Co-creation and stroke rehabilitation: a scoping review.

PURPOSE: Co-creation is identified as a concept with potential to address many challenges in modern healthcare systems. Its application within stroke rehabilitation is yet to be reviewed. The purpose of this paper is to identify when and how co-creation has been used in the literature to develop services and approaches to stroke survivor care and rehabilitation. MATERIALS AND METHODS: A scoping review was conducted guided by the framework outlined by Arksey and O'Malley. Articles were included if they involved co-creation with stroke survivors and identified co-creation as their methodology to develop post-stroke services. Quality appraisal of included articles was completed. RESULTS: The search strategy identified 565 articles. Fourteen articles met inclusion criteria. The results demonstrate that co-creation as a methodology to develop stroke rehabilitation services is a contemporary field, producing both technology and non-technology-based interventions, predominately in the community context. Co-creation application was inconsistent, with a plethora of methodologies used, and terminology to describe co-creation varying between the studies. CONCLUSIONS: Co-creation in stroke rehabilitation is currently in an expanding and rudimentary phase. This review identified the variability of its application, with future work needed to establish clarity and consistency in terminology and methodologies utilised to operationalise co-creation in stroke rehabilitation.Implications for rehabilitationCo-creation is a contemporary and evolving service improvement approach in stroke rehabilitation, utilised most commonly in the community context.Inconsistent terminology and diverse methodologies are utilised to enact co-creation in stroke rehabilitation.Opportunities exist to advance co-creation in the stroke rehabilitation space through developing consistency in its application, and further investigation into its use with the stroke survivor population.

Utilizing apolipoprotein E genotypes and associated comorbidities for the assessment of the risk for dementia.

Introduction: Dementia is associated with many comorbidities while being related to Apolipoprotein E (ApoE) polymorphism. However, it is unclear how these clinical illnesses and genetic factors modify the dementia risk. Methods: We enrolled 600 dementia cases and 6000 matched non-dementia controls, with identified ApoE genotype (ε4/ε4, ε4/ε3, and ε3/ε3). Eight comorbidities were selected by medical records, and counted if occurring within 3 years of enrollment. Results: The dementia group had a higher ratio of carrying ε4 allele and prevalence of comorbidities than the non-dementia group. Homozygous ε4 carriers presented the broken line of dementia risk with the peak age at 65-75 years and odds ratio (OR) up to 6.6. The risk only emerged after 65 years of age in ε3/ε4 subjects with OR around 1.6-2.4 when aged > 75 years. Cerebrovascular accident (CVA) is the commonest comorbidity (14.6%). CVA, sleep disorder, and functional gastrointestinal disorders remained as significant risk comorbidities for dementia throughout all age groups (OR = 1.7-5.0). When functional gastrointestinal disorder and ε4 allele both occurred, the dementia risk exceeded the summation of individual risks (OR = 3.7 and 1.9 individually, OR = 6.0 for the combination). Comorbidities could also be predictors of dementia. Conclusion: Combining the genetic and clinical information, we detected cognitive decline and optimize interventions early when the patients present a specific illness in a particular age and carry a specific ApoE allele. Of comorbidities, functional gastrointestinal disorder is the strongest predicting factor for dementia in ε4 allele carriers.

Evaluation of stroke pre-hospital management in Lebanon from symptoms onset to hospital arrival and impact on patients' status at discharge: a pilot study.

BACKGROUND: Hospital arrival time after acute ischemic stroke onset is the major factor limiting the eligibility of patients to receive intravenous thrombolysis. Shortening the prehospital delay is crucial to reducing morbidity and mortality for stroke patients. The study was conducted to investigate the factors that influence hospital arrival time after acute stroke onset in the Lebanese population and to assess the effect of the prehospital phase on patients' prognosis at discharge. METHOD: A prospective cross-sectional study was performed in eleven hospitals from April to July 2021 including 100 patients having stroke symptoms or transient ischemic attack (TIA). Two questionnaires were used to collect data addressing patient management in the pre-hospital phase and the in-hospital phase. Descriptive and bivariate analyses were done to evaluate the potential associations between prognosis, pre-hospital characteristics, and other factors. RESULTS: The patients' mean age was 70.36 ± 12.25 years, 43 (53.8%) of them were females, and 79 (85%) arrived within 3 hours after symptoms onset. Diabetic patients had a significant delay in hospital arrival compared with non-diabetics (27.0%vs.7.1%, p-value = 0.009). Moreover, 37 (75.5%) of school-level education patients arrived early at the hospital compared to 7 (100%) of university-level education (p-value = 0.009). The modified Rankin Scale (mRS) at discharge in patients with hemorrhagic stroke (10 (90%)) was worse than that in patients with ischemic stroke (38 (80%)) or TIA (3 (15%)) (p-value< 0.001). CONCLUSION: The study findings make it imperative to raise awareness about stroke symptoms among the Lebanese population. Emergency Medical Services should be utilized appropriately in the transportation of stroke patients to achieve optimal patient outcomes.

COVID-19 lockdown impact on quality of treatment and outcomes of STEMI and stroke patients in a large tertiary medical center: an observational study.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic affected health-care systems worldwide, leading to fewer admissions and raising concerns about the quality of care. The objective of this study was to investigate the early effects of the COVID-19 pandemic on quality of care among stroke and ST-elevation myocardial infarction (STEMI) patients, focusing on clinical outcomes and direct treatment costs. METHOD: This retrospective, observational study was based on the 10-week period that included the first wave of the COVID-19 pandemic in Israel (15 February 2020-30 April 2020). Emergency department admissions for stroke and STEMI were compared with parallel periods in 2017-2019, focusing on demographics, risk and severity scores, and the effect of clinical outcomes on hospitalization costs. RESULTS: The 634 stroke and 186 STEMI cases comprised 16% and 19% fewer admissions, respectively, compared to 2019. No significant changes were detected in demographics, most disease management parameters, readmission and mortality outcomes. The mean door-to-balloon time increased insignificantly by 33%, lowering the health quality indicator (HQI) for treatment in <90 min from 94.7% in 2017-2019 to 83% in 2020 (P = 0.022). Among suspected stroke patients, 97.2% underwent imaging, with 28% longer median time from admission (P = 0.05). Consequently, only 24.3% met the HQI of imaging in <29 min, compared to 45.5% in 2017-2019 (P < 0.01). Increased length of stay and more intensive care unit admissions were the leading causes of 6.5% increased mean cost of STEMI patients' initial hospitalization, which totaled $29 300 in the COVID-19 period (P = 0.008). CONCLUSION: The initial pandemic period caused a decline in HQIs linked to diagnostic and treatment protocols, without changes in outcomes, but with increased hospitalization costs. Medical information and awareness of life-threatening conditions among patients and caregivers should be increased to enable proper diagnosis and management.

Primary membranoproliferative glomerulonephritis in a child with down syndrome complicated with CVA: A case report.

Introduction: Down syndrome (DS) is a genetic disorder that affects multiple organs but glomerular lesions were reported only in case reports such as focal segmental glomerulosclerosis (FSGS), and Membranoproliferative glomerulonephritis (MPGN). Case presentation: A 14-year-old male child with DS was presented with generalized edema over three months. Laboratory tests revealed nephrotic syndrome (NS) and urinary tract infection (UTI). Renal ultrasound consisted with CKD. Kidney biopsy corresponded with MPGN. Also, all investigations for secondary underlying disorders came back negative suggesting the idiopathic form. Moreover, the status complicated with cerebrovascular accident (CVA), which has not been described in a DS- patient with glomerulonephritis. Discussion/conclusion: The relationship between DS and the incidence of glomerulonephritis is unclear. we suggest regular monitoring of renal function and urinalysis in different-age patients with Down syndrome, because early detection of renal disorders may prevent or slow down the progression and could be beneficial for increasing survival.

What is the Optimal Low-Density Lipoprotein Cholesterol?

One's total atherosclerotic plaque burden is related to his or her cumulative exposure to low-density lipoprotein cholesterol (LDL-C) and other apoB-containing lipoproteins. Long-term exposure to lower LDL-C levels is associated with a lower risk of cardiovascular events compared with shorter term exposure to lower LDL-C. New lipid-reducing agents have been able to reduce LDL-C to previously unseen levels, showing efficacy in safely decreasing rates of atherosclerotic cardiovascular disease in primary and secondary prevention populations. To date, an LDL-C level less than which there is no clinical benefit has not yet been identified.

Thrombotic and Clinical Outcomes in Patients with Hematologic Malignancy and COVID-19.

BACKGROUND: Venous thromboembolism (VTE) is a common complication in acute COVID-19 and those with hematologic malignancy (HM) may be at an even higher risk. We performed a retrospective analysis of patients with history of HM and acute COVID-19 to evaluate thrombotic and clinical outcomes. METHODS: Patients with COVID-19 were identified by positive SARS-CoV-2 PCR test. Our primary endpoints were rate of VTE and CVA in patients with HM compared to the general population (GP). Secondary outcomes included composite thrombotic events (CVA + VTE), COVID-19 fatality, respiratory support, ICU admission rates, and length of ICU stay RESULTS: A total of 833 patients were evaluated, 709 in the GP cohort, 124 patients in the HM cohort. CVA was more prevalent in the HM cohort (5.4% vs. 1.6%, P = .011). Rates of VTE were numerically higher for the HM cohort (8.0% vs. 3.6%, P = .069). The composite thrombotic rate was increased in the HM cohort (13.4% vs. 5.2%, P = .005). Patients with HM had a higher inpatient fatality rate (35.5% vs. 11.3%, P < .001), required more respiratory support (74.6% vs. 46.5%, P < .001) and had a higher rate of ICU admission (31.9% vs. 12.1%, P = .001). CONCLUSION: Our data demonstrated an increased rate of composite thrombotic (CVA + VTE) outcomes, indicating HM patients with acute COVID-19 are at increased risk of thrombosis. Irrespective of disease status, HM patients also have significantly increased need for intensive care, respiratory support, and have higher fatality rates.

Perioperative neurologic outcomes of right versus left upper extremity access for fenestrated-branched endovascular aortic aneurysm repair.

OBJECTIVE: Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access. METHODS: During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. RESULTS: UE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74). CONCLUSIONS: Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.

Management and Prevention of Cerebrovascular Accidents in SARS-CoV-2-Positive Patients Recovering from COVID-19: a Case Report and Review of Literature.

We discuss the current understanding of COVID-19's neurological implications, their basis, and the evolving clinical consensus with a focus on cerebrovascular stroke. We further illustrate the potential significance of these implications with the aid of an accompanying case report outlining the disease course and treatment of a COVID-19 patient suffering from ischemic stroke and pulmonary embolism. The ever-growing strain on the global healthcare system due to the spread of the novel coronavirus SARS-CoV-2 requires focused attention on urgent care of independent, coexisting, and associated comorbidities, including cerebrovascular accidents. For illustration purposes, we outline the case of a 68-year-old female presenting with COVID-19 subsequently complicated by bilateral pulmonary embolism and a right-sided cerebrovascular accident. The patient was successfully managed pharmacologically and discharged without significant neurological deficit. The evidence for a hypercoagulable state in this patient along with discussion of mechanistic bases, corroborative evidence from the literature, along with relevant guidance on screening, treatment, and prophylaxis is offered. Greater study of the pathogenesis of COVID-19-related cerebrovascular complications and revisiting current guidelines on their management including potentially heightened levels of thromboprophylaxis are warranted.

Invited Review: The spectrum of neuropathology in COVID-19.

There is increasing evidence that patients with Coronavirus disease 19 (COVID-19) present with neurological and psychiatric symptoms. Anosmia, hypogeusia, headache, nausea and altered consciousness are commonly described, although there are emerging clinical reports of more serious and specific conditions such as acute cerebrovascular accident, encephalitis and demyelinating disease. Whether these presentations are directly due to viral invasion of the central nervous system (CNS) or caused by indirect mechanisms has yet to be established. Neuropathological examination of brain tissue at autopsy will be essential to establish the neuro-invasive potential of the SARS-CoV-2 virus but, to date, there have been few detailed studies. The pathological changes in the brain probably represent a combination of direct cytopathic effects mediated by SARS-CoV-2 replication or indirect effects due to respiratory failure, injurious cytokine reaction, reduced immune response and cerebrovascular accidents induced by viral infection. Further large-scale molecular and cellular investigations are warranted to clarify the neuropathological correlates of the neurological and psychiatric features seen clinically in COVID-19. In this review, we summarize the current reports of neuropathological examination in COVID-19 patients, in addition to our own experience, and discuss their contribution to the understanding of CNS involvement in this disease.

Performing Duplex within 72 Hours of Transient Ischemic Attack May Decrease Mortality, the Israeli National Program for Quality Indicators experience.

BACKGROUND: With diagnostic imaging, such as a duplex of the carotid arteries, finding of stenosis and atherosclerotic plaque and consequent end arterectomy may be important for decreasing the danger of developing cerebrovascular accident after transient ischemic attack (TIA). OBJECTIVES: To measure performance rates of duplex of carotid arteries within 72 hours of TIA diagnosis. METHODS: The denominator included all patients who were admitted to emergency departments because of TIA, and the numerator included those who underwent duplex within 72 hours of admission. Inclusion criteria included all patients older than 18 years who were admitted because of TIA according to the ICD9 codes. RESULTS: Measuring this indicator started in 2015 with 5504 patients and a 58% success rate. The figures for the years 2016, 2017, and 2018 were 5309, 5447, and 5278 patients with success rates of 73%, 79%, and 83%, respectively. Six of 26 hospitals (23.0%) reached the target of 80% in 2018. From 2015 to 2018 a total of 21,538 patients were admitted to emergency departments in Israel and diagnosed with TIA. Of these, 15,722 (72.9%) underwent duplex within 72 hours. The mortality rate within 30 days from diagnosis was 0.81% in patients who performed duplex within 72 hours of diagnosis and 2.37% in patients who did not, odds ratio 2.676, 95% confidence interval 2.051-3.492, P < 0.0001. These results indicate a statistically significant decrease of 65.82. CONCLUSIONS: A significant decrease in mortality was noted in patients with a new diagnosis of TIA who underwent duplex within 72 hours of diagnosis.

The efficacy and safety of intravenous tranexamic acid in hip fracture surgery: A systematic review and meta-analysis.

OBJECTIVE: The present meta-analysis was conducted to compare the efficacy and safety of intravenous application of tranexamic acid (TXA) with placebo in patients with hip fracture undergoing hip surgeries. METHODS: PubMed, EMBASE and Cochrane Library were searched from inception until March 2018. A combined searching strategy of subject words and random words was adopted. Only randomized clinical trials were included. The comparisons regarding transfusion rate, total blood loss, intraoperative blood loss, postoperative blood loss, postoperative haemoglobin and postoperative thromboembolic complications were conducted. The meta-analysis was performed using Review Manager 5.3, and the bias evaluation was based on the Cochrane Handbook 5.1.0. RESULTS: Ten randomized controlled trials published from 2007 to 2018 were included in the meta-analysis. The results showed that there were significant differences in the two groups concerning transfusion rate of allogeneic blood [risk ratio (RR) = 0.66, 95% confidence interval (CI): 0.56 to 0.78, P = 0.003], total blood loss [mean difference (MD) = -273.00, 95% CI: -353.15 to -192.84, P < 0.00001], intraoperative blood loss (MD = -76.63, 95% CI: -139.55 to -13.71, P = 0.02), postoperative blood loss (MD = -125.29, 95% CI: -221.96 to -28.62, P = 0.01) and postoperative haemoglobin (MD = 0.80, 95% CI: 0.38 to 1.22, P = 0.0002). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 1.38, 95% CI: 0.74 to 2.55, P = 0.31). CONCLUSIONS: This meta-analysis of the available evidence implies that the intravenous route of TXA shows an ability to reduce transfusion requirements and total blood loss, not increasing the incidence of thromboembolic events in patients undergoing hip surgeries. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: The result of this meta-analysis shows that the utilization of intravenous TXA in patients with hip fracture undergoing hip surgeries possesses great potential in reducing blood loss and allogeneic blood transfusion safely.

May-Thurner Syndrome and Patent Foramen Ovale: A Rare Etiology of Cryptogenic Stroke.

Patients who present with stroke or transient ischemic attacks (TIA) in the setting of patent foramen ovale (PFO) mandate investigation of the lower extremities and pelvis in order to determine a possible source of thromboembolic disease. Imaging studies including Doppler ultrasound of the extremities may not be sufficient to diagnose the presence of anatomic variants that predispose patients to thrombus formation. May-Thurner syndrome (MTS) is characterized by extrinsic compression of the common iliac veins or inferior vena cava which leads to chronic physiologic changes within the vasculature. This condition increases risk of venous occlusion, diminution of venous flow, and most significantly, formation of thrombi. In this case report, we present a young Hispanic female diagnosed with ischemic cerebral vascular accident (CVA) secondary to thromboembolism in the setting of May-Thurner syndrome and a PFO, a rare etiology of cryptogenic CVA.

Neurological complications after thoracic endovascular aortic repair. Does the left subclavian artery coverage without revascularization increase the risk of neurological complications in patients after thoracic endovascular aortic repair?

INTRODUCTION: One of the most severe complications after TEVAR is ischemic stroke and spinal cord ischemia (SCI) resulting in severe disability. These complications can be fatal up to 30% of cases, so it is very important to define risk factors associated with the occurrence of such events. The aim of this study was to define the causes and risk factors associated with the occurrence of neurological complications in patients after TEVAR. MATERIALS AND METHODS: We performed a retrospective analysis of 51 patients undergoing TEVAR in the Department of Vascular Surgery of Military Teaching Hospital in Wroclaw between 2014 and 2017. In 18 patients LSA coverage was managed without revascularization (35.29%), and in 33 patients LSA remained uncovered (64.71%). RESULTS: We did not find any statistically significant difference in the incidence of stroke and spinal cord ischemia in patients with covered and uncovered LSA (stroke p = 0.37, SCI p = 0.58). In the group of patients with covered and uncovered LSA, we did not find any significant differences in the incidence of additional comorbidities such as obesity, ischemic heart disease, hypertension or previous stroke. CONCLUSIONS: There is no difference in stroke and SCI occurrence between patients with covered and uncovered LSA. Although there are many studies analysing the risk of such complications, there is no specific consensus regarding the treatment of LSA coverage. Randomised clinical trials on a large group of patients are still needed.

Systemic Lupus Erythematosus: Symptoms and Signs at Initial Presentations.

BACKGROUND: Systemic Lupus Erythematosus (SLE) is an autoimmune multisystem inflammatory condition that causes microvascular inflammation with the production of various auto-antibodies that play a major role in its pathogenesis. SLE can affect both sexes, all ages, and all ethnic groups with widespread geographical and socioeconomic backgrounds. Asia encompasses people of many sociocultural backgrounds with diverse ethnic. OBJECTIVE: Due to a lack of national epidemiological research, the incidence and prevalence of SLE in Middle Eastern and Arab countries, have only recently been studied. This article aims to explore the status of SLE in Oman and to record symptoms and signs of SLE at first presentation. METHODOLOGY: Medical records of all patients diagnosed with SLE at the Royal Hospital from 2006 to 2014 were reviewed for information recorded at first visit. SLE diagnosis was based on the American College of Rheumatology classification criteria; ACR97 (which includes the clinical manifestation and laboratory evidence). Patients with SLE disease manifestations extrapolated and analyzed. There were 966 patients diagnosed with SLE during the period from 2006 to 2014. Mean (SD) age at presentations was 35.5 (11.5) years. Majority of patients were female which constitutes 88.7% of the total SLE patients with mean age 27.6 (1.4) years. RESULTS: Constitutional symptoms were found in 48.68 of SLE population including fatigue in 35.22%, and weight changes in 13.43%. The cutaneous manifestations that were present included malar rash 37.69%, photosensitivity 35.10%, discoid lupus 17.63%, and hair loss 39.29%. Musculoskeletal manifestations were commonly seen among the studied population including arthralgia in 68.75%, myalgia in 55.65%, arthritis in 48.31%, whilst myositis, tendon abnormalities and avascular necrosis were found in only 2.47%, 0.31% and 1.98%. respectively. CONCLUSION: This is the first study of the symptoms and signs at initial clinical presentation of SLE patients compared to other studies done regionally where most have focused on clinical manifestations during the progression course of SLE. SLE manifestations may be related to the differences in the genetic make-up of the patients who come from various ethnic groups despite similar geography or sociocultural background, or to referral bias, as some studies were performed in the nephrology units and others in the rheumatology units. There is a pressing need to establish a nationwide and regional collaboration to establish LUPUS and to put forward a strategic planning with each MOH to provide an easy and efficient report of SLE cases and provide various effective management for such a debilitating syndrome.

The effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) on the treatment of aphasia caused by cerebrovascular accident (CVA).

Background: Aphasia is a common outcome of Cerebrovascular Accident (CVA) in which clinical interventions have limited effectiveness. Some evidence suggests that noninvasive stimulation of the brain can have beneficial effects in the treatment of CVA induced aphasia. In patients with motor aphasia, repetitive Transcranial Magnetic Stimulation (rTMS) is used to facilitate long-term improvement in speech ability. Since identifying effective methods for treating CVA induced aphasia can be very important in subsequent decision-making and treatment interventions, the objective of this study was to evaluate the effect of low-frequency TMS in Broca's area in the right hemisphere on the treatment of CVA induced motor aphasia. Methods: This clinical trial enrolled 24 patients with a clinical diagnosis of motor aphasia caused by CVA using convenient sampling. In this study, the effect of stimulation of Broca's area in the right hemisphere was examined by low-frequency rTMS (one Hz) on aphasia caused by CVA. To conduct verbal fluency test in patients, their correct responses to the selected images before and after rTMS during a certain time were recorded and compared by non-parametric Wilcoxon test using SPSS16 and the significance level was considered <0.05. Registration ID of this research in IRCT is IRCT2014052417814N1. Results: The study findings suggested a significant difference between Wilcoxon test results of patients before and after rTMS (z= -4.401), and it was found that using low-frequency rTMS in the right hemisphere was effective on improving dysarthria in the study population with 95 percent confidence interval (p<0.001). Conclusion: According to the findings, low-frequency rTMS has the potential to be considered as a treatment for patients with nonfluent aphasia caused by CVA.

[The modern approaches to the restoration of postural balance in the patients suffering from the consequences of an acute cerebrovascular accident (CVA)].

BACKGROUND: the most frequent and severe consequences of an acute cerebrovascular accident (CVA) are locomotor and coordination disorders which significantly increase the risk of falling in a static position and when walking. The methods used for the rehabilitation of the affected patients are designed in the first place to enable the patients to acquire the skills necessary for maintaining the static balance. The modern equipment allows to carry out coordination training in the static position and also during walking. AIM: The objective of the present study was to evaluate, based on the results of our original research, the feasibility and effectiveness of the application of the «Balance tutor¼ system developed for the restoration of static and dynamic balance in the framework of the combined rehabilitation treatment of the patients suffering from impaired postural balance as a consequence of acute cerebrovascular accident (CVA). MATERIALS AND METHODS: A total of 56 patients presenting with impaired postural balance following CVA were available for the examination. All of them underwent functional testing to assess the static and dynamic balance, walking abilities, and the risk of falling down including the study with the use of computer-assisted stabilometry. RESULTS: The study has demonstrated that the inclusion of the «Balance tutor¼ system for the restoration of the static and dynamic balance in the combined rehabilitative treatment of the patients having postural balance disorders after the CVA reduces the risk of fall for a walking patient, improves his (her) static and dynamic balance, increases the patient's ability to move without exterior help. The patients comprising the main study group were found to experience a decrease of statokinesiogram space in the «eyes are open¼ position (p = 0.0576, the Mann-Whitney U test) as well as a reliable decrease of the statokinesiogram space in the «eyes are closed¼ position (p=0.0063, the Mann-Whitney U test). Similar changes occurred in speed of pressure center relocation. By the end of the rehabilitation course, the patients of the main group exhibited a reliable enhancement in the dynamic balance rates estimated with the use of the Berg Balance Scale (p=0.028, Tukey's criterion), an increase in stability based at the Tinneti scale, p=0.0291; Tukey's criterion), and a decrease of the risk of falling during walk assessed with the application of Dynamic Gait Index scale (p = 0.0001, Tukey's criterion). DISCUSSION: The results of the present study with the inclusion of the «Balance tutor¼ system in the program of combined rehabilitation of the patients suffering from the consequences of CVA in the form of the postural balance impairment give evidence of the feasibility and effectiveness of this approach. There is reason to believe that its application is likely to reduce the risk of falling down and to improve characteristics of static and dynamic balance. CONCLUSION: The inclusion of the «Balance tutor¼ system in the program of combined rehabilitation of the patients suffering from the consequences of CVA in the form of the postural balance impairment is both feasible and effective.

Factores determinantes de la calidad de vida en pacientes sobrevivientes a un ictus / Decisive factors for the quality of life of patients who survived an ictus

Introducción: Las enfermedades cerebrovasculares (ECV) son causa de afectación de la calidad de vida (CV) y de discapacidad; los factores asociados a una afectación de la CV varían entre un estudio y otro, teniendo en cuenta el uso de instrumentos de medición de la calidad de vida (escalas) adaptadas a determinadas áreas geográficas. Objetivo: Determinar aquellos factores más influentes en la afectación de la calidad de vida en pacientes que han sufrido un ictus, a través de los resultados expuestos en la literatura. Material y Métodos: Se consultaron un total de 53 fuentes de información, entre ellas 47 artículos de revistas científicas, 2 tesis doctorales, así como informes estadísticos y se tuvo acceso a los principales gestores de la red informática. Desarrollo:Se consideraron conceptos sobre la calidad de vida relacionada con la salud en pacientes sobrevivientes a un ictus, los factores asociados a su afectación, la valoración de las escalas de calidad de vida para el ictus y la importancia de realizar estudios con un enfoque más integral. Conclusiones: Independientemente de la existencia de un grupo de variables comunes, imprescindibles en todo estudio relacionado con la calidad de vida en pacientes sobrevivientes a un ictus, cada grupo investigador debe tener en cuenta aquellos elementos que más se ajusten según sus objetivos para iniciar el proceso de investigación(AU)

Introduction: Cerebrovascular diseases (CVD) are a cause of affectedness related to quality of life (QL), and disability; the factors related to an affectedness of the quality of life vary from one study to another, considering the use of tools to measure the quality of life (scales) adapted to particular geographic areas. Objective:To determine those factors that influence the most in the affectedness related to the quality of life of patients who have suffered an ictus, through the results presented in the literature on this topic. Material and methods:A total of 53 sources of information were consulted, among them 47 articles from scientific journals, 2 PhD thesis, and statistical reports. Also, it was possible to have access to the main managers of computing networks. Development:Concepts of the health-related quality of life of those patients who survived an ictus were considered, as well as the factors associated with their affectedness, the scales for quality of life assessment of patients with ictus, and the importance to conduct studies with a more integral approach. Conclusions:Independently of the existence of a group of common variables, which are essential in any study related to the quality of life of patients who survive an ictus, each research group has to keep in mind those elements that adapt most to the objectives in order to begin a research process(AU)

Comparison of Nutech Functional Score with European Stroke Scale for Patients with Cerebrovascular Accident Treated with Human Embryonic Stem Cells: NFS for CVA Patients Treated with hESCs.

PURPOSE: Stem cell therapy is a promising modality for treatment of patients with chronic cerebrovascular accident (CVA) in whom treatment other than physiotherapy or occupational therapy does not address the repair or recovery of the lost function. In this study, the author aimed at evaluating CVA patients treated with human embryonic stem cell (hESC) therapy and comparing their study outcomes with globally accepted European Stroke Scale (ESS) to that with novel scoring system, Nutech functional score (NFS), a 21-point positional and directional scoring system for assessing patients with CVA. MATERIALS AND METHODS: Patients diagnosed with CVA were assessed with NFS and ESS before and after hESC therapy. NFS assessed the patients in the direction of 1-5 (bad to good), where 5 was considered as the highest possible grade (HPG). The findings were obtained for the patients who scored HPG, and had shown improvement by at least one grade. RESULTS: Overall, 66.7% of patients scored HPG level on the NFS scale and about 62.5% of the patients scored HPG according to the ESS scale. Approximately, 52.2% patients showed an improvement of 100% (by at least one grade) on NFS scale. None of the patients showed 100% improvement in the alteration of the score by at least one grade when scored with ESS. CONCLUSION: NFS and ESS scores show that a large population of CVA patients was benefitted with hESC therapy. NFS was found to give more convincing results than ESS, and overcomes the shortcomings of ESS.

Literature Review on the Effects of tDCS Coupled with Robotic Therapy in Post Stroke Upper Limb Rehabilitation.

Today neurological diseases such as stroke represent one of the leading cause of long-term disability. Many research efforts have been focused on designing new and effective rehabilitation strategies. In particular, robotic treatment for upper limb stroke rehabilitation has received significant attention due to its ability to provide high-intensity and repetitive movement therapy with less effort than traditional methods. In addition, the development of non-invasive brain stimulation techniques such as transcranial Direct Current Stimulation (tDCS) has also demonstrated the capability of modulating brain excitability thus increasing motor performance. The combination of these two methods is expected to enhance functional and motor recovery after stroke; to this purpose, the current trends in this research field are presented and discussed through an in-depth analysis of the state-of-the-art. The heterogeneity and the restricted number of collected studies make difficult to perform a systematic review. However, the literature analysis of the published data seems to demonstrate that the association of tDCS with robotic training has the same clinical gain derived from robotic therapy alone. Future studies should investigate combined approach tailored to the individual patient's characteristics, critically evaluating the brain areas to be targeted and the induced functional changes.