a crossover, randomized, double-blind approach. Results: Compared to sham, real tDCS did not enhance bimanual motor skill learning, retention, or generalization in patients, and no correlation with impairment was noted. The healthy individuals performed better than patients on bimanual motor skill learning, but generalization was similar in both groups. Conclusion: A short motor skill learning session with a robotic device resulted in the retention and generalization of a complex skill involving bimanual cooperation. The tDCS strategy that would best enhance bimanual motor skill learning after stroke remains unknown. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT02308852, identifier: NCT02308852.

Do Non-COVID-19 Patients' Behaviour Towards Emergency Changed During the COVID-19 Outbreak? A Severity-Based Approach.

Objective: During the COVID-19 pandemic, the number of patients presenting to the emergency department (ED) declined. The main goal of this study was to compare and describe the non-COVID-19 patient's disease severity presentation during the pandemic with its pre-pandemic severity. Methods: We conducted a retrospective observational study. We selected two samples of visits: one during the first COVID-19 wave of 2020 (pandemic period, PP) and the other during the same months of 2019 (control period, CP). The primary endpoints were the comparison of severity and distribution of the Emergency Severity Index (ESI). Secondary endpoints were comparisons of specific patient characteristics (age, sex, length of the symptoms before the visits, spontaneous visits or not, return home or not). Results: The mean ESI of the visits during the PP (3.19) was statistically significantly lower (P = 0.001) than it was in the CP (3.43). These changes were more pronounced during the months of March (3.03 versus 3.33, P = 0.037) and April (2.96 versus 3.48, P < 0.001). The change in ESI was mainly due to an increase in the proportion of visits by patients with an ESI score of 3 (42% versus 28%, P < 0.001). There were no differences in the characteristics of patients except a decline in patients whose symptoms had a duration of more than 30 days (2% during PP versus 4% during CP, P = 0.03). Conclusion: The COVID-19 pandemic caused a change in the pattern of non-COVID-19 visits, with proportionally more severe presentations based on the ESI. To our knowledge, this is the first description of changes in behaviour in ED visits by specifically non-COVID-19 patients.

Bimanual motor skill learning with robotics in chronic stroke: comparison between minimally impaired and moderately impaired patients, and healthy individuals.

BACKGROUND: Most activities of daily life (ADL) require cooperative bimanual movements. A unilateral stroke may severely impair bimanual ADL. How patients with stroke (re)learn to coordinate their upper limbs (ULs) is largely unknown. The objectives are to determine whether patients with chronic supratentorial stroke could achieve bimanual motor skill learning (bim-MSkL) and to compare bim-MSkL between patients and healthy individuals (HIs). METHODS: Twenty-four patients and ten HIs trained over 3 consecutive days on an asymmetrical bimanual coordination task (CIRCUIT) implemented as a serious game in the REAplan® robot. With a common cursor controlled by coordinated movements of the ULs through robotic handles, they performed as many laps as possible (speed constraint) on the CIRCUIT while keeping the cursor within the track (accuracy constraint). The primary outcome was a bimanual speed/accuracy trade-off (biSAT), we used a bimanual coordination factor (biCO) and bimanual forces (biFOP) for the secondary outcomes. Several clinical scales were used to evaluate motor and cognitive functions. RESULTS: Overall, the patients showed improvements on biSAT and biCO. Based on biSAT progression, the HI achieved a larger bim-MSkL than the patients with mild to moderate impairment (Fugl-Meyer Assessment Upper Extremity (FMA-UE): 28-55, n = 15) but not significantly different from those with minimal motor impairment (FMA-UE: 66, n = 9). There was a significant positive correlation between biSAT evolution and the FMA-UE and Stroke Impact Scale. CONCLUSIONS: Both HI and patients with chronic stroke training on a robotic device achieved bim-MSkL, although the more impaired patients were less efficient. Bim-MSkL with REAplan® may be interesting for neurorehabilitation after stroke. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT03974750. Registered 05 June 2019. https://clinicaltrials.gov/ct2/show/NCT03974750?cond=NCT03974750&draw=2&rank=1.

Evidence of Motor Skill Learning in Acute Stroke Patients Without Lesions to the Thalamus and Internal Capsule.

BACKGROUND: It is currently unknown whether motor skill learning (MSkL) with the paretic upper limb is possible during the acute phase after stroke and whether lesion localization impacts MSkL. Here, we investigated MSkL in acute (1-7 days post) stroke patients compared with healthy individuals (HIs) and in relation to voxel-based lesion symptom mapping. METHODS: Twenty patients with acute stroke and 35 HIs were trained over 3 consecutive days on a neurorehabilitation robot measuring speed, accuracy, and movement smoothness variables. Patients used their paretic upper limb and HI used their nondominant upper limb on an MSkL task involving a speed/accuracy trade-off. Generalization was evaluated on day 3. All patients underwent a 3-dimensional magnetic resonance imaging used for VSLM. RESULTS: Most patients achieved MSkL demonstrated by day-to-day retention and generalization of the newly learned skill on day 3. When comparing raw speed/accuracy trade-off values, HI achieved larger MSkL than patients. However, relative speed/accuracy trade-off values showed no significant differences in MSkL between patients and HI on day 3. In patients, MSkL progression correlated with acute motor and cognitive impairments. The voxel-based lesion symptom mapping showed that acute vascular damage to the thalamus or the posterior limb of the internal capsule reduced MSkL. CONCLUSIONS: Despite worse motor performance for acute stroke patients compared with HI, most patients were able to achieve MSkL with their paretic upper limb. Damage to the thalamus and posterior limb of the internal capsule, however, reduced MSkL. These data show that MSkL could be implemented into neurorehabilitation during the acute phase of stroke, particularly for patients without lesions to the thalamus and posterior limb of the internal capsule. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01519843.

The interest of 100 versus 200 Hz tetanic stimulations to quantify low levels of residual neuromuscular blockade with mechanomyography: a pilot study.

A more sensitive method than the train-of-four ratio seems required to detect low levels of residual neuromuscular blockade before tracheal extubation. The goal of the study was to determine the potential benefit of 5 s of 100 versus 200 Hz tetanic stimulation to quantify the residual block with mechanomyography in anesthetised patients. Twenty informed and consenting 18- to 80-year-old patients undergoing nose surgery were included. On the left hand, neuromuscular transmission was continuously monitored by acceleromyography. On the right side, a new mecanomyographic device (Isometric Thumb Force©) recorded the force of thumb adduction (N) developed during 5 s of 100- and 200 Hz tetanic stimulations of the ulnar nerve at three consecutive times: baseline before inducing the neuromuscular blockade, at the time of contralateral train-of-four ratio 0.9 recovery, and 3 min after additional sugammadex reversal. Tetanic Fade Ratios (TFR = F residual/F max) were compared between 100 and 200 Hz stimulations using Student's t test. At the time of TOF ratio 0.9 recovery, both 100 and 200 Hz TFR were significantly decreased compared to baseline (0.61 and 0.16 on average, respectively, p < 0.0001). The 200 Hz TFR was significantly lower than the 100 Hz TFR (p < 0.0001). There were no differences between baseline and post-reversal TFR. The 200 Hz TFR has the potential to better describe low levels of residual neuromuscular blockade than the TOF ratio and 100 Hz TFR and would benefit from further investigations. Retrospectively registered in the Australian and New Zealand Clinical Trials Registry ACTRN12619000273189.

Influence of post-COVID-19 deconfinement on psychiatric visits to the emergency department.

OBJECTIVE: During the deconfinement period after the coronavirus disease-2019 (COVID-19) pandemic, the number and characteristics of psychiatric visits changed in our emergency department (ED). We aimed to assess changes in the number of visits and characterize the profiles of these patients. METHODS: In this retrospective observational study, we examined the number of psychiatric ED visits and their proportion among the total number of ED visits. We also evaluated psychiatric visits characteristics during a one-month period after the declaration of deconfinement, and we compared those characteristics to characteristics observed during the same month over the previous 4 years. RESULTS: The number of psychiatric visits to our emergency department during deconfinement was similar to the number observed in the same month of previous years. However, the proportion of psychiatric visits to our emergency department among all visits to the ED rose during deconfinement to a level never before observed. The mean proportion of psychiatric admissions to all ED admissions rose from 3.5% in past years to 5.3% during deconfinement (p = 0.013). Moreover, during deconfinement, more visits (80%) were without an acute intoxication compared to past years (58.5%; p = 0.031). Also, in the deconfinement period, more visits lacked a follow-up consultation organized at discharge (40%) compared to the historical period (25%, p = 0.036). CONCLUSIONS: The deconfinement period after the first wave COVID-19 changed the number and type of psychiatric emergency medicine consultations at our hospital, suggesting a psychiatric impact of confinement during this pandemic. These findings will be of interest to practitioners and politicians in the coming months.