Reliability of measurements of muscle tone and muscle power in stroke patients

OBJECTIVES: to establish the reliability of the modified Ashworth scale for measuring muscle tone in a range of muscle groups (elbow, wrist, knee and ankle; flexors and extensors) and of the Medical Research Council scale for measuring muscle power in the same muscle groups and their direct antagonists. DESIGN: a cross-sectional study involving repeated measures by two raters. We estimated reliability using the kappa statistic with quadratic weights (Kw). SETTING: an acute stroke ward, a stroke rehabilitation unit and a continuing care facility. SUBJECTS: people admitted to hospital with an acute stroke-35 patients, median age 73 (interquartile range 65-80), 20 men and 15 women. RESULTS: inter- and intra-rater agreement for the measurement of power was good to very good for all tested muscle groups (Kw = 0.84-0.96, Kw = 0.70-0.96). Inter- and intra-rater agreement for the measurement of tone in the elbow, wrist and knee flexors was good to very good (Kw = 0.73-0.96, Kw = 0.77-0.94). Inter- and intra-rater agreement for the measurement of tone in the ankle plantarflexors was moderate to good (Kw = 0.45-0.51, Kw = 0.59-0.64). CONCLUSIONS: the Medical Research Council scale was reliable in the tested muscle groups. The modified Ashworth scale demonstrated reliability in all tested muscle groups except the ankle plantarflexors. If reliable measurement of tone at the ankle is required for a specific purpose (e.g. to measure the effect of therapeutic intervention), further work will be necessary.     

Bacteriology of the marine environment: implications for clinical therapy

Ocean water and tissue samples were obtained from a variety of sources with phylogenetic and geographic diversity. Purified bacterial colonies were isolated and identification procedures were performed. A total of 67 isolates were recovered. Thirty-eight isolates belonged to the genus Vibrio and included six species. Twenty-four non-fermentative bacteria and four Gram-positive isolates were recovered. Antibiotic susceptibility testing showed that while the non-fermentative marine bacteria generally were susceptible to the antibiotics tested, marine Vibrio species were relatively resistant to a wide variety of antimicrobials. Antibiotics effective against all species included imipenem, trimethoprim/sulfamethoxazole, and chloramphenicol. Further recommendations for treatment are based on sensitivity in culture. Some isolates failed to grow in the medium used for susceptibility testing. Because commercial test kits may not yield accurate identifications of bacteria, the acquisition of antimicrobial susceptibility data gains added importance.     

Bacteriology of the freshwater environment: implications for clinical therapy

Water and animal tissue samples were obtained from sources in Tennessee, California, and Florida. Purified bacterial colonies were isolated and organisms identified. Fifty-eight isolates were recovered. Twenty-seven Gram-negative isolates were identified. Gram-positive organisms were of the coryneform group or Bacillus species. Antibiotic susceptibility testing showed that Aeromonas species were relatively resistant to a wide variety of antimicrobials, which included trimethoprim, cefazolin, and ampicillin. Antibiotics effective against more than 90% of Gram-negative isolates included ciprofloxacin, imipenem, ceftazidime, and trimethoprim-sulfamethoxazole. Freshwater Gram-positive organisms did not display any unexpected susceptibility features. Recommendation for treatment are based on sensitivity in culture and the potentially serious nature of infections caused by Aeromonas species.     

The pathophysiologic role of the brain renin-angiotensin system in stroke protection: clinical implications

The brain possesses the same renin-angiotensin system (RAS) as the systemic circulation. Recent experimental studies have shown that the brain RAS plays an important role in stroke and neuronal protection through its effector peptide angiotensin (Ang) II. Ang II exerts its stroke-protective effects through stimulation of Ang II type 2 (AT2) receptors. Angiotensin receptor blockers (ARBs) exert a dual influence, which is important in their stroke protective effects. They selectively block the Ang II type 1 (AT1) receptors, decreasing local vasoconstriction, and allow free Ang II to stimulate the unoccupied AT2 receptor and increase local vasodilation, resulting in the alleviation of local brain ischemia and limiting the volume and extent of brain loss. In contrast, angiotensin-converting enzyme (ACE) inhibitors, by decreasing the amount of Ang II production, may diminish the stroke-protective effects of Ang II. This perhaps could be a reason for the inferior stroke-protective effect of ACE inhibitors compared with ARBs, which has been demonstrated in several clinical trials. The evidence for this effect of ARBs compared with ACE inhibitors, however, is only indirect. Ongoing clinical trials with head-to-head comparisons of ARBs and ACE inhibitors will hopefully provide the needed information.     

Androgen deprivation therapy for prostate cancer: implications for cardiometabolic clinical care

Prostate cancer (PCa) is the most common malignancy in men. Androgen deprivation therapy (ADT) plays an important role in the management of locally advanced and metastatic PCa. Its use in combination with external beam radiation and as an adjuvant therapy has resulted in improved survival in a subset of patients with locally advanced disease. In men with metastatic disease, ADT results in improvement in pain and overall quality of life. In addition to these two clinical settings where ADT has proven benefits, it is also being increasingly used in patients experiencing biochemical recurrence and those with early stage localized disease, even though no survival advantage has been demonstrated. ADT has significant adverse effects such as sexual dysfunction, decreased lean mass, increased fat mass, decreased quality of life, anemia, and osteoporosis. Recently, insulin resistance, diabetes, and metabolic syndrome have emerged as complications of ADT. Some data also suggests that ADT might be responsible for incident cardiovascular disease. Since the majority of men with PCa die of conditions other than their malignancy, recognition and management of these adverse effects is important. This paper serves as a focused review of recent studies examining the metabolic abnormalities and cardiovascular disease related to ADT.     

The anti-inflammatory effects of nebivolol in human coronary smooth muscle cells: clinical implications

Given that the majority of hypertensives require more than one drug to control blood pressure, the pleitropic effects (especially anti-inflammatory effects) and favourable metabolic profile of nebivolol could make it an alternative drug regimen for hypertensives requiring beta-blocker treatment. Although standard beta-blockers seem to have a hard time at present, we are convinced that perhaps the new generation beta-blockers such as nebivolol might yet 'rescue' the reputation of beta blockers in the near-future.     

The future of gene therapy for stroke

New diagnostic and treatment strategies are being developed for stroke. Gene therapy has several potential advantages over classical pharmacologic therapy. Direct administration of DNA into the brain offers the advantage of producing high concentrations of therapeutic agents in a relatively localized environment. Gene transfer also provides longer duration of effect than traditional drug therapy. Recent studies indicate that gene transfer can produce functional proteins in brain parenchyma and cerebral blood vessels after stroke. In animal models, gene transfer may reduce effects of cerebral ischemia or subarachnoid hemorrhage. This review summarizes some current methods of gene transfer to the brain and recent progress that may lead to gene therapy for stroke.     

卒中康复治疗进展

脑血管意外的大量患者通过早期诊断、早期救治得以存活，但同时成为重度、长期残疾的主要人群。现就有关卒中综合病区、半暗区和强制诱导运动治疗方面的进展分述如下。     

The immunology of HIV infection: implications for therapy.

It is known that antiretroviral drugs can induce immunologic improvement in patients with acquired immunodeficiency syndrome (AIDS) and other manifestations of HIV infection. However, the improvements so attained are often partial and transient. This may result from a number of factors, including incomplete inhibition of human immunodeficiency virus (HIV) replication by available agents, the development of viral drug resistance, the effect of cytokines, or thymic damage. An understanding of this problem may be important in further development of AIDS therapies. It will also be important to learn how to best assess the response to various therapies. In this regard, the CD4 count is evolving as a mortality risk indicator in AIDS and as such may find utility in assessing new therapeutic approaches. We have observed that in a cohort of gay men receiving antiretroviral therapy in a research environment, nearly all deaths occurred in individuals with fewer than 50 CD4 cells/mm3. However, the relationship between the CD4 count and the hazard of dying may be influenced by a number of factors (e.g., active intravenous drug use, extreme poverty, etc.), and further studies are needed to define the relationship between CD4 and clinical endpoints under a variety of conditions.     

Novel oral anticoagulants for stroke prevention in atrial fibrillation: Key trial findings and clinical implications

Novel oral anticoagulants have the potential to improve stroke prevention in patients who have atrial fibrillation and an elevated risk of stroke by overcoming several limitations of warfarin, such as the need for regular monitoring and dose adjustment, and the existence of multiple drug interactions and dietary restrictions. In recently completed phase III trials in patients with non-valvular atrial fibrillation, common findings for dabigatran, rivaroxaban, and apixaban compared with warfarin included: risk reductions for stroke and systemic embolism, significantly fewer hemorrhagic strokes and intracranial hemorrhages, and reductions in mortality, although different trends were seen in several endpoints. However, the trials had important differences in terms of design, populations studied, and statistical analysis that preclude comparison between trials and should be considered when interpreting findings. In this article, data for novel anticoagulants are reviewed and some potential practical implications are highlighted.     

急性脑卒中综合性治疗模式的优越性

目的　探讨综合性治疗 [卒中单元 ,(strokeunit) ]模式对急性脑卒中治疗的优越性。方法　选择在澳大利亚卒中单元治疗的 2 0 7例急性脑卒中病人为A组 ,同期在我科常规治疗的 32 6例为B组。入选标准统一为经CT或MRI确诊发病 48h内的急性脑卒中 ,比较两组主要临床指标。结果　A组 1 4d内病死率为 5 3 % ,其中死于非脑内原因占 2 7 3 % ,感染发生率 1 7 9% ,而B组分别为1 0 4%、64 7%、47 9% ,差异具有显著性 (P <0 0 1 )。 2 1d神经功能评分和随访 90dRankin积分差异也有显著性 (P <0 0 1 )。结论　在综合性治疗模式下急性脑卒中患者的预后 ,比在我科常规治疗模式下的疗效更具有优越性     

Test-retest reliability of pulse amplitude tonometry measures of vascular endothelial function: implications for clinical trial design

Endothelial dysfunction is an important outcome for assessing vascular health in intervention studies. However, reliability of the standard non-invasive method (flow-mediated dilation) is a significant challenge for clinical applications and multicenter trials. We evaluated the repeatability of pulse amplitude tonometry (PAT) to measure change in pulse wave amplitude during reactive hyperemia (Itamar Medical Ltd, Caesarea, Israel). Twenty healthy adults completed two PAT tests (mean interval = 19.5 days) under standardized conditions. PAT-derived measures of endothelial function (reactive hyperemia index, RHI) and arterial stiffness (augmentation index, AI) showed strong repeatability (intra-class correlations = 0.74 and 0.83, respectively). To guide future research, we also analyzed sample size requirements for a range of effect sizes. A crossover design powered at 0.90 requires 28 participants to detect a 15% change in RHI. Our study is the first to show that PAT measurements are repeatable in adults over an interval greater than 1 week.     

Gene therapy for stroke: 2006 overview

Gene therapy is a promising approach for treatment of stroke and other cerebrovascular diseases, although it may take many years to realize. Gene therapy could occur prior to a stroke (eg, to stabilize atherosclerotic plaques) and/or following a stroke (eg, to prevent vasospasm after subarachnoid hemorrhage [SAH] or reduce injury to neurons by ischemic insult). We have transferred the gene coding for vasoactive calcitonin gene-related peptide via cerebrospinal fluid, and demonstrated attenuation of vasospasm after SAH. Transfer of neuroprotective genes or small interfering RNA for neurotoxic genes has good potential for ischemic stroke. In this brief report, we review recent developments in experimental gene therapy for stroke. Fundamental advances, including development of safer, more specific gene transfer vectors, are discussed.     

The murmur of papillary muscle dysfunction in acute myocardial infarction: clinical features and prognostic implications

The systolic murmur of papillary muscle dysfunction is a well-recognized feature of acute myocardial infarction (AMI), but no large prospective studies have determined its incidence, associated variables, and prognostic implications. Of 1653 patients who entered our data base with MI, 283 (17%) were classified as having a systolic murmur suggesting mitral regurgitation. At hospital discharge, there was a 5% incidence. There was a higher incidence of systolic murmur in non-Q wave AMI than in inferior or anterior Q wave MI (24% vs 13% and 15%, p less than 0.001). Advanced age, previous MI, and heart failure were all associated with systolic murmur (p less than 0.01). Persistent pain in the coronary care unit occurred more often in those with systolic murmur (45% vs 26%, p less than 0.0001). Systolic murmur was associated with an S3 and bibasilar rales (p less than 0.001) in the hospital; however, it was inversely related to peak creatine kinase and unrelated to heart failure or ejection fraction at discharge. Univariate predictors of mortality associated with systolic murmur included complex premature ventricular contractions at discharge and a non-Q wave location. Patients with systolic murmur had higher hospital and 1-year mortalities than those without systolic murmurs (p less than 0.01). When systolic murmur was present during hospitalization, the average time to reinfarction was 2.5 times earlier than when no systolic murmur was present (84 vs 214 days, p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)