Virtual Reality-Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial.

BACKGROUND: A growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)-based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function. OBJECTIVE: The primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants' homes. METHODS: A total of 51 chronic stroke participants were randomized to treatment (n=26, 51%; Jintronix system) or standard care (n=25, 49%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group. RESULTS: No statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78%) of them having baseline low or moderate arm function, compared with 3 (33%) participants in the standard care group. Furthermore, 56% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0% (0/10) less-active participants. CONCLUSIONS: These findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services. TRIAL REGISTRATION: ClinicalTrials.gov NCT02491203; https://clinicaltrials.gov/ct2/show/NCT02491203. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1016/j.cct.2015.12.006.

Predictors and outcomes associated with radial versus femoral access for intervention in patients with acute coronary syndrome in a real-world setting: results from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2010.

BACKGROUND: Use of transradial intervention (TRI) is becoming more popular, and recent studies suggest an advantage for TRI in high-risk patients presenting with acute coronary syndrome (ACS). The aim of our study was to describe current utilization and outcomes of transradial intervention (TRI) in real-world patients presenting with ACS. METHODS: Data were derived from the ACS Israeli Survey (ACSIS 2010), a nationwide prospective survey of patients presenting with ACS over a 2-month period. Follow-up was continued for up to 1 year. RESULTS: Of 1815 ACS patients undergoing coronary angiography, 613 (34%) underwent TRI, which was more likely to be employed among patients with lower-risk characteristics. Patients undergoing TRI had significantly lower 30-day mortality and in-hospital bleeding. On multivariate analysis, the risk of in-hospital major bleeding was reduced by 60% in patients undergoing TRI (P=.04). However, no significant differences in other components of major adverse cardiac events or mortality were demonstrated at 30 days. All-cause mortality at 1 year was significantly lower among patients who underwent TRI. However, after multivariate adjustment, this effect was no longer significant. CONCLUSIONS: In our study of real-world patients, better TRI outcomes are related largely to lower baseline risk of patients allocated to this approach, suggesting that TRI may be underutilized in high-risk ACS patients.

Contemporary use and outcome of percutaneous coronary interventions in patients with acute coronary syndromes: insights from the 2010 ACSIS and ACSIS-PCI surveys.

AIMS: In patients with acute coronary syndromes (ACS), percutaneous coronary intervention (PCI) is the mainstay of treatment based on current guidelines. In this paper we describe contemporary management and outcomes of patients with ACS treated by PCI in the national ACS Israeli survey (ACSIS) performed in March and April 2010. METHODS AND RESULTS: The ACSIS 2010 registry was conducted in all 25 hospitals in Israel and included "all comers" admitted with ACS. In-hospital and 30-day outcome was assessed. The registry included 2,193 patients with ACS. Coronary angiography was performed in 86.1% and PCI in 75.1% of cases. The mean age was 62.5 years, the transradial approach was used in 32% of patients and overall use of drug-eluting stents was 34%. Procedural complications were extremely low at less than 1%. The thirty-day mortality rate was 2.1% and the repeated myocardial infarction (MI) rate was 2.5%. The major adverse cardiac and cerebral events (MACCE) rate was 5.6%. Multivariable analysis identified age, chronic renal failure, and hyperglycaemia on admission as independent predictors of 30-day mortality for all subsets of ACS, and Killip class >I on admission and prior MI for patients with ST-elevation ACS only. CONCLUSIONS: When evidence-based medicine is applied in the treatment of patients with ACS, clinical outcome is favourable. Several clinical predictors identify high-risk patients who require special attention.

Cardiovascular events in patients received combined fibrate/statin treatment versus statin monotherapy: Acute Coronary Syndrome Israeli Surveys data.

BACKGROUND: The effect of combination of fibrate with statin on major adverse cardiovascular events (MACE) following acute coronary syndrome (ACS) hospitalization is unclear. The main aim of this study was to investigate the 30-day rate of MACE in patients who participated in the nationwide ACS Israeli Surveys (ACSIS) and were treated on discharge with a fibrate (mainly bezafibrate) and statin combination vs. statin alone. METHODS: The study population comprised 8,982 patients from the ACSIS 2000, 2002, 2004, 2006, 2008 and 2010 enrollment waves who were alive on discharge and received statin. Of these, 8,545 (95%) received statin alone and 437 (5%) received fibrate/statin combination. MACE was defined as a composite measure of death, recurrent MI, recurrent ischemia, stent thrombosis, ischemic stroke and urgent revascularization. RESULTS: Patients from the combination group were younger (58.1±11.9 vs. 62.9±12.6 years). However, they had significantly more co-morbidities (hypertension, diabetes), current smokers and unfavorable cardio-metabolic profiles (with respect to glucose, total cholesterol, triglyceride and HDL-cholesterol). Development of MACE was recorded in 513 (6.0%) patients from the statin monotherapy group vs. 13 (3.2%) from the combination group, p = 0.01. 30-day re-hospitalization rate was significantly lower in the combination group: 68 (15.6%) vs. 1691 (19.8%) of patients, respectively; p = 0.03. Multivariable analysis identified the fibrate/statin combination as an independent predictor of reduced risk of MACE with odds ratio of 0.54, 95% confidence interval 0.32-0.94. CONCLUSION: A significantly lower risk of 30-day MACE rate was observed in patients receiving combined fibrate/statin treatment following ACS compared with statin monotherapy. However, caution should be exercised in interpreting these findings taking into consideration baseline differences between our observational study groups.