Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation

BackgroundLower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.Patients and methodsIn a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.ResultsOne hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R²: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).ConclusionsHigher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.

KEY MESSAGE

• Higher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.
• Higher SES is associated with significantly higher utilization of outpatient therapies.
• Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery.
• Article registration: clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT04119479","term_id":"NCT04119479"}}NCT04119479.

     

Renal Uptake,Excretion, and Retention of Mercury

A modification is proposed for the conventional pH stat assay for human plasma and erythrocyte cholinesterases. Principal advantages for the micromodification are smaller sample size afforded by collection of specimens in microhematocrit tubes and reduction in subsequent sample-handling time. Red blood cell (RBC) washing and recentrifugation steps are eliminated. Although the basic assay procedure remains unchanged, titration parameters are changed to accommodate smaller sample volumes. Results from either assay procedure are comparable, as shown by statistically significant regressions of micromodification assay data upon those of conventional pH stat procedure.     

Defecation disturbances after cystectomy for urinary bladder cancer

Study Type – Preference (prospective cohort) Level of Evidence 4 What’s known on the subject? and What does the study add? Functional gastrointestinal symptoms and problems are common after radical cystectomy with urinary diversion. This study adds new important epidemiological data on this group of symptoms.

OBJECTIVE

• ? To describe and compare long‐term defecation disturbances in patients who had undergone a cystectomy due to urinary bladder cancer with non‐continent urostomies, continent reservoirs and orthotopic neobladder urinary diversions.

PATIENTS AND METHODS

• ? During their follow‐up we attempted to contact all men and women aged 30–80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals.
• ? During a qualitative phase we identified defecation disturbances as a distressful symptom and included this item in a study‐specific questionnaire together with free‐hand comments. The patients completed the questionnaire at home.
• ? Outcome variables were dichotomized and the results are presented as relative risks with 95% confidence interval.

RESULTS

• ? The questionnaire was returned from 452 (92%) of 491 identified patients. Up to 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability).
• ? A sense of decreased straining capacity was reported by 20% of the men and women with non‐continent urostomy and 14% and 8% of those with continent reservoirs and orthotopic neobladders, respectively.

CONCLUSIONS

• ? Of the cystectomized individuals 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability).
• ? Those wanting to improve the situation for bladder cancer survivors may consider communicating before surgery the possibility of stool‐emptying problems, and asking about them after surgery.

     

Rectal adenocarcinoma: assessment of tumour involvement of the lateral resection margin by MRI of resected specimen.

The aim of the present study was to investigate whether MRI could predict tumour involvement of the lateral resection margin on resected rectal cancer specimens. 26 specimens obtained after total mesorectal excision were examined in the sagittal and axial plane on a clinical 1.5 T MR system using phased-array surface coils. The shortest distance between the deepest point of tumour penetration and the lateral resection margin was measured. This distance is referred to as LRM. The results were correlated to measurements on digital images of giant histopathological sections. The total number of lymph nodes and lymph node metastases was also counted. LRM was less than or equal to 1 mm (a distance considered for non-radically excised tumours) in eight of the histopathological specimens. On MR images of the resected specimen, LRM was less than or equal to 1 mm in seven of these specimens. LRM was shorter in MR examinations than in histopathological giant sections in 11 specimens. The sensitivity, specificity, positive and negative predictive values for prediction of tumour involvement of the lateral resection margin (LRM < or = 1 mm) by MR of the resected specimen were 88%, 78%, 64% and 93%, respectively. Presence of lymph node metastases could not accurately be predicted by MR. However, it is concluded that the presence of a tumour free lateral resection margin can be predicted by MRI of resected rectal specimens when this exceeds 1 mm.     

Transverse displacement of the proximal segment after bilateral sagittal osteotomy: a comparison of lag screw fixation versus miniplates with monocortical screw technique.

PURPOSE: The purpose of the present study was to compare lag screw fixation versus miniplates with monocortical screw technique with respect to the amount of transverse displacement of the proximal segment after bilateral sagittal osteotomy (BSO) for mandibular advancement surgery. PATIENTS AND METHODS: We conducted a multicenter, retrospective investigation of 82 patients who underwent a mandibular advancement with BSO and rigid internal fixation. Forty-five patients from Denmark and Sweden, the miniplate fixation group, received a rigid fixation consisting of miniplates with monocortical screws. Thirty-seven patients from the Mayo Clinic, the lag screw fixation group, received a rigid fixation with lag screw fixation of the mandible. The transverse displacement and angulation of the proximal segments were measured on posterior-anterior cephalometric radiographs, using the best-fit method. RESULTS: After BSO, 44 of 45 patients in the miniplate fixation group showed an increased transverse intergonion distance with a mean of 5.0 mm and an increase transverse interramus width with a mean of 2.4 mm. Thirty-six of 37 patients in the lag screw fixation group had an increased intergonial width with a mean of 5.6 mm, and 35 of 37 patients showed an increased transverse interramus width with a mean of 3.3 mm. t tests showed that there were no significant differences between the 2 groups with respect to these 2 variables. CONCLUSIONS: Our results indicate that transverse displacements of the proximal segments occur after BSO surgery with both miniplate or lag screw fixation technique. Attention and future studies should focus on possible complications that transverse displacement of the proximal segment may cause.     

p53, p21 and mdm2 expression vs the response to radiotherapy in transitional cell carcinoma of the bladder

OBJECTIVE: To identify, in a retrospective study, possible molecular markers predictive of radioresponsiveness in patients with transitional cell carcinoma (TCC) of the bladder. PATIENTS AND METHODS: Patients with T2-T4a TCC treated with preoperative radiotherapy and cystectomy were included in the study if their cystectomy specimen was pT3b (in 42) or pT0 (in 17). Because treatment schedules changed over time, radiotherapy was given either as 2 Gy x 23 over 4-5 weeks with cystectomy 4-5 weeks later (in 23), or as 4 Gy x 5 during 1 week with cystectomy in the following week (in 36 patients). Protein expression of p53, mdm2 and p21 (CDKN1 A/WAF1/CIP1/SDI1) was assessed immunohistochemically in biopsies taken before radiotherapy. RESULTS: There was no difference in protein expression when comparing all patients with pT0 and pT3b. However, for patients receiving 46 Gy, increased p53 expression (but not p21 or mdm2) predicted the absence of residual tumour (P = 0.005): six of seven patients with > 50% p53 expression had pT0 in the cystectomy specimen, whereas 10 of 12 patients with < or = 5% expression had pT3b. Over-expression of p53 correlated with longer overall (P = 0.045) and cancer-specific survival (P = 0.020). CONCLUSION: The expression of mdm2 or p21 did not predict radioresponsiveness in patients with TCC of the bladder. The role of p53 remains unclear; the view that p53 over-expression confers radioresistance in bladder cancer is not supported.