Assessment of the Implementation of Critical Pathway in Stroke Patients: A 10-Year Follow-Up Study.

BACKGROUND: The complications after stroke inhibit functional recovery and worsen the prognosis of patients. The implementation of a critical pathway (CP) can facilitate functional recovery after stroke by enabling comprehensive and systematic structured rehabilitation. OBJECTIVE: To evaluate the effects of the implementation of CP in stroke patients for 10 years. METHODS: The data were collected from 960 patients who were diagnosed with a stroke at the university hospital emergency room, who were transferred to the rehabilitation center after the acute phase, and who were discharged after undergoing comprehensive rehabilitation. Based on data collected over a period of 10 years, changes in demographic and stroke characteristics, preexisting medical conditions, poststroke complications, and functional states, as well as length of stay (LOS), were evaluated before and after CP implementation. The modified Rankin Scale (mRS) and the Korean version of the Modified Barthel Index (K-MBI) were used to evaluate functional states. RESULTS: There were no significant differences in demographic and stroke characteristics before and after CP implementation. For those with preexisting medical conditions, there was no significant difference between before and after CP implementation. The majority of the complications were significantly decreased after the implementation of CP. Except for hemorrhagic stroke patients, the Brunnstrom stage in the ischemic and total stroke patients after CP implementation was significantly increased in the upper and lower extremities. The total hospitalization LOS and rehabilitation center hospitalization times were significantly reduced in ischemic and total stroke patients. There was no statistically significant difference in the functional gain of K-MBI and the efficiency of rehabilitation between before and after CP implementation. CONCLUSION: The implementation of CP allows for better application of evidence- and guideline-based key interventions and helps to provide early, comprehensive, organized, and more specialized care to stroke patients. Despite limited evidence, CP is still recommended as a means of promoting best practices in hospital care for stroke patients.

The Availability of Radiological Measurement of Femoral Anteversion Angle: Three-Dimensional Computed Tomography Reconstruction.

OBJECTIVE: To assess the intra-rater and inter-rater reliability for measuring femoral anteversion angle (FAA) by a radiographic method using three-dimensional computed tomography reconstruction (3D-CT). METHODS: The study included 82 children who presented with intoeing gait. 3D-CT data taken between 2006 and 2014 were retrospectively reviewed. FAA was measured by 3D-CT. FAA is defined as the angle between the long axis of the femur neck and condylar axis of the distal femur. FAA measurement was performed twice at both lower extremities by each rater. The intra-rater and inter-rater reliability were calculated by intraclass correlation coefficient (ICC). RESULTS: One hundred and sixty-four lower limbs of 82 children (31 boys and 51 girls, 6.3±3.2 years old) were included. The ICCs of intra-rater measurement for the angle of femoral neck axis (NA) were 0.89 for rater A and 0.96 for rater B, and those of condylar axis (CA) were 0.99 for rater A and 0.99 for rater B, respectively. The ICC of inter-rater measurement for the angle of NA was 0.89 and that of CA was 0.92. By each rater, the ICCs of the intrarater measurement for FAA were 0.97 for rater A and 0.95 for rater B, respectively and the ICC of the inter-rater measurement for FAA was 0.89. CONCLUSION: The 3D-CT measures for FAA are reliable within individual raters and between different raters. The 3D-CT measures of FAA can be a useful method for accurate diagnosis and follow-up of femoral anteversion.

Effects of kinesthetic haptic feedback on standing stability of young healthy subjects and stroke patients.

BACKGROUND: Haptic control is a useful therapeutic option in rehabilitation featuring virtual reality interaction. As with visual and vibrotactile biofeedback, kinesthetic haptic feedback may assist in postural control, and can achieve balance control. Kinesthetic haptic feedback in terms of body sway can be delivered via a commercially available haptic device and can enhance the balance stability of both young healthy subjects and stroke patients. METHOD: Our system features a waist-attached smartphone, software running on a computer (PC), and a dedicated Phantom Omni® device. Young healthy participants performed balance tasks after assumption of each of four distinct postures for 30 s (one foot on the ground; the Tandem Romberg stance; one foot on foam; and the Tandem Romberg stance on foam) with eyes closed. Patient eyes were not closed and assumption of the Romberg stance (only) was tested during a balance task 25 s in duration. An Android application running continuously on the smartphone sent mediolateral (ML) and anteroposterior (AP) tilt angles to a PC, which generated kinesthetic haptic feedback via Phantom Omni®. A total of 16 subjects, 8 of whom were young healthy and 8 of whom had suffered stroke, participated in the study. RESULTS: Post-experiment data analysis was performed using MATLAB®. Mean Velocity Displacement (MVD), Planar Deviation (PD), Mediolateral Trajectory (MLT) and Anteroposterior Trajectory (APT) parameters were analyzed to measure reduction in body sway. Our kinesthetic haptic feedback system was effective to reduce postural sway in young healthy subjects regardless of posture and the condition of the substrate (the ground) and to improve MVD and PD in stroke patients who assumed the Romberg stance. Analysis of Variance (ANOVA) revealed that kinesthetic haptic feedback significantly reduced body sway in both categories of subjects. CONCLUSION: Kinesthetic haptic feedback can be implemented using a commercial haptic device and a smartphone. Intuitive balance cues were created using the handle of a haptic device, rendering the approach very simple yet efficient in practice. This novel form of biofeedback will be a useful rehabilitation tool improving the balance of stroke patients.

Retrospective assessment of the implementation of critical pathway in stroke patients in a single university hospital.

OBJECTIVE: To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital. METHODS: A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS). RESULTS: After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident. CONCLUSION: After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Medial antebrachial cutaneous nerve injury after brachial plexus block: two case reports.

Medial antebrachial cutaneous (MABC) nerve injury associated with iatrogenic causes has been rarely reported. Local anesthesia may be implicated in the etiology of such injury, but has not been reported. Two patients with numbness and painful paresthesia over the medial aspect of the unilateral forearm were referred for electrodiagnostic study, which revealed MABC nerve lesion in each case. The highly selective nature of the MABC nerve injuries strongly suggested that they were the result of direct nerve injury by an injection needle during previous brachial plexus block procedures. Electrodiagnostic studies can be helpful in evaluating cases of sensory disturbance after local anesthesia. To our knowledge, these are the first documented cases of isolated MABC nerve injury following ultrasound-guided axillary brachial plexus block.

O-GlcNAcase is essential for embryonic development and maintenance of genomic stability.

Dysregulation of O-GlcNAc modification catalyzed by O-GlcNAc transferase (OGT) and O-GlcNAcase (OGA) contributes to the etiology of chronic diseases of aging, including cancer, cardiovascular disease, type 2 diabetes, and Alzheimer's disease. Here we found that natural aging in wild-type mice was marked by a decrease in OGA and OGT protein levels and an increase in O-GlcNAcylation in various tissues. Genetic disruption of OGA resulted in constitutively elevated O-GlcNAcylation in embryos and led to neonatal lethality with developmental delay. Importantly, we observed that serum-stimulated cell cycle entry induced increased O-GlcNAcylation and decreased its level after release from G2/M arrest, indicating that O-GlcNAc cycling by OGT and OGA is required for precise cell cycle control. Constitutively, elevated O-GlcNAcylation by OGA disruption impaired cell proliferation and resulted in mitotic defects with downregulation of mitotic regulators. OGA loss led to mitotic defects including cytokinesis failure and binucleation, increased lagging chromosomes, and micronuclei formation. These findings suggest an important role for O-GlcNAc cycling by OGA in embryonic development and the regulation of the maintenance of genomic stability linked to the aging process.

O-GlcNAc modification modulates the expression of osteocalcin via OSE2 and Runx2.

O-Linked beta-N-acetylglucosamine (O-GlcNAc) modification, a reversible post-translational modification, has been implicated in the regulation of protein stability, subcellular localization of proteins and protein-protein interaction. Here, we demonstrate that O-GlcNAc modification regulates the expression of osteocalcin, an osteoblast-specific marker, via Runx2 transcriptional activity in osteoblastic differentiation. Protein-associated O-GlcNAc was increased during osteoblastic differentiation in MC3T3-E1 preosteoblasts. In addition, PUGNAc, an inhibitor of O-GlcNAcase, potentiated the expression of osteocalcin caused by ascorbic acid, parathyroid hormone (PTH) and forskolin. By conducting activity assays of the osteocalcin promoter and transcription factor, we found that the OSE2 site in the osteocalcin promoter and Runx2 were important for increased osteocalcin promoter activity by PUGNAc. Furthermore, PUGNAc led to increased O-GlcNAc modification of Runx2, which regulated the transcription of its target gene osteocalcin. Thus, these data provide evidence that O-GlcNAc modification may be a new mode of osteoblastic differentiation regulation.