Gender and the functional outcome of elderly ischemic stroke patients.

The purpose of this study was to investigate the effect of gender on the functional outcome after ischemic stroke. In a retrospective chart review we studied 919 survivors of ischemic stroke admitted for rehabilitation at a geriatric rehabilitation ward of a university affiliated hospital. Functional outcome of female and male patients was assessed by Functional Independence Measurement (FIM) at admission and discharge. Data were analyzed by t test, Chi-square test and Linear Regression. A total number of 919 patients were admitted of whom 56% were males. A higher proportion of male patients reported ischemic heart disease (p<0.001), hypercholesterolemia (p=0.035), Parkinson's disease (p=0.044), and previous stroke (p<0.001). Males had also higher Mini-Mental State Examination (MMSE) scores (p<0.001). Total FIM at admission (62.54 ± 25.98 and 66.00 ± 25.49; p=0.043), and total FIM at discharge (80.39 ± 30.35 and 85.59 ± 29.08; p=0.008), motor FIM at admission (40.04 ± 18.89 and 42.51 ± 18.47; p=0.047) and motor FIM at discharge (56.41 ± 23.04 and 60.44 ± 21.84; p=0.007) were higher among male patients. However, a trend for a borderline statistical difference was observed for FIM gains upon discharge between men and women. A multiple linear regression analysis showed that total FIM at discharge was neither associated with male nor female gender (ß=-0.009; p=0.69). The findings suggest that the functional outcome of male survivors presenting for rehabilitation after acute ischemic stroke is slightly better. After adjusting for possible covariates, gender did not emerge as an independent predictor for higher FIM at discharge, suggesting that gender should not be held as adversely affecting rehabilitation of such patients.

Bladder management and the functional outcome of elderly ischemic stroke patients.

The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 ± 16.46 vs. 17.59 ± 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = -0.407; p<0.001) and age (beta = -0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation.

Endovascular management of vertebral arteriovenous fistulas: the Toronto experience.

OBJECTIVE: This study was designed to evaluate the effectiveness of the endovascular management under angiographic control of vertebral arteriovenous fistulas (AVF). DESIGN: The study included a retrospective chart review. METHOD: Of the eight patients with AVF (2 traumatic, 6 spontaneous) referred to the interventional neuroradiology group at the Toronto Hospital between May 1986 and August 1994, endovascular embolization was attempted in six cases. RESULTS: All cases were successful, with no residual fistula flow, mortality, or morbidity. CONCLUSIONS: Vertebral AVFs are rare; therefore, most centres have had limited experience with their management. Endovascular management has proven to be less difficult and to have less morbidity than surgical management in these cases.

Monobloc and facial bipartition osteotomies: quantitative assessment of presenting deformity and surgical results based on computed tomography scans.

PURPOSE: The results of monobloc (MB) or facial bipartition (FB) osteotomies on 23 consecutive patients operated on between 1987 and 1991 were evaluated. PATIENTS AND METHODS: A previously described method of clinically relevant linear measurements taken from preoperative and postoperative computed tomographic scans of these patients was used to document their presenting dysmorphology and the results of surgical correction initially and 1 year after operation. These data were compared with control values, and a percentage of normal for each measurement was derived for each patient. RESULTS: In the patients with craniofacial dysostosis undergoing an MB osteotomy, the initial cranial vault length (87% of normal), medial orbital wall length (87%), zygomatic arch length (84%), and extent of globe protrusion (134%) all indicated horizontal (anterior-posterior) deficiency of the upper and middle face. After surgery, these measurements moved closer to age-matched control values. At the 1-year interval a minor degree of relapse was evident. In the patients with craniofacial dysostosis who were believed to need an FB osteotomy, the globe protrusion (142% of normal), medial orbital wall length (85%), and zygomatic arch lengths (83%) all indicated horizontal (anterior-posterior) deficiency in the upper and middle face. In addition, the anterior interorbital distance (123% of normal), mid-interorbital distance (122%), and intertemporal distance (126%) all indicated upper face hypertelorism. As a result of the FB osteotomy, anterior bony projection was achieved, and the hypertelorism was improved, but fell short of age-matched normal values. In the patients with frontonasal dysplasia, cranio-orbital clefting, and isolated orbital hypertelorism who underwent an FB osteotomy, preoperative measurements showed a distinct widening of the whole upper midface with forward projection of the medial relative to the lateral orbital walls. The orbital measurements revealed a substantially widened anterior interorbital distance (175% of normal), increased mid-interorbital distance (123%), and an increased distance between the lateral orbital walls (106%). After the surgical procedure, these measurements were improved and relatively stable but not completely normalized. CONCLUSION: The use of quantitative measurements in the initial evaluation, intraoperative skeletal reshaping, and assessment of early and late reconstructive results provides useful benchmarks.

Fungal sinusitis.

Fungal disease of the paranasal sinuses is an important and underrecognized entity that affects both immunocompromised and previously healthy subjects. The spectrum of disease includes fungal balls, allergic fungal sinusitis, chronic indolent fungal sinusitis, and invasive fungal sinusitis. The radiologic, immunologic, and histopathologic findings are unique for each of these conditions. The surgical and medical management of these diseases is discussed and four case studies are presented.

How to manage burns in primary care.

Burns are common injuries; more than 200,000 occur in Canada annually. Nearly all burn injuries can be managed on on outpatient basis. Appropriate treatment depends on burn depth, extent, and location. Special types of burns, such as chemical, tar, and electrical injuries, need specific management strategies. Prevention through education is important to reduce the incidence of burns.

Surgical correction of the Treacher Collins malar deficiency: quantitative CT scan analysis of long-term results.

This paper describes an alternative means of reconstruction of the Treacher Collins zygomatic deficiency and presents a consecutive patient series with long-term follow-up documented by clinical and quantitative means employing CT-derived craniofacial skeletal measurements. Eight children (mean age at operation 10.5 years) underwent bilateral zygomatic reconstruction with full-thickness, T-shaped calvarial bone grafts contoured three-dimensionally and then inset and stabilized with plate-and-screw fixation, with exposure provided only by a coronal incision. Orbital floor defects and graft donor sites were repaired with fixed split-thickness cranial bone. No complications occurred during surgery, and donor sites healed without clinical defect. Zygomatic augmentation was achieved in all patients, with follow-up ranging from 24 to 50 months (mean 35 months). CT scanning done before surgery, immediately afterward, and again 1 year or more later demonstrated significant increases in lateral orbital wall length, lateral orbital distance, interzygomatic arch distance, and zygomatic arch length. The late postoperative scans showed that these changes were maintained. However, effective treatment of the surrounding soft-tissue and eyelid deficiencies remains an unsolved problem.

Craniofacial skeletal measurements based on computed tomography: Part II. Normal values and growth trends.

Current diagnosis and surgical correction of craniofacial anomalies would benefit from accurate quantitative and standardized points of reference. A retrospective study was undertaken to define normal values for a series of craniofacial measurements and to evaluate the growth patterns of the craniofacial complex through axial computed tomography (CT). Fifteen measurements were taken from 542 CT scan series of skeletally normal subjects. The measurement values were then divided into 1-year age categories from 1 to 17 years, and into four age groups for those under 1 year of age. The normal range and growth pattern of measurement values for the cranial vault, orbital region, and upper midface are presented. The overall size of the cranio-orbito-zygomatic skeleton reaches more than 85 percent of adult size by age 5 years. The cranial vault grows rapidly in the first year of life but growth levels off early. The upper midface grows at a slower rate in infancy, but continues to grow later in childhood and early adolescence. Knowledge of the differential growth patterns and normal measurement values in the craniofacial region will help improve diagnostic accuracy, staging of reconstruction, precision of corrective surgery, and follow-up of patients.

Craniofacial skeletal measurements based on computed tomography: Part I. Accuracy and reproducibility.

Computed tomography (CT) is a useful modality for the management of craniofacial anomalies. A study was undertaken to assess whether CT measurements of the upper craniofacial skeleton accurately represent the bony region imaged. Measurements taken directly from five dry skulls (approximate ages: adults, over 18 years; child, 4 years; infant, 6 months) were compared to those from axial CT scans of these skulls. Excellent agreement was found between the direct (dry skull) and indirect (CT) measurements. The effect of head tilt on the accuracy of these measurements was investigated. The error was within clinically acceptable limits (less than 5 percent) if the angle was no more than +/- 4 degrees from baseline (0 degrees). Objective standardized information gained from CT should complement the subjective clinical data usually collected for the treatment of craniofacial deformities.