Challenges in adapting a stroke unit in a middle-income country: warning about costs and underfunding to achieve the Brazilian Ministry of Health's benchmark.

Background: Since the implementation of the stroke care line in Brazil, the relationship (adequacy) of costs spent during hospitalization with the Brazilian Ministry of Health indicators for a stroke unit have not yet been analyzed. Aims: This study aimed to assess the adequacy of a comprehensive stroke center for key performance indicators and analyze the costs involved in hospitalization. We verified the association between stroke severity at admission and care costs during hospitalization. Methods: A retrospective medical chart review of 451 patients was performed using semiautomatic electronic data from a single comprehensive stroke center in Brazil between July 2018 and January 2020. Clinical and resource utilization data were collected, and the mean acute treatment cost per person was calculated. The Kruskal-Wallis test with Dunn's post-test was used to compare the total costs between stroke types and reperfusion therapies. A robust linear regression test was used to verify the association between stroke severity at hospital admission and the total hospitalization costs. Good adequacy rates were observed for several indicators. Results: Data from 451 patients were analyzed. The stroke unit had good adaptation to key performance indicators, but some critical points needed revision and improvement to adapt to the requirements of the Ministry of Health. The average total cost of the patient's stay was the USD 2,637.3, with the daily hospitalization, procedure, operating room, and materials/medication costs equating to USD 2,011.1, USD 220.7, USD 234.1, and USD 98.8, respectively. There was a positive association between the total cost and length of hospital stay (p < 0.001). Conclusion: The stroke unit complied with most of the main performance indicators proposed by the Brazilian Ministry of Health. Underfunding of the costs involved in the hospitalization of patients was verified, and high costs were associated with the length of stay, stroke severity, and mechanical thrombectomy.

To what extent does frailty mediate the association between age and the outcomes of brain reperfusion following acute ischemic stroke?

Objective: We evaluated the extent to which frailty mediated the association between age, poor functional outcomes, and mortality after acute ischemic stroke when patients were treated with brain reperfusion (thrombolytic therapy and/or thrombectomy). Materials and methods: This retrospective cohort study included patients diagnosed with ischemic stroke who had undergone intravenous cerebral reperfusion therapy and/or mechanical thrombectomy. We created a mediation model by analyzing the direct natural effect of an mRS score > 2 and death on age-mediated frailty according to the Frailty Index. Results: We enrolled 292 patients with acute ischemic stroke who underwent brain reperfusion. Their mean age was 67.7 ± 13.1 years. Ninety days after the stroke ictus, 54 (18.5%) participants died, and 83 (28.4%) lived with moderate to severe disability (2 < mRS < 6). In the mediation analysis of the composite outcome of disability (mRS score > 2) or death, frailty accounted for 28% of the total effect of age. The models used to test for the interaction between age and frailty did not show statistically significant interactions for either outcome, and the addition of the interaction did not significantly change the direct or indirect effects, nor did it improve model fit. Conclusion: Frailty mediated almost one-third of the effect of age on the composite outcome of disability or death after acute ischemic stroke.

Influence of CReatine supplementation on mUScle mass and strength after stroke (ICaRUS Stroke Trial): study protocol for a randomized controlled trial.

BACKGROUND: Stroke is a leading cause of mortality and disability, and its sequelae are associated with inadequate food intake which can lead to sarcopenia. The aim of this study is to verify the effectiveness of creatine supplementation on functional capacity, strength, and changes in muscle mass during hospitalization for stroke compared to usual care. An exploratory subanalysis will be performed to assess the inflammatory profiles of all participants, in addition to a follow-up 90 days after stroke, to verify functional capacity, muscle strength, mortality, and quality of life. METHODS: Randomized, double-blind, unicenter, parallel-group trial including individuals with ischemic stroke in the acute phase. The duration of the trial for the individual subject will be approximately 90 days, and each subject will attend a maximum of three visits. Clinical, biochemical, anthropometric, body composition, muscle strength, functional capacity, degree of dependence, and quality of life assessments will be performed. Thirty participants will be divided into two groups: intervention (patients will intake one sachet containing 10g of creatine twice a day) and control (patients will intake one sachet containing 10g of placebo [maltodextrin] twice a day). Both groups will receive supplementation with powdered milk protein serum isolate to achieve the goal of 1.5g of protein/kg of body weight/day and daily physiotherapy according to the current rehabilitation guidelines for patients with stroke. Supplementation will be offered during the 7-day hospitalization. The primary outcomes will be functional capacity, strength, and changes in muscle mass after the intervention as assessed by the Modified Rankin Scale, Timed Up and Go test, handgrip strength, 30-s chair stand test, muscle ultrasonography, electrical bioimpedance, and identification of muscle degradation markers by D3-methylhistidine. Follow-up will be performed 90 days after stroke to verify functional capacity, muscle strength, mortality, and quality of life. DISCUSSION: The older population has specific nutrient needs, especially for muscle mass and function maintenance. Considering that stroke is a potentially disabling event that can lead the affected individual to present with numerous sequelae, it is crucial to study the mechanisms of muscle mass loss and understand how adequate supplementation can help these patients to better recover. TRIAL REGISTRATION: The Brazilian Clinical Trials Registry (ReBEC) RBR-9q7gg4 . Registered on 21 January 2019.

Non-invasive Brain Stimulation Can Reduce Unilateral Spatial Neglect after Stroke: ELETRON Trial.

OBJECTIVE: Rehabilitation top-down techniques based on brain stimulation present variable outcomes in unilateral spatial neglect (USN) after stroke. This study aimed to examine the effects of physical therapy after anodal and cathodal transcranial direct current stimulation (A-tDCS and C-tDCS, respectively) to improve visuospatial and functional impairments in individuals with USN after stroke. METHODS: This double-blinded, pilot randomized clinical trial enrolled patients with USN after ischemic stroke. Randomization was stratified according to the Behavior Inattention Test-Conventional (BIT-C) and Catherine Bergego Scale (CBS). Outpatient physical therapy was conducted for 7.5 weeks after 20 minutes of tDCS. The primary outcome was the USN degree evaluated by the BIT-C. Secondary outcomes were the difference in CBS score, stroke severity (National Institutes of Health Stroke Scale [NIHSS]), disability (modified Rankin Scale), autonomy (Barthel Index, Functional Independence Measure), and quality of life (EuroQol Group 5-Dimension Self-Report Questionnaire). Outcomes were analyzed using an analysis of covariance model corrected by age, baseline NIHSS, and baseline BIT-C. Pairwise post hoc comparisons were performed using Bonferroni correction. RESULTS: In the primary outcomes, A-tDCS led to greater improvement in BIT-C after intervention (mean difference [MD] = 18.4, 95% confidence interval [CI] = 3.9-32.8, p = 0.008) compared to sham. However, no significant differences were observed between A-tDCS and C-tDCS (MD = 13.9, 95% CI = -0.3 to 28.1, p = 0.057), or C-tDCS and sham (MD = 4.5, 95% CI = -9.7 to 18.8, p = 0.99). There were no significant differences between groups in terms of secondary outcomes. INTERPRETATION: A-tDCS associated with physical therapy can decrease the severity of USN after stroke. However, these preliminary findings must be confirmed by collecting additional evidence in a larger phase 3 trial. ANN NEUROL 2022;92:400-410.

Transcranial doppler as screening method for sickling crises in children with sickle cell anemia: a latin America cohort study.

BACKGROUND: Sickle cell anemia (SCA) is the leading cause of childhood stroke. We aimed to evaluate whether altered cerebral flow velocities, as measured by transcranial Doppler (TCD), are associated with vaso-occlusive complications in addition to stroke in pediatric SCA patients. METHODS: We evaluated 37 children aged between 2 and 16 years with SCA who underwent screening for TCD between January 2012 and October 2018. Genotypic profiles and demographic data were collected, TCD examinations were performed during follow-up, and the presence of sickling crises was compared. Survival analyses were performed using simple frailty models, in which each predictor variable was analyzed separately in relation to the occurrence of a sickling crisis. RESULTS: The variables related to sickle cell crises in the univariate analysis were peak systolic velocity (PSV) in the middle cerebral artery (MCA), hazard ratio (HR) 1.01 (1.00-1.02) p = 0.04; end-diastolic velocity (EDV) in the MCA, HR 1.02 (1.01-1.04) p = 0.01; time average mean maximum velocity (TAMMV) in the basilar artery (BA), HR 1.02 (1.00-1.04) p = 0.04; hemoglobin, HR 0.49 (0.38-0.65) p < 0.001; hematocrit, HR 0.78 (0.71-0.85) p < 0.001; leukocyte counts, HR 1.1 (1.05-1.15) p < 0.001; platelets counts, HR 0.997 (0.994-0.999) p = 0.02; and reticulocyte numbers, HR 1.14 (1.06-1.23) p < 0.001. CONCLUSIONS: Our results indicate PSV and EDV in the MCA and TAMMV in the BA as markers of risk for the occurrence of sickling crises in SCA.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil.

Objectives: Cerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke. Materials and Methods: This retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments. Results: Patients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069-13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376-9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients. Conclusion: Altogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Use of artificial intelligence as an instrument of evaluation after stroke: a scoping review based on international classification of functioning, disability and health concept.

INTRODUCTION: To understand the current practices in stroke evaluation, the main clinical decision support system and artificial intelligence (AI) technologies need to be understood to assist the therapist in obtaining better insights about impairments and level of activity and participation in persons with stroke during rehabilitation. METHODS: This scoping review maps the use of AI for the functional evaluation of persons with stroke; the context involves any setting of rehabilitation. Data were extracted from CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, PEDRO Web of Science, IEEE Xplore, AAAI Publications, ACM Digital Library, MathSciNet, and arXiv up to January 2021. The data obtained from the literature review were summarized in a single dataset in which each reference paper was considered as an instance, and the study characteristics were considered as attributes. The attributes used for the multiple correspondence analysis were publication year, study type, sample size, age, stroke phase, stroke type, functional status, AI type, and AI function. RESULTS: Forty-four studies were included. The analysis showed that spasticity analysis based on ML techniques was used for the cases of stroke with moderate functional status. The techniques of deep learning and pressure sensors were used for gait analysis. Machine learning techniques and algorithms were used for upper limb and reaching analyses. The inertial measurement unit technique was applied in studies where the functional status was between mild and severe. The fuzzy logic technique was used for activity classifiers. CONCLUSION: The prevailing research themes demonstrated the growing utility of AI algorithms for stroke evaluation.

The Role of Transthoracic Echocardiography in the Evaluation of Patients With Ischemic Stroke.

Background: Ischemic stroke can be classified into five etiological types, according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and its adequate investigation and characterization can aid in its clinical management and in preventing new events. Transthoracic echocardiography (TTE) plays a key role in investigating its etiology; approximately one-third of the patients remain without an adequate definition of the etiology or are classified as the undetermined TOAST type. Objectives: To evaluate if the percentage of patients with indeterminate etiology according to the TOAST classification decreased after transthoracic echocardiography, to determine whether or not the prognosis after ischemic stroke is worse among patients classified as the undetermined TOAST type, and to verify the predictive capacity of echocardiography on the prognosis after ischemic stroke. Methods: In this retrospective cohort study, clinical, neurological, and echocardiographic examinations were conducted when the patient was hospitalized for stroke. In-hospital mortality and functional capacity were evaluated at hospital discharge and 90 days thereafter. Multiple linear regression and multiple logistic regression models were adjusted for confounding factors. The level of significance was 5%. Results: A total of 1,100 patients (men = 606; 55.09%), with a mean age of 68.1 ± 13.3 years, were included in this study. Using TTE, 977 patients (88.82%) were evaluated and 448 patients (40.7%) were classified as the undetermined TOAST type. The patients who underwent TTE were 3.1 times less likely to classified as the undetermined TOAST type (OR = 0.32; p < 0.001). Echocardiography during hospitalization was a protective factor against poor prognosis, and reduced the odds of in-hospital death by 11.1 times (OR: 0.090; p < 0.001). However, the presence of the undetermined TOAST classification elevated the chance of mortality during hospitalization by 2.0 times (OR: 2.00; p = 0.013). Conclusions: Echocardiography during hospitalization for ischemic stroke reduces the chances of an undetermined TOAST classification and the risk of in-hospital mortality. However, being classified as the undetermined TOAST type increases the chance of mortality during hospitalization, suggesting that evaluating patients using echocardiography during hospitalization for acute ischemic stroke is important.

The Impact of Age on Mortality and Disability in Patients With Ischemic Stroke Who Underwent Cerebral Reperfusion Therapy: A Brazilian Cohort Study.

Introduction: The main driver for increased stroke prevalence is the aging of the population; however, the best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Therefore, the aim was studying the association of age with clinical outcomes (mortality and functional disability) in stroke patients who underwent cerebral reperfusion therapy at hospital discharge and 90 days after ictus. Methods: This was a retrospective (stroke databank analysis) cohort study of participants who had been diagnosed with ischemic stroke and undergone intravenous cerebral reperfusion therapy or mechanical thrombectomy. The variable of interest was patient age, which was categorized into four groups: (1) up to 59 years; (2) 60 to 69 years; (3) 70 to 79 years old; and (4) above 79 years. The primary outcome was mortality at hospital discharge and 90 days after stroke, and the secondary outcome was functional capacity at hospital discharge and 90 days after stroke. Results: A total of 281 patients was included in the study (235 treated by thrombolysis alone, and 46 treated with mechanical thrombectomy). The mean age of the total sample was 67 ± 13.1 years. The oldest patients had the most unfavorable outcomes, except for mortality rate, at hospital discharge (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001) and 90 days after stroke (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001). Conclusion: Cerebral reperfusion was a viable treatment for ischemic stroke in both elderly and very elderly patients, as it did not increase mortality. However, it was observed that older individuals had worse functional outcomes at hospital discharge and 90 days after stroke.

Safety of the effective radiation dose received during stroke hospitalization.

BACKGROUND: Neuroimaging is widely used for diagnosis and treatment of stroke. However, little is known about whether the radiation doses received by patients comply with international safety guidelines. OBJECTIVES: The aim of this study was to evaluate the effective radiation dose received while in hospital for stroke and analyze its safety according to current guidelines. METHODS: This cross-sectional study included 109 patients who were hospitalized and diagnosed with ischemic stroke. The National Institutes of Health Stroke Scale was used to evaluate stroke severity, the Bamford clinical classification was used for topography, and the TOAST classification was used for etiology. The computed tomography dose index and size-specific dose estimates were used to calculate the effective radiation dose (ERD) received while in hospital. A Mann-Whitney test was used to compare the ERD received by thrombolysed and non-thrombolysed patients. Non-parametric statistics were used to analyze the data with a 95% confidence interval. RESULTS: During the study period, the median ERD received was 10.9 mSv. Length of stay was not associated with radiation exposure. No differences were demonstrated in ERD according to stroke etiology or Bamford clinical classification. Patients who had CT perfusion (only or in addition to CT or angiotomography) received the highest ERD (46.5 mSv) and the difference compared to those who did not (10.8 mSv) was statistically significant (p<0.001). No differences were found in the ERD between thrombolysed and non-thrombolysed patients. There was no correlation between ERD while in hospital and stroke severity. CONCLUSIONS: According to the current national guidelines, the protocol for examining images at our stroke unit is safe in terms of the ERD received by the patient while in hospital. There was no difference in the ERD received by patients stratified by thrombolytic treatment or stroke severity.

CONTEXTO: A neuroimagem é amplamente utilizada para o diagnóstico e tratamento do acidente vascular cerebral (AVC). No entanto, pouco se sabe se a dose de radiação recebida nesses exames está de acordo com as diretrizes internacionais de segurança. OBJETIVOS: O objetivo deste estudo foi avaliar a dose de radiação efetiva (DRE) durante a hospitalização por AVC. MÉTODOS: Trata-se de estudo transversal com 109 pacientes hospitalizados com diagnóstico de AVC isquêmico. A gravidade do AVC foi avaliada pela National Institutes of Health Stroke Scale, a topografia pela classificação clínica de Bamford e a etiologia pelo Trial of ORG 10172 in Acute Stroke Treatment (TOAST). O índice de dose recebida no exame de tomografia computadorizada (TC) e as estimativas de dose específicas foram usados ​​para calcular a DRE recebida durante a hospitalização. O teste de Mann-Whitney foi utilizado para comparar a DRE recebida por pacientes trombolisados ​​e não trombolisados. Estatísticas não paramétricas foram utilizadas para analisar os dados. RESULTADOS: Durante o período do estudo, a DRE foi de 10,9 mSv. O tempo de internação não foi associado à exposição à radiação. Nenhuma diferença foi demonstrada na DRE de acordo com a etiologia e classificação clínica de Bamford. Os pacientes que fizeram perfusão (isolada, associada à TC ou angiotomografia) receberam a maior DRE (46,5 mSv) em comparação aos que não fizeram (10,8 mSv), sendo estatisticamente significativo (p <0,001). Não foram encontradas diferenças na DRE entre pacientes trombolisados e não trombolisados. Não houve correlação entre a DRE durante a hospitalização com a gravidade do AVC. CONCLUSÕES: De acordo com as atuais diretrizes nacionais, o protocolo de exame de imagens na unidade de AVC é seguro em relação à DRE recebido pelo paciente durante a internação. Não houve diferença na DRE dos pacientes de acordo com o tratamento trombolítico e a gravidade do AVC.

Respiratory Function and Grip Strength in the Acute Phase of Stroke Are Associated with Stroke Severity and Disability at Hospital Discharge.

Introduction. Stroke can lead to musculoskeletal and respiratory dysfunction, chronic deconditioning, and functional limitations, as well as long-term complications. OBJECTIVE: The aim of this study was to evaluate the association between respiratory function and grip strength in the acute phase of stroke and stroke severity, disability, and autonomy in the long term. METHODS: This was a cohort study including 46 patients in the stroke unit. The stroke patients were assessed in the stroke unit at the following moments: at admission by the clinical and haemodynamic stability, demographic and anthropometric data, hand grip strength, stroke severity by National Institutes of Health Stroke Scale (NIHSS) score, and respiratory function using a manovacuometer; during hospitalization by clinical complications and the length of stay; and at hospital discharge and 90 days after discharge by the degrees of functional capacity and dependence using NIHSS, modified Rankin scale (mRs), and Barthel index. Data analysis was performed by multiple linear regression to verify the association between respiratory function and grip strength and the outcomes. RESULTS: The median length of stay in the stroke unit was 7 days. A negative correlation was found between the palmar prehension strength on the unaffected side and mRs at discharge (ß = -0.034, p = 0.049). The NIHSS scores at discharge (ß = -0.034, p = 0.049). The NIHSS scores at discharge (ß = -0.034, p = 0.049). The NIHSS scores at discharge (. CONCLUSION: It was concluded that a loss of grip strength is associated with a loss of ability and autonomy at discharge and poor respiratory function is associated with stroke severity at discharge.

Effect of ankle-foot orthosis on functional mobility and dynamic balance of patients after stroke: Study protocol for a randomized controlled clinical trial.

INTRODUCTION: Stroke is the principal cause of impairment in the motor function and gait of adults. One of the resources used in rehabilitation to optimize gait is a prescription of ankle-foot orthosis (AFO), and the most prescribed AFOs are Fixed AFO and Articulated AFO; however, it is not known which of these options is more effective for these individuals. The aim of this study is to evaluate the impact of different types of ankle-foot orthosis functional mobility and dynamic balance in stroke patients. METHODS: Prospective randomized controlled clinical trial with 2 parallel groups will be conducted, and the aim is to recruit 50 patients with stroke diagnosis within 1 year, who indicated that they use both types of orthotics, who had a previous Rankin score less than or equal to 3, and who obtained AFO orthosis through the Hospital Clinics at the Botucatu Medical School (HCBMS) São Paulo, Brazil. After a specific evaluation by a physiotherapist, the patient will receive 1 of the AFO types via randomization. After 30 days, the patient will be reevaluated. The primary outcomes will be balance and mobility, which will be evaluated by the Time Up Go Test (TUG) and Tinetti's Scale of Mobility and Balance (TSMB). The secondary outcomes will be quality of life and the levels of anxiety and depression, which will be evaluated with the European (5D) Quality of Life Scale (Euroqol) and Hospital Anxiety and Depression Scale (HADS). Group allocation will be not concealed because the blinding of participants and of therapists that provide intervention is not possible, and all analyses will be based on an intention-to-treat principle. This study was approved by the Human Research Ethics Committee of the São Paulo State University UNESP, number 2.367.953. The results will be published in relevant journal. DISCUSSION: The results of this study will contribute to clinical practice by identifying the type of AFO orthosis that is more suitable for this condition, helping to standardize prescription of these orthoses by professionals, and guiding future research studies on this subject, which is still incompletely defined in the literature. TRIAL REGISTRATION: RBR-6SF2VV (March 5, 2018).

Influence of an exercise program on cardiac remodeling and functional capacity in patients with stroke (CRONuS trial): study protocol for a randomized controlled trial.

BACKGROUND: Cardiovascular rehabilitation is one of the treatment options for post-stroke individuals in order to improve functional independence in activities of daily life and reduce energy expenditure. The aim of this trial is to evaluate the effect of an exercise program on the echocardiographic variables, functional capacity, inflammatory response, neurological status, nutritional status, cardiologic evaluation, and quality of life of patients after stroke. METHODS/DESIGN: This is a randomized controlled trial including patients with ischemic stroke in the chronic phase. The patients will be evaluated at the beginning of the study and after 16 weeks. This will include clinical and physical evaluation, 6-min walk test, neurological assessment, nutritional assessment, ambulatory blood pressure monitoring, transthoracic echocardiography, and assessment of the quality of life. The sample size has been determined as 40 patients, who will be divided into two groups: control group (CG; n = 20) and intervention group (IG; n = 20). The CG will undergo conventional physiotherapy for 45 min, three times a week, up to 16 weeks, while the IG will be put on a cardiovascular rehabilitation program consisting of heating, aerobic exercise, and muscle strengthening for 45 min, three times a week, for 16 weeks. The primary endpoint will be functional capacity following a 6-min walk test (delta maxVO2) and morphofunctional echocardiographic variables (indexed left ventricular mass) before and after the intervention. DISCUSSION: We expect to observe an improvement in cardiac structural and functional abnormalities in the IG, on echocardiography and biochemical examination, and that the improvement of these parameters after cardiovascular rehabilitation will have a favorable impact on the functional capacity and quality of life of patients after stroke. TRIAL REGISTRATION: REBEC, RBR-4wk4b3. Registered on 19 September 2016.

Validation of the Catherine Bergego Scale in patients with unilateral spatial neglect after stroke.

The Catherine Bergego Scale (CBS) is a scale to evaluates the impact of unilateral spatial neglect (USN) on everyday life of patients after stroke. OBJECTIVE: The aim of this study was to evaluate the reliability and comprehension of the Portuguese version of the CBS for patients with USN after stroke. METHODS: This was a cross-sectional study in patients with stroke and USN. The CBS was translated, culturally adapted and applied by two independent investigators. The patients were also evaluated by the Behavioural Inattention Test (BIT), NIHSS, mRS and Barthel scale to assess USN severity, neurological function, disability and autonomy consecutively. Consistency and coherence were analysed using Cronbach's α, inter-observer reliability by Kappa, and the correlation between the CBS, BIT, NIHSS, mRS, and Barthel was determined using Pearson correlation. RESULTS: Twenty-two patients were evaluated and the observed Cronbach's α=0.913. For intra-observer reproducibility, the 10 items showed a reasonable and high reliability between evaluators. The CBS showed a negative correlation with the BIT. There was a low correlation between the BIT and NIHSS, mRS and Barthel index. CONCLUSION: The CBS is an adequate and validated scale for assessing patients with USN after stroke in a Brazilian population.

A Escala de Catherine Bergego (CBS) é uma escala para avaliar o impacto da negligência espacial unilateral (USN) no cotidiano de pacientes após AVC. OBJETIVO: Não há validação da CBS para população brasileira e o objetivo deste estudo foi avaliar a confiabilidade e compreensão da versão em português da CBS para pacientes com USN após AVC. MÉTODOS: Trata-se de um estudo transversal em pacientes com AVC e USN. A CBS foi traduzida, adaptada culturalmente e aplicada por dois investigadores independentes. Os pacientes também foram avaliados pelo Behaviour Innatention Test (BIT), NIHSS, mRS e Barthel para avaliar a gravidade da USN, função neurológica, incapacidade e autonomia consecutivamente. A consistência e a coerência foram analisadas pelo coeficiente α de Cronbach, a confiabilidade interobservador foi avaliada pelo coeficiente kappa e a correlação entre o CBS, BIT, NIHSS, mRS e Barthel foi avaliada pela correlação de Pearson. RESULTADOS: Vinte e dois pacientes foram avaliados e observaram-se consistência e coerência pelo coeficiente α de Cronbach=0,913. Na análise da reprodutibilidade intraobservador, os 10 itens da escala apresentaram confiabilidade razoável e alta entre os avaliadores. O CBS mostrou correlação negativa com o BIT. Houve baixa correlação entre BIT e NIHSS, mRS e índice de Barthel. CONCLUSÃO: A CBS é uma escala adequada e validada para avaliar pacientes com USN após AVC em uma população brasileira e de língua portuguesa.

Noninvasive Brain Stimulations for Unilateral Spatial Neglect after Stroke: A Systematic Review and Meta-Analysis of Randomized and Nonrandomized Controlled Trials.

Background: Unilateral spatial neglect (USN) is the most frequent perceptual disorder after stroke. Noninvasive brain stimulation (NIBS) is a tool that has been used in the rehabilitation process to modify cortical excitability and improve perception and functional capacity. Objective: To assess the impact of NIBS on USN after stroke. Methods: An extensive search was conducted up to July 2016. Studies were selected if they were controlled and noncontrolled trials examining transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and theta burst stimulation (TBS) in USN after stroke, with outcomes measured by standardized USN and functional tests. Results: Twelve RCTs (273 participants) and 4 non-RCTs (94 participants) proved eligible. We observed a benefit in overall USN measured by the line bisection test with NIBS in comparison to sham (SMD -2.35, 95% CI -3.72, -0.98; p = 0.0001); the rTMS yielded results that were consistent with the overall meta-analysis (SMD -2.82, 95% CI -3.66, -1.98; p = 0.09). The rTMS compared with sham also suggested a benefit in overall USN measured by Motor-Free Visual Perception Test at both 1 Hz (SMD 1.46, 95% CI 0.73, 2.20; p < 0.0001) and 10 Hz (SMD 1.19, 95% CI 0.48, 1.89; p = 0.54). There was also a benefit in overall USN measured by Albert's test and the line crossing test with 1 Hz rTMS compared to sham (SMD 2.04, 95% CI 1.14, 2.95; p < 0.0001). Conclusions: The results suggest a benefit of NIBS on overall USN, and we conclude that rTMS is more efficacious compared to sham for USN after stroke.

Adductor Pollicis Muscle Thickness and Obesity Are Associated with Poor Outcome after Stroke: A Cohort Study.

BACKGROUND: Nutritional status may influence outcome after stroke. It is possible that some obese individuals present reduced fat-free mass. AIMS: We aimed to determine if bedside evaluation of body composition by the body mass index (BMI), adductor pollicis muscle thickness (APMT) and arm muscle area (AMA), and the combination of low APMT or AMA with obesity are associated with disability 90 days after stroke. METHODS: A cohort study evaluating 120 patients hospitalized at the Stroke Unit was carried out. Data were expressed as average ± standard deviation or median and percentiles. Obesity was evaluated by BMI and fat-free mass by the APMT and AMA. Receiver operating characteristic (ROC) curves and multivariate logistic regression analysis were used to measure whether APMT and obesity were associated with modified Rankin Scale (mRS) ≥3 (disability) within 90 days of stroke. The data were adjusted for National Institutes of Health Stroke Scale (NIHSS), sex, age, type of stroke, and thrombolysis. The significance level was 5%. RESULTS: Of 120 patients, we came up with the following demographics: men: 66 (55.0%); mean age: 66.6 ± 13.2 years; ischemic stroke: 109 (90.8%); mean NIHSS: 4 (2-10); thrombolysis: 18 (16.5%). Considering mRS ≥3, ROC curve analysis showed that the value of the cutoff for APMT was <12.5 mm. In multivariate analysis adjusted for the above factors, each 1 mm of increase in APTM reduced the chance of disability by 31%. The intersection of obesity with APMT <12.5 mm increased by 37-fold the risk of disability. AMA was not associated with mRS ≥3. CONCLUSION: Lower APMT alone or in combination with obesity was associated with poor functional status.

Amnestic dementia impairment in Parkinson's disease: The role of body composition, ageing and insulin resistance.

BACKGROUND: The risk of cognitive impairment associated with Parkinson's disease (PD) is related to ageing. The role of body compartmentalization and associated metabolic dysfunctions, as a risk factor for dementia in PD is still not clear. OBJECTIVE: To investigate body mass distribution, insulin resistance, and other parameters in patients without dementia, and those with dementia classified as compromised delayed memory. SUBJECTS AND METHODS: We recorded body composition, basal levels of insulin resistance, and other data from 135 patients, who were followed for at least two years. The patients completed a Brief Cognitive Battery test. Patients with delayed recall memory impairment were assessed using the Mattis dementia rating scale. RESULTS: There was a correlation between age and the patient's scores. Age was negatively correlated with scores on all of the screening battery subtests (p ≤ 0.001), while formal education was positively correlated with the test scores. Insulin resistance was higher in non-demented patients compared to patients with impaired memory (p = 0.0027). There was no association between body composition and cognitive dysfunction in patients with PD. CONCLUSIONS: The results of this study indicate an apparent decrease in insulin resistance associated with cognitive impairment in PD. We found no correlations between body composition and memory dysfunction associated with PD.

Higher salt preference in heart failure patients.

Heart failure (HF) is a complex syndrome that involves changes in behavioral, neural and endocrine regulatory systems. Dietary salt restriction along with pharmacotherapy is considered an essential component in the effective management of symptomatic HF patients. However, it is well recognized that HF patients typically have great difficulty in restricting sodium intake. We hypothesized that under HF altered activity in systems that normally function to regulate body fluid and cardiovascular homeostasis could produce an increased preference for the taste of salt. Therefore, this study was conducted to evaluate the perceived palatability (defined as salt preference) of food with different concentrations of added salt in compensated chronically medicated HF patients and comparable control subjects. Healthy volunteers (n=25) and medicated, clinically stable HF patients (n=38, NYHA functional class II or III) were interviewed and given an evaluation to assess their preferences for different amounts of saltiness. Three salt concentrations (0.58, 0.82, and 1.16 g/100 g) of bean soup were presented to the subjects. Salt preference for each concentration was quantified using an adjective scale (unpleasant, fair or delicious). Healthy volunteers preferred the soup with medium salt concentration (p=0.042), HF patients disliked the low concentration (p<0.001) and preferred the high concentration of salted bean soup (p<0.001). When compared to healthy volunteers, HF patients demonstrated a significantly greater preference for the soup with a high salt concentration (p=0.038). It is concluded that medicated, compensated patients under chronic treatment for HF have an increased preference for salt.