Design and preliminary evaluation of the FINGER rehabilitation robot: controlling challenge and quantifying finger individuation during musical computer game play.

BACKGROUND: This paper describes the design and preliminary testing of FINGER (Finger Individuating Grasp Exercise Robot), a device for assisting in finger rehabilitation after neurologic injury. We developed FINGER to assist stroke patients in moving their fingers individually in a naturalistic curling motion while playing a game similar to Guitar Hero. The goal was to make FINGER capable of assisting with motions where precise timing is important. METHODS: FINGER consists of a pair of stacked single degree-of-freedom 8-bar mechanisms, one for the index and one for the middle finger. Each 8-bar mechanism was designed to control the angle and position of the proximal phalanx and the position of the middle phalanx. Target positions for the mechanism optimization were determined from trajectory data collected from 7 healthy subjects using color-based motion capture. The resulting robotic device was built to accommodate multiple finger sizes and finger-to-finger widths. For initial evaluation, we asked individuals with a stroke (n = 16) and without impairment (n = 4) to play a game similar to Guitar Hero while connected to FINGER. RESULTS: Precision design, low friction bearings, and separate high speed linear actuators allowed FINGER to individually actuate the fingers with a high bandwidth of control (-3 dB at approximately 8 Hz). During the tests, we were able to modulate the subject's success rate at the game by automatically adjusting the controller gains of FINGER. We also used FINGER to measure subjects' effort and finger individuation while playing the game. CONCLUSIONS: Test results demonstrate the ability of FINGER to motivate subjects with an engaging game environment that challenges individuated control of the fingers, automatically control assistance levels, and quantify finger individuation after stroke.

Anti-VEGF response in macular hemorrhage and incidence of retinal pigment epithelial tears.

OBJECTIVE: To study the visual and anatomic outcomes of serial anti-vascular endothelial growth factor (anti-VEGF) therapy for severe macular hemorrhage in eyes with exudative age-related macular degeneration (AMD). DESIGN: Consecutive retrospective analysis. PARTICIPANTS: Twenty eyes from 20 patients with severe macular hemorrhage (greater than 50% blockage with formal fluorescein angiography [FA]) secondary to wet AMD were studied. METHODS: We performed a chart review of patients at a single centre from May 2006 to September 2009. Presenting visual acuity and diameter of hemorrhage were recorded as well as number of injections, time by which no hemorrhage was remaining, and final anatomic outcome. Cardiovascular risk factors and use of antiplatelet medication or anticoagulation were noted. RESULTS: Average presenting visual acuity was 1.55 (20/710), and number of injections needed for resolution of hemorrhage was 4. Visual acuity significantly improved from 1.55 (20/710) to 0.70 (20/100) after injections. Thirty-five percent of eyes were found to have an associated retinal pigment epithelial (RPE) tear, and these eyes were found to have received more injections. Final visual acuity was not significantly different in eyes with RPE tears compared with nontear eyes. Eighty-one percent of patients had associated cardiovascular risk factors; antiplatelet therapy and anticoagulation were not found to play a role in hemorrhage size. CONCLUSIONS: RPE tears are found in a significant number of individuals with large macular hemorrhages secondary to exudative macular degeneration, but with continued treatment with anti-VEGF therapy, visual acuity can significantly improve even in the presence of these tears. Eyes with severe macular hemorrhage thus should be considered candidates for anti-VEGF therapy.

Willingness to pay for cataract surgery in rural Southern China.

PURPOSE: To study willingness to pay for cataract surgery, and its associations, in Southern China. DESIGN: Cross-sectional willingness-to-pay interview incorporating elements of the open-ended and bidding formats. PARTICIPANTS: Three-hundred thirty-nine persons presenting for cataract screening in Yangjiang, China, with presenting visual acuity (VA) < or = 6/60 in either eye due to cataract. METHODS: Subjects underwent measurement of their VA and a willingness-to-pay interview. Age, gender, literacy, education, and annual income also were recorded. MAIN OUTCOME MEASURES: Maximum amount that the subjects would be willing to pay for cataract surgery. RESULTS: Among 325 (95.9%) subjects completing the interview, 169 (52.0%) were 70 years or older, 213 (65.5%) were women, and 217 (66.8%) had an annual income of <5000 renminbi (5000 = US 625 dollars). Eighty percent (n = 257) of participants were willing to pay something for surgery (mean, 442+/-444 renminbi [US 55 dollars+/-55]). In regression models, older subjects were willing to pay less (8 renminbi [US 1 dollar] per year of age; P = 0.01). Blind subjects were significantly more likely (odds ratio, 5.7; 95% confidence interval, 1.7-19.3) to pay anything for surgery, but would pay on average 255 renminbi (US 32 dollars) less (P = 0.004). Persons at the highest annual income level (>10,000 renminbi [US 1250 dollars]) would pay 50 dollars more for surgery than those at the lowest level (<5000 renminbi) (P = 0.0003). The current cost of surgery in this program is 500 renminbi (US 63 dollars). CONCLUSIONS: Sustainable programs will need to attract younger, more well-to-do persons with better vision, while still providing access to the neediest patients.

Diets and cardiovascular disease: an evidence-based assessment.

With rising obesity, despite low-fat diet recommendations, there is an increased interest in weight loss and alternative dietary approaches for cardiovascular health. Physicians must have an understanding of the literature to better counsel their patients about diets and cardiovascular disease. This review examines several dietary approaches to cardiovascular health and evaluates the available scientific evidence regarding these diets.

Association of interatrial shunts and migraine headaches: impact of transcatheter closure.

OBJECTIVES: To examine the relationship between patent foramen ovale (PFO) or atrial septal defect (ASD) with the incidence of migraine headache (MHA) and assess whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA. BACKGROUND: Migraine headache is present in 12% of adults and has been associated with interatrial communications. This study examined the relationship between PFO or ASD with the incidence of MHA and assessed whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA. METHODS: A sample of 89 (66 PFO/23 ASD) adult patients underwent transcatheter closure of an interatrial communication using the CardioSEAL (n = 22), Amplatzer PFO (n = 43), or the Amplatzer ASD (n = 24) device. RESULTS: Before the procedure, MHA was present in 42% of patients (45% of patients with PFO and 30% of patients with ASD). At three months after the procedure, MHA disappeared completely in 75% of patients with MHA and aura and in 31% of patients with MHA without aura. Of the remaining patients, 40% had significant improvement (>or=2 grades by the Migraine Disability Assessment Questionnaire) of MHA. CONCLUSIONS: Transcatheter closure of PFO or ASD results in complete resolution of MHA in 60% of patients (75% of patients with migraine and aura) and improvement in symptoms in 40% of the remaining patients. Interatrial communications may play a role in the etiology of MHA either through paradoxic embolism or humoral factors that escape degradation in bypassing the pulmonary circulation. A randomized trial is needed to determine whether transcatheter closure of interatrial shunts is an effective treatment for MHA.

The metabolic syndrome: what to treat, how to treat, what are the goals?

Metabolic syndrome is a cluster of risk factors for cardiovascular disease that include obesity, atherogenic dyslipidemia, raised blood pressure, and insulin resistance. The growing trend of obesity is associated with increased prevalence of metabolic syndrome. Optimizing diet and exercise are still the leading therapy for controlling the metabolic syndrome. Based on the current evidence, further emphasis should be placed on aggressive management of other metabolic risk factors such as high blood pressure and dyslipidemia.

Incidence of thrombus formation on the CardioSEAL and the Amplatzer interatrial closure devices.

Transcatheter closure for atrial septal defect (ASD) and patent foramen ovale (PFO) is a promising alternative to surgical closure or anticoagulant therapy. A potential complication is thrombus formation on the device after implantation. From February 2001 to June 2003, 66 patients with atrial communication were treated successfully with the Amplatzer device (16 septal and 20 PFO occluders) or the CardioSEAL device (30). Patients were discharged on antiplatelet medication (aspirin and clopidogrel) and/or anticoagulation. Fifty patients (76%) had transesophageal echocardiography (TEE) 1 month after device implantation (28 +/- 10 days). No patient experienced a thromboembolic episode during follow-up. TEE revealed that thrombus formation occurred more frequently on the CardioSEAL device (5 of 23 patients; 22%) than on the Amplatzer device (0 of 27 patients; 0%) (p = 0.02). Although thrombus disappeared or markedly diminished after additional anticoagulation therapy in 3 patients, 1 patient had surgical explantation of the device due to progressive increase in the size of thrombus with hypermobility despite intensive anticoagulation therapy. There was no variable associated with the presence of thrombus formation on the occluder other than the use of the CardioSEAL device. One month after insertion, the CardioSEAL device is more likely to have thrombus present than the Amplatzer device.