Optimizing the Management of Spasticity in People With Spinal Cord Damage: A Clinical Care Pathway for Assessment and Treatment Decision Making From the Ability Network,an International Initiative

The recognition, evaluation, and management of disabling spasticity in persons with spinal cord damage (SCD) is a challenge for health care professionals, institutions, health systems, and patients. To guide the assessment and management of disabling spasticity in individuals with SCD, the Ability Network, an international panel of clinical experts, developed a clinical care pathway. The aim of this pathway is to facilitate treatment decisions that take into account the effect of disabling spasticity on health status, individual preferences and treatment goals, tolerance for adverse events, and burden on caregivers. The pathway emphasizes a patient-centered, individualized approach and the need for interdisciplinary coordination of care, patient involvement in goal setting, and the use of assessment and outcome measures that lend themselves to practical application in the clinic. The clinical care pathway is intended for use by health care professionals who provide care for persons with SCD and disabling spasticity in various settings. Barriers to optimal spasticity management in these people are also discussed. There is an urgent need for the clinical community to clarify and overcome barriers (knowledge-based, organizational, health system) to optimizing the management of spasticity in people with SCD.     

A comparison of performance on the Keitel Functional Test by persons with systemic sclerosis and rheumatoid arthritis

Purpose: The purpose of this study is to compare lower extremity impairments in persons with systemic sclerosis, rheumatoid arthritis, and healthy controls.

Methods: The participants were a convenience sample of 64 persons with systemic sclerosis, 58 persons with rheumatoid arthritis, and 30 healthy controls. The Keitel Functional Test was used to assess lower extremity joint motion and strength. Demographic information on age, disease duration, employment, and perceived overall health was also collected.

Results: Significant differences were found between the healthy control group and both the systemic sclerosis and rheumatoid arthritis groups in rising from a chair, squatting, walking 30?m, walking up and downstairs, and the total score. For hip external rotation, there were significant differences between all three groups for the right hip; for the left hip, the systemic sclerosis group had significantly less motion than the other two groups. For standing on toes, there was only a significant difference between the systemic sclerosis and the healthy control groups.

Conclusions: Persons with systemic sclerosis and rheumatoid arthritis have similar levels of lower extremity impairments but greater impairments compared to the healthy controls. These impairments may lead to decreased mobility paired with difficulties with activities of daily living such as lower extremity dressing, bathing, and feet care.

• Implications for Rehabilitation

• Persons with systemic sclerosis and rheumatoid arthritis have similar levels of lower extremity impairments but greater impairments compared to the healthy controls.

• Findings from this study indicate a need for rehabilitation for persons with systemic sclerosis and rheumatoid arthritis as the lower extremity impairments may lead to decreased mobility paired with difficulties with daily living activities such as lower extremity dressing, bathing, and feet care.

• The Keitel Functional Test could be used as a quick screening test for lower extremity impairments.

     

The SYNERGY trial: study design and rationale

Background Enoxaparin was shown to be superior to unfractionated heparin in the patients with non-ST-segment elevation acute coronary syndromes (ACS) in the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Events study and the Thrombolysis In Myocardial Infarction (TIMI) 11B trial. However, enoxaparin has had limited acceptance in clinical practice, in part because of the contemporary management of these patients, which includes glycoprotein IIb/IIIa inhibition and the use of early invasive management strategies. Study Design The Superior Yield of the New strategy of Enoxaparin, Revascularization and GlYcoprotein IIb/IIIa inhibitors (SYNERGY) trial is an 8000-patient, prospective, randomized, open-label, multicenter investigation of enoxaparin compared with unfractionated heparin in patients at high risk with non-ST-segment elevation ACS treated with an early invasive strategy. The primary efficacy end point is death or nonfatal myocardial infarction 30 days after enrollment. Implications The SYNERGY trial is the largest study currently planned for the acute therapy of patients with non-ST-segment elevation ACS and the first large trial since the publication of the revised American College of Cardiology/American Heart Association guidelines for the management of these patients. In addition to evaluating the potential superiority of enoxaparin over unfractionated heparin, this investigation will provide important observations of current treatment strategies in patients with ACS. (Am Heart J 2002;143:952-60.)     

HLA-linked congenital adrenal hyperplasia results from a defective gene encoding a cytochrome P-450 specific for steroid 21-hydroxylation.

We have determined the molecular genetic basis of congenital adrenal hyperplasia due to 21-hydroxylase (21-OHase) deficiency. This common disorder of cortisol biosynthesis is HLA-linked. The haplotype HLA-(A3);Bw47;DR7 is strongly associated with 21-OHase deficiency and always carries a null allele at the locus encoding the C4A (Rodgers) form of the fourth component (C4) of complement. It seemed likely that this haplotype carries a deletion encompassing the genes encoding both C4A and 21-OHase. We hypothesized that the HLA-linked defect involved a structural gene for the adrenal microsomal cytochrome P-450 specific for steroid 21-hydroxylation. Using a plasmid with a 520-base-pair bovine adrenal cDNA insert encoding the middle third of the cytochrome P-450 polypeptide, we compared hybridization patterns in DNA from normal and 21-OHase-deficient individuals. Normal human DNA yielded two fragments that hybridized with the probe after digestion with either restriction endonuclease EcoRI [12- and 14-kilobase (kb) fragments] or Taq I (3.7 and 3.2 kb). One of these bands (the first mentioned in each digest) was absent in DNA from a cell line derived from a patient homozygous for HLA-Bw47. DNA from six unrelated patients homozygous for 21-OHase deficiency who were heterozygous for HLA-Bw47 yielded diminished relative intensity of the 3.7-kb Taq I band in five patients, consistent with a heterozygous deletion, and complete disappearance of the 3.7-kb band in one. This deletion segregated with HLA-Bw47 in a large pedigree carrying 21-OHase deficiency and HLA-Bw47. Thus, 21-OHase deficiency sometimes results from the deletion of a specific cytochrome P-450 gene and sometimes, presumably, from smaller mutations. This gene is probably located very near the C4A gene.     

Sonography of Responsive Versus Nonresponsive Ectopic Pregnancies

This case series describes changes in size, vascularity, and cul‐de‐sac fluid in 30 patients with ectopic pregnancies who were treated with systemic methotrexate. Pretreatment and posttreatment transvaginal sonography of the ectopic pregnancies was performed with color Doppler imaging, and the images were assessed for changes in size, vascularity, and cul‐de‐sac free fluid. There was a trend for nonresponders to show increased vascularity on serial examinations, although this finding was also seen in a single responder. There was also a trend for nonresponders with increased vascularity to be associated with a greater increase in β‐human chorionic gonadotropin levels and responders with decreased vascularity to be associated with a greater decrease in β‐human chorionic gonadotropin levels.     

Neurobehavioral disability in stroke patients during subacute inpatient rehabilitation: prevalence and biopsychosocial associations

Background and Objectives: There are scarce data on post-stroke neurobehavioral disability (NBD). The aim of this study was to identify the prevalence of NBD in a subacute inpatient stroke population and examine potential associations with demographic, stroke-related, functional and psychosocial variables.

Methods: 82 survivors of stroke were consecutively recruited during their inpatient rehabilitation admission. Nursing staff rated NBD in patients using the St Andrews –Swansea Neurobehavioral Outcome Scale (SASNOS). Measures of patient functional independence (FIM), cognition (MoCA), and mood symptoms (HADS) were collected in addition to nursing reports of whether observed NBD negatively impacted on the patient or those around them.

Results: NBD relating to interpersonal relationships (44.4% of participants) and cognition (52.4%) were highly prevalent within the sample while NBD relating to inhibition (1.2%), aggression (3.6%), and communication (2.5%) were relatively rare. Presence of NBD was significantly associated with reduced functional independence (r_s=0.39, p < 0.01) and associated with trends in cognitive impairment (r_s=0.29, p = 0.03), increased anxiety (r_s=-0.43, p = 0.02) and depressive symptoms (r_s=-0.43, p = 0.02). Presence of NBD was significantly correlated with negative impact to the patient and those around them across all SASNOS domains (r_s range 0.42 - 0.45, all p ≤ 0.01).

Conclusions: NBD is common within a subacute stroke inpatient population, particularly interpersonal and cognitive difficulties and preliminary analyses indicate associations with reduced functional ability, cognition and mood. There is a need to provide education and support to clinicians to facilitate routine assessment and management of NBD following stroke.     

Dissociations of Visual Recognition in a Developmental Agnosic: Evidence for Separate Developmental Processes

We report the results of tests investigating the recognition of faces, places, and objects in a developmental agnosic, because dissociations of visual recognition in developmental agnosics provide insight into the separable procedures performing recognition and the developmental origins of these procedures. TA is a software engineer in his early 40s with developmental prosopagnosia. He performs normally on tests of low-level vision, and he names objects at the basic level normally. In order to compare his recognition abilities for different classes, we have presented him with a famous landmarks test, a famous faces test, and old/new discriminations involving unfamiliar faces, houses, natural landscapes, cars, horses, guns, sunglasses, and tools. He was impaired on the face recognition tests, but performed normally on the place recognition tests. He also showed severe impairments with horses and cars, borderline impairments with guns and sunglasses, and normal performance with tools. These results indicate that the developmental processes that assemble the procedures used for face recognition and certain types of object recognition are separate from those processes that produce the procedures used for place recognition.