The impact of transcranial direct current stimulation (tDCS) combined with modified constraint-induced movement therapy (mCIMT) on upper limb function in chronic stroke: a double-blind randomized controlled trial

Purpose: This pilot double-blind sham-controlled randomized trial aimed to determine if the addition of anodal tDCS on the affected hemisphere or cathodal tDCS on unaffected hemisphere to modified constraint-induced movement therapy (mCIMT) would be superior to constraints therapy alone in improving upper limb function in chronic stroke patients. Methods: Twenty-one patients with chronic stroke were randomly assigned to receive 12 sessions of either (i) anodal, (ii) cathodal or (iii) sham tDCS combined with mCIMT. Fugl–Meyer assessment (FMA), motor activity log scale (MAL), and handgrip strength were analyzed before, immediately, and 1 month (follow-up) after the treatment. Minimal clinically important difference (mCID) was defined as an increase of ≥5.25 in the upper limb FMA. Results: An increase in the FMA scores between the baseline and post-intervention and follow-up for active tDCS group was observed, whereas no difference was observed in the sham group. At post-intervention and follow-up, when compared with the sham group, only the anodal tDCS group achieved an improvement in the FMA scores. ANOVA showed that all groups demonstrated similar improvement over time for MAL and handgrip strength. In the active tDCS groups, 7/7 (anodal tDCS) 5/7 (cathodal tDCS) of patients experienced mCID against 3/7 in the sham group. Conclusion: The results support the merit of association of mCIMT with brain stimulation to augment clinical gains in rehabilitation after stroke. However, the anodal tDCS seems to have greater impact than the cathodal tDCS in increasing the mCIMT effects on motor function of chronic stroke patients.

• Implications for Rehabilitation

• The association of mCIMT with brain stimulation improves clinical gains in rehabilitation after stroke.

• The improvement in motor recovery (assessed by Fugl–Meyer scale) was only observed after anodal tDCS.

• The modulation of damaged hemisphere demonstrated greater improvements than the modulation of unaffected hemispheres.

     

Comparison of Neuroplastic Responses to Cathodal Transcranial Direct Current Stimulation and Continuous Theta Burst Stimulation in Subacute Stroke

Objective

To investigate the effects of cathodal transcranial direct current stimulation (tDCS) and continuous theta burst stimulation (cTBS) on neural network connectivity and motor recovery in individuals with subacute stroke.

Application and outcomes of therapy combining transcranial direct current stimulation and virtual reality: a systematic review

Purpose: To evaluate the methods and major outcomes of transcranial direct current stimulation (tDCS) combined with virtual reality (VR) therapy in randomized controlled trials.

Method: A systematic review was performed following PRISMA guidelines using PubMed, PubMed Central, Web of Science and CAPES periodic databases, with no time restriction. The studies were screened for the following inclusion criteria: human subjects, combination of VR and tDCS methods, and randomized controlled study design. All potentially relevant articles were independently reviewed by two researchers, who reached a consensus on which articles met the inclusion criteria. The PEDro scale was used to evaluate the studies.

Results: Eleven studies were included, all of which utilized a variety of tDCS and VR application methods. The main outcomes were found to be beneficial in intervention groups of different populations, including improvements in body sway, gait, stroke recovery, pain management and vegetative reactions.

Conclusions: The use of tDCS combined with VR showed positive results in both healthy and impaired patients. Future studies with larger sample sizes and homogeneous participants are required to confirm the benefits of tDCS and VR.

• Implications for Rehabilitation

• tDCS with VR intervention can be an alternative to traditional rehabilitation programs.

• tDCS with VR is a promising type of intervention with a variety of positive effects.

• Application of tDCS with VR is appropriated to both healthy and impaired patients.

• There is no consensus of tDCS with VR application.

     

Mirror Therapy Enhances Motor Performance in the Paretic Upper Limb After Stroke: A Pilot Randomized Controlled Trial

Objective

To investigate the effectiveness of mirror therapy (MT) combined with bilateral arm training and graded activities to improve motor performance in the paretic upper limb after stroke.

Design

Randomized, controlled, assessor-blinded study.

Setting

Inpatient stroke rehabilitation center of a tertiary care teaching hospital.

Participants

Patients with first-time ischemic or hemorrhagic stroke (N=20), confined to the territory of the middle cerebral artery, occurring <6 months before the commencement of the study.

Intervention

The MT and control group participants underwent a patient-specific multidisciplinary rehabilitation program including conventional occupational therapy, physical therapy, and speech therapy for 5 d/wk, 6 h/d, over 3 weeks. The participants in the MT group received 1 hour of MT in addition to the conventional stroke rehabilitation.

Main Outcome Measures

The Upper Extremity Fugl-Meyer Assessment for motor recovery, Brunnstrom stages of motor recovery for the arm and hand, Box and Block Test for gross manual hand dexterity, and modified Ashworth scale to assess the spasticity.

Results

After 3 weeks of MT, mean change scores were significantly greater in the MT group than in the control group for the Fugl-Meyer Assessment (P=.008), Brunnstrom stages of motor recovery for the arm (P=.003) and hand (P=.003), and the Box and Block Test (P=.022). No significant difference was found between the groups for modified Ashworth scale (P=.647).

Conclusions

MT when combined with bilateral arm training and graded activities was effective in improving motor performance of the paretic upper limb after stroke compared with conventional therapy without MT.     

Apathy and Health-Related Quality of Life in Stroke

Objective

To examine differences in health-related quality of life (HRQOL) in stroke survivors with and without apathy.

Design

Cross-sectional study.

Setting

Acute stroke unit in a regional hospital.

Participants

Stroke survivors (N=391) recruited from the acute stroke unit.

Interventions

Not applicable.

Main Outcome Measures

Participants were divided into apathy and nonapathy groups. Participants who scored ≥36 on the Apathy Evaluation Scale, clinician's version formed the apathy group. HRQOL was measured with the 2 component scores, mental component summary (MCS) and physical component summary (PCS), of the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12). Demographic and clinical information were obtained with the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS).

Results

Thirty-six (9%) participants had apathy. The apathy group had significantly lower MCS and PCS scores. After adjusting for sex, education, diabetes mellitus, and NIHSS, MMSE, GDS, and BI scores, the MCS score in the apathy group remained significantly lower.

Conclusions

Apathy has a significant negative effect on HRQOL in stroke survivors, particularly on their mental health. Interventions for apathy could improve the HRQOL of stroke survivors.     

Activity Limitations Experienced by People With Stroke Who Receive Inpatient Rehabilitation: Differences Between 2001, 2005, and 2011

Objective

To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011.

Design

A multicenter observational study of 3 periods.

Setting

Inpatient rehabilitation units (N=15).

Participants

Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011).

Interventions

Not applicable.

Main Outcome Measures

Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge.

Results

All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts.

Conclusions

In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.     

Polarity-specific modulation of pain processing by transcranial direct current stimulation – a blinded longitudinal fMRI study

Background

To enrich the hitherto insufficient understanding regarding the mechanisms of action of transcranial direct current stimulation (tDCS) in pain disorders, we investigated its modulating effects on cerebral pain processing using functional magnetic resonance imaging (fMRI).

Methods

Thirteen right-handed healthy participants received 20 min of 1.5 mA tDCS applied over the primary motor cortex thrice and under three different stimulation pattern (1.anodal-tDCS, 2.cathodal-tDCS, and 3.sham-tDCS) in a blinded cross-over design. After tDCS neural response to electric trigeminal-nociceptive stimulation was investigated using a block designed fMRI.

Results

Pain stimulation showed a distinct activation pattern within well-established brain regions associated with pain processing. Following anodal tDCS increased activation was detected in the thalamus, basal ganglia, amygdala, cingulate, precentral, postcentral, and dorsolateral prefrontal cortex, while cathodal t-DCS showed decreased response in these areas (p_FWE?<?0.05). Interestingly the observed effect was reversed in both control conditions (visual- and motor-stimulation). Behavioral data remained unchanged irrespective of the tDCS stimulation mode.

Conclusions

This study demonstrates polarity-specific modulation of cerebral pain processing, in reconfirmation of previous electrophysiological data. Anodal tDCS leads to an activation of the central pain-network while cathodal tDCS does not. Results contribute to a network-based understanding of tDCS’s impact on cerebral pain-processing.

     

Comparison of the Test-Retest Reliability of the Balance Computerized Adaptive Test and a Computerized Posturography Instrument in Patients With Stroke

Objective

To compare the test-retest reliabilities of the scores of the Balance Computerized Adaptive Test (CAT) and the Biodex Balance System in patients with stroke.

Design

A repeated-measures design (at a 1-wk interval) was used to examine the test-retest reliabilities of the scores of the Balance CAT and the Biodex Balance System.

Setting

One rehabilitation unit in a local hospital.

Participants

Patients (N=50) with stroke for more than 6 months and undergoing outpatient rehabilitation completed the Balance CAT and the eyes open (EO)/closed (EC) tests, but only 17 patients finished the Limit of Stability (LOS) test because they were unable to reach all the targets.

Interventions

Not applicable.

Main Outcome Measures

The Balance CAT and 2 computerized tests of the Biodex Balance System, namely the EO/EC test and the LOS, were used to evaluate balance function.

Results

The test-retest reliabilities of the scores of the Balance CAT (Pearson r=.92, minimal detectable change [MDC] percent=12.8%) was excellent. Those of the EO/EC and LOS tests were poor to good (Pearson r=.56–.85, MDC%=50.8%–126.9%).

Conclusions

The test-retest reliabilities of the scores of the Balance CAT were sufficient for assessing balance function in patients with stroke. Moreover, the test-retest reliabilities of the scores of the Balance CAT, one of the functional balance measures, were superior to those of the Biodex Balance System, 1 type of computerized posturography instrument. Therefore, the Balance CAT may be a more reliable measure for clinicians and researchers to use in assessing the balance function of patients with stroke for more than 6 months.     

Inpatient Stroke Rehabilitation Lengths of Stay in Canada Derived From the National Rehabilitation Reporting System, 2008 and 2009

Objective

To determine rehabilitation length of stay (LOS) for patients with stroke in Canada, and to evaluate which factors contribute to variations in LOS.

Design

A retrospective cohort study of Canadians rehabilitating from stroke using medical, functional, and sociodemographic variables extracted from the Canadian Institute for Health Information's National Rehabilitation Reporting System.

Setting

Canadian rehabilitation hospitals providing stroke rehabilitation services.

Participants

Patients with stroke (N=11,983) admitted to rehabilitation hospitals from January 2008 through December 2009.

Interventions

None.

Main Outcome Measures

Rehabilitation LOSs were calculated nationally and regionally. Regression models incorporating sociodemographic and clinical measures were constructed to test their effect on LOS.

Results

The median stroke rehabilitation LOSs was 35 days (quartiles: 20d, 54d). LOSs varied regionally within Canada. A multivariable regression model including age, FIM motor function scores at admission, and geographic region explained 20% of the variation in LOSs. Modeling these data using a Function-Related Groups case-mix model explained 16% of the variation in LOSs.

Conclusions

FIM motor function scores at admission along with age and geographic region best predicted rehabilitation LOS. These variables explained 20% of the variation in LOSs. Despite regional differences in LOSs, patient characteristics were similar between regions. Other nonpatient factors not captured in these data may contribute to a greater extent in determining stroke rehabilitation LOS.     

A systematic review of goal directed fluid therapy: Rating of evidence for goals and monitoring methods

Purpose

To review the literature on goal directed fluid therapy and evaluate the quality of evidence for each combination of goal and monitoring method.

Materials and Methods

A search of major digital databases and hand search of references was conducted. All studies assessing the clinical utility of a specific fluid therapy goal or set of goals using any monitoring method were included. Data was extracted using a pre-determined pro forma and papers were evaluated using GRADE principles to assess evidence quality.

Results

Eighty-one papers met the inclusion criteria, investigating 31 goals and 22 methods for monitoring fluid therapy in 13 052 patients. In total there were 118 different goal/method combinations. Goals with high evidence quality were central venous lactate and stroke volume index. Goals with moderate quality evidence were sublingual microcirculation flow, the oxygen extraction ratio, cardiac index, cardiac output, and SVC collapsibility index.

Conclusions

This review has highlighted the plethora of goals and methods for monitoring fluid therapy. Strikingly, there is scant high quality evidence, in particular for non-invasive G/M combinations in non-operative and non-intensive care settings. There is an urgent need to address this research gap, which will be helped by methodologies to compare utility of G/M combinations.     

Association Between the Volume of Inpatient Rehabilitation Therapy and the Risk of All-Cause and Cardiovascular Mortality in Patients With Ischemic Stroke

Objective

To investigate the relationship between the volume of inpatient rehabilitation therapy and mortality among patients with acute ischemic stroke, as well as to assess whether the association varies with respect to stroke severity.

Design

A retrospective study with a cohort of consecutive patients who had acute ischemic stroke between January 1, 2008, and June 30, 2009.

Setting

Referral medical center.

Participants

Adults with acute ischemic stroke (N=1277) who were admitted to a tertiary hospital.

Interventions

Not applicable.

Main Outcome Measure

Stroke-related mortality.

Results

During the median follow-up period of 12.3 months (ranging from January 1, 2008, to December 31, 2009), 163 deaths occurred. Greater volume of rehabilitation therapy was associated with a reduced risk of all-cause and cardiovascular mortality (P for trend <.001 for both). Compared with the first tertile, the third tertile of rehabilitation volume was associated with a 55% lower risk of all-cause mortality (hazard ratio [HR]=.45; 95% confidence interval [CI], .30–.65) and a 50% lower risk of cardiovascular mortality (HR=.50; 95% CI, .31–.82). The association did not vary with respect to stroke severity (P for interaction = .45 and .73 for all-cause and cardiovascular mortality, respectively).

Conclusions

The volume of inpatient rehabilitation therapy and mortality were significantly inversely related in the patients with ischemic stroke. Thus, further programs aimed at promoting greater use of rehabilitation services are warranted.     

Efficacy of low-level laser therapy applied at acupuncture points in knee osteoarthritis: a randomised double-blind comparative trial

Objective

To evaluate the efficacy of low-level laser therapy (LLLT) applied to acupuncture points on the knee joint in combination with exercise and advice in patients with knee osteoarthritis.

Design

Randomised, double-blind, comparative clinical trial.

Participants

Forty-nine patients with knee osteoarthritis were assigned at random into two groups: active laser group (n = 26) and placebo laser group (n = 23).

Intervention

Using a gallium aluminium arsenide laser device, patients received either active or placebo LLLT at five acupuncture points on the affected knee during nine sessions.

Outcome measures

Patients were assessed using a visual analogue scale (VAS) and the Saudi Knee Function Scale (SKFS) at baseline, the fifth treatment session, the last treatment session, 6 weeks post intervention and 6 months post intervention.

Results

VAS scores showed a significant improvement in the active laser group compared with the placebo laser group at 6 weeks post intervention [mean difference −1.3, 95% confidence interval (CI) of the difference −2.4 to −0.3; P = 0.014] and 6 months post intervention (mean difference −1.8, 95% CI of the difference −3.0 to −0.7; P = 0.003) using the independent samples test. SKFS scores also showed a significant improvement in the active laser group compared with the placebo laser group at the last treatment session (median difference −15, 95% CI of the difference −27 to −2; P = 0.035) and 6 months post intervention (median difference −21, 95% CI of the difference −34 to −7; P = 0.006) using the Mann–Whitney U test.

Conclusions

The results demonstrate that short-term application of LLLT to specific acupuncture points in association with exercise and advice is effective in reducing pain and improving quality of life in patients with knee osteoarthritis.     

Utilization of Behavioral Therapy Services Long-Term After Traumatic Brain Injury in Young Children

Objective

To examine associations of clinical need, defined by elevated parent ratings of child behavior problems and utilization of behavioral health services in young children with traumatic brain injury (TBI) and an orthopedic injury (OI) comparison group.

Design

Parents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months postinjury.

Setting

Children's hospitals and a general hospital.

Participants

Participants included parents of 3 groups of children injured between 3 and 7 years of age (N=139): 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI.

Interventions

Not applicable.

Main Outcome Measures

Parents completed ratings of child behavior, mental health symptomology, and family functioning at both visits; at the extended follow-up, they reported utilization of behavior therapy or counseling services since the 18-month follow-up visit.

Results

Children with TBI had more behavior problems than those with OI. Although clinical need at both follow-ups was associated with greater service utilization at the extended follow-up, all groups had unmet needs as defined by a clinical need in the absence of services. Lower socioeconomic status was associated with higher rates of unmet need across groups.

Conclusions

The results document unmet long-term behavioral health needs after both TBI and OI in children and underscore the importance of monitoring and treatment of postinjury behavior problems.     

Impact of Anxiety on Health-Related Quality of Life After Stroke: A Cross-Sectional Study

Objective

To examine the impact of anxiety on health-related quality of life (HRQOL) of stroke survivors.

Design

Cross-sectional study.

Setting

Acute stroke unit in a regional hospital.

Participants

Patients (N=374) from an acute stroke unit.

Interventions

Not applicable.

Main Outcome Measures

The presence of anxiety was defined as a score of ≥8 on the anxiety subscale of the Hospital Anxiety Depression Scale. HRQOL was measured by the total score and 12 domain scores of the Stroke Specific Quality of Life (SSQOL) scale. Demographic characteristics and history of medical conditions were also recorded. Clinical characteristics were obtained using the following scales: National Institutes of Health Stroke Scale, Barthel Index, Mini-Mental State Examination, and Geriatric Depression Scale (GDS).

Results

Eighty-six (23%) stroke survivors had anxiety. The anxiety group had significantly more women (62.8% vs 35.1%), higher GDS scores (7.5±4.5 vs 3.5±3.6), and lower scores for total SSQOL (3.9±0.6 vs 4.5±0.6) and SSQOL domains of energy (2.0±1.2 vs 3.4±1.4), mood (3.6±1.5 vs 4.6±0.9), personality (3.4±1.7 vs 4.4±1.1), and thinking (2.4±1.2 vs 3.5±1.4), after adjustment for sex and GDS score. In subsequent multivariate regression analysis, the Hospital Anxiety Depression Scale anxiety score was negatively associated with the SSQOL total score (r=−.154) and 5 of the 12 domain scores, namely energy (r=−.29), mood (r=−.102), personality (r=−.195), thinking (r=−.136), and work/productivity (r=−.096).

Conclusions

Anxiety has a negative effect on HRQOL of stroke survivors, independent from depression. Interventions for anxiety should improve stroke survivors' quality of life.     

Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury

Objective

The purpose of this study was to assess the effect of goal-directed therapy (GDT), after cardiac surgery, on the incidence of acute kidney injury (AKI).

Design

This is a prospective observational study designed to achieve and maintain maximum stroke volume for 8 hours, in patients after cardiac surgery.

Setting

This is a single-center study in a 15-bedded cardiothoracic intensive care unit (ICU).

Participants

Participants are patients after coronary artery bypass grafting and/or aortic valve surgery.

Interventions

Patients in the GDT group received cardiac output monitoring and fluid challenges targeting an increase in stroke volume by at least 10%. Stroke volume maximization was maintained for a period of 8 hours from admission to the ICU. All other aspects of care were dictated by the clinical team. Patients in the standard therapy (ST) group had intravenous fluids in accordance with the routine practice of the unit. Patients were divided into the GDT and ST group dependant on availability of cardiac output monitors and allocation of nursing staff with training in GDT. Patients’ data were collected prospectively in both groups.

Measurements and main results

One hundred twenty-three patients received GDT compared with 141 patients in the ST group. Both groups received similar volumes of fluid (GDT, 2905 [1367] mL vs 2704 [1393] mL; P = .09). Incidence of AKI was reduced in the GDT group (n = 8 [6.5%] vs n = 28 [19.9%]; P = .002). The median duration of hospital stay was 6 (4) days in the GDT group vs 7 (8) days in the ST, P = .004.

Conclusion

Postoperative GDT in patients after cardiac surgery was associated with reduction in the incidence of AKI and a reduction in ICU and hospital duration of stay.     

Investigating the Role of Backward Walking Therapy in Alleviating Plantar Pressure of Patients With Diabetic Peripheral Neuropathy

Objective

To investigate the effect of combination therapy of backward walking training and alpha-lipoic acid (ALA) treatment on the distribution of plantar pressure in patients with diabetic peripheral neuropathy (DPN).

Design

This study is a double-blinded, randomized controlled trial. The test group was treated with combination therapy of backward walking exercise and ALA (ALA for 2wk, backward walking exercise for 12wk), and the control group only received ALA treatment.

Setting

Clinical and laboratory setting.

Participants

Patients with DPN (N=60) were divided into the test group (n=30) or control group (n=30).

Interventions

Backward walking exercise with ALA treatment for the test group; lipoic acid treatment for the control group.

Main Outcome Measure

Plantar pressure before and after treatment was tested and analyzed with the flatbed plantar pressure measurement system.

Results

After treatment, peak plantar pressure in the forefoot dropped for both the test and control groups; peak plantar pressure for the test group dropped significantly. Peak plantar pressure in the medial foot slightly increased for the test group, suggesting a more even distribution of plantar pressure in the test group after treatment.

Conclusions

The combination therapy of ALA and backward walking proved to be more effective than ALA monotherapy. Backward walking also proved to have an ameliorating effect on balance ability and muscle strength of patients with DPN.     

Temporal Patterns of the Trunk Muscles Remain Altered in a Low Back–Injured Population Despite Subjective Reports of Recovery

Objective

To compare temporal activation patterns from 24 abdominal and lumbar muscles between healthy subjects and those who reported recovery from recent low back injury (LBI).

Design

Cross-sectional comparative study.

Setting

University neuromuscular function laboratory.

Participants

Healthy adult volunteers (N=81; 30 LBI, 51 asymptomatic subjects).

Interventions

Trunk muscle electromyographic activity was collected during 2 difficulty levels of a supine trunk stability test aimed at challenging lumbopelvic control.

Main Outcome Measures

Principal component (PC) analysis was applied to determine differences in temporal and/or amplitude electromyographic patterns between groups. Mixed-model analyses of variance were performed on PC scores that explained more than 89% of the variance (α=.05).

Results

Four PCs explained 89% and 96% of the variance for the abdominal and back muscles, respectively, with both muscle groups having similar shapes in the first 3 PCs. Significant interactions or group main effects were found for all PC scores except PC4 for the back extensors. Overall activation amplitudes for both the abdominal and back muscles (PC1 scores) were significantly (P<.05) higher for the LBI group, with both abdominal and back muscles of the LBI group demonstrating an increased response to the leg-loading phase (PC2 scores) compared with the asymptomatic group. Differences were also found between groups in their preparatory activity (PC3 scores), with the LBI group having a higher early relative amplitude of abdominal and back extensor activity.

Conclusions

Despite perceived readiness to return to work and low pain scores, muscle activation patterns remained altered in this LBI group, including reduced synergistic coactivation and increased overall amplitudes as well as greater relative amplitude differences during specific phases of the movement. Electromyographic measures provide objective information to help guide therapy and may assist with determining the level of healing and return-to-work readiness after an LBI.     

Warfarin Use and Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation in a Large Managed Care Population

Background

Stroke prevention is a goal of atrial fibrillation (AF) management, but discontinuation of warfarin anticoagulation therapy is common.

Objective

To investigate the association between warfarin discontinuation and hospitalization for stroke among nonvalvular AF (NVAF) patients enrolled in managed care.

Methods

Patients with NVAF who initiated warfarin therapy from January 2005 through June 2009 were included. Warfarin discontinuation was defined as a supply gap >60 days without evidence of International Normalized Ratio measurements. Follow-up, which was a variable time period from warfarin initiation until the earlier of death, disenrollment from the health plan, or June 30, 2010, was divided into periods of warfarin treatment and discontinuation. Stroke events were identified based on claims for inpatient stays with a primary diagnosis of stroke or transient ischemic attack. Cox proportional hazards models were constructed to assess the relationship between warfarin discontinuation and incident stroke while adjusting for baseline demographics, stroke and bleeding risk, and comorbidities, as well as time-dependent antiplatelet use, stroke, and bleeding events in the previous warfarin treatment period.

Results

Among warfarin initiators with NVAF (N = 16,253), 51.4% discontinued warfarin therapy at least once during a mean follow-up of 668 days. Stroke risk was significantly greater during warfarin discontinuation periods compared with therapy periods (hazard ratio = 1.60; 95% CI, 1.35–1.90; P < 0.001).

Conclusions

More than half of patients on warfarin had treatment gaps or discontinued therapy. Therapy gaps were associated with increased stroke risk.     

Effect of corticosteroids on arginine vasopressin–containing vasopressor therapy for septic shock: a case control study

Purpose

Studies showing corticosteroids decrease time to shock reversal in septic shock did not include arginine vasopressin, which also may reduce the duration of catecholamine therapy. Thus, the effect of corticosteroids on vasopressin-containing vasopressor regimens is unknown. We designed this study to evaluate the effect of corticosteroids on time to vasopressin-containing vasopressor withdrawal and the proportion of patients alive without vasopressors at day 7.

Methods

This retrospective, case-control study included patients admitted to the intensive care units of an academic medical center who received vasopressin-containing vasopressor regimens for septic shock with or without concomitant corticosteroids. Twenty-one corticosteroid-treated patients were matched to those without corticosteroids.

Results

Both groups had similar Acute Physiology And Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, and Sequential Organ Failure Assessment (SOFA) scores. There was no significant difference in median time to vasopressor withdrawal (65 hours vs 20 hours, P = .09) whether corticosteroids were given or withheld. Patients who received corticosteroids, however, were significantly more likely alive without vasopressors at day 7 than patients who received a vasopressin-containing vasopressor regimen alone (80.9% vs 47.6%, P = .02).

Conclusions

Although corticosteroids did not improve the time to withdrawal of vasopressin-containing vasopressor therapy they significantly increased the proportion of patients alive without vasopressors at day 7.