Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.Methods:Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.Results:There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).Conclusion:This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

Stroke is a life-threatening condition caused by interruption of the blood supply to any part of the brain. Stroke causes acute neurological disorders and long-term disabilities and imposes economic, social and health impacts on individuals and their families.1 Survivors of stroke are left with mental and physical disabilities that cause social and economic burdens and impair quality of life (QOL). In Saudi Arabia stroke is becoming a rapidly increasing problem and a primary cause of morbidity and mortality.2 Worldwide the incidence of first-time stroke was 17 million during 1990-2000.3 Cerebrovascular diseases including stroke is a leading cause of mortality,4 and stroke is the fifth leading cause of death, but it remains the first cause of disability in the USA.5 By 2030 there will be almost 12 million stroke deaths and 70 million stroke survivors globally.6 Stroke has an adverse influence on the QOL of patients. The onset of stroke is sudden, and unlike other disabling conditions, it leaves patients and their family’s ill prepared for its sequelae.7 Stroke may create unique conditions that affect the patients’ QOL, involving dysfunctions in physical, emotional, memory, thinking, and social interactions.8Stroke is an urgent health care issue. It is a common cause of the hospital admissions. Immediate admission to the neuro-intensive care unit can facilitate early stroke treatment strategies.9 Stroke patients in the intensive care unit (ICU) experience a decrease in physical activity that represents a significant stress on the body and leads to a considerable decrease in functional status, increases morbidity, mortality rate, and duration of hospital stay and cost of care.10 In addition to comorbid diseases, patients on mechanical ventilation have many barriers to mobility because they are surrounded by tubes, catheters, life support and monitoring equipment. Additionally, other factors besides weakness, such as sleep loss, lack of social communication, nutritional status, sedation, and an ICU culture that encourages bed rest further contribute to functional deterioration.11 There is considerable loss of the muscle mass during the initial weeks of immobility in the ICU, therefore its management is inherently related to QOL after discharge.12 Considerable published evidence indicates that patients in ICUs have high morbidity and mortality, high costs of care and a marked decline in functional status.13,14Early and progressive mobilization program has been described as a key component for patients in the ICU. It may decrease post stroke complications such as infections, deep venous thrombosis, pneumonia, pressure ulcers, falls and de-conditioning with bed rest.15 It has been recognized that mobilization of post stroke patients is essential to prevent hospital-associated complications, functional decline and facilitate recovery.16 Moreover, the benefits of early mobilization include decreased ICU-acquired weakness, improved functional recovery within hospital,17 Effective stroke intervention begins the day the patient has a stroke.18 It has a positive effect on patient functional ability, promotes positive psychological effects and improves walking at hospital discharge and reduces hospital length of stay.19 While on the other hand, long term inactivity may affect the patients’ physical, social, emotional, behavioral, and psychological pattern.20 In addition, secondary changes associated with stroke-related inactivity include muscle atrophy, a shift in muscle fiber type to a greater predominance of fast-fatigable, insulin-resistant fibers, loss of cardiovascular fitness, and increased intramuscular fat.21 Therefore, early mobilization program which is a complex intervention that needs crucial patient assessment and management, as well as interdisciplinary team collaboration and training.22,23 The early mobilization may improve patient outcomes and recovery.24 Few studies have investigated the role of increased mobility in ICU patients. Therefore, this prospective intervention trial evaluated the effectiveness of an early mobility program administered by physical therapists and nursing personnel for stroke patients admitted in ICU.     

Antifungal efficiency of wild plants against human-opportunistic pathogens

BackgroundFungal infection with opportunistic fungi can cause a serious problem for immunocompromised persons such as organ-transplant recipients, cancer, and HIV/AIDS patients. Control of these organisms using natural products is an interesting strategy to avoid the use of heavy chemotherapy in patients.ObjectiveThis study aimed to use the extract of Forsskaolea tenacissima L. and Xanthium spinosum L. to suppress the growth of Candida albicans and Geotrichum candidum and to investigate their potential mode of action.Materials and methodsDifferent plant extracts were tested for their antifungal activity using disc diffusion method and their mode of action was explored using the scanning electron microscopy (SEM) and gas chromatography-mass spectrometry (GC-MS).ResultsThe results showed that chloroform extract of X. spinosum was the most effective against G. candidum, inhibiting its growth at very low concentration (38 μg/mL). Chloroform extract of F. tenacissima was the most effective against C. albicans, with a minimum inhibitory concentration of 39 μg/mL. SEM demonstrated the fungitoxicity of the plant extracts against both pathogens. C. albicans treated with plant extract were invaginated and ruptured and the treated mycelia of G. candidum were distorted and squashed. GC-MS analysis showed that the chloroform extract of both plants had 13 different compounds.ConclusionDue to these promising results, these extracts should be further investigated and tested on different strains of C. albicans and G. candidum towards validation of their efficacy as a natural drug.     

How to Tailor Structural Colors for Extended Visibility and White Light Generation Employing Direct Laser Interference Patterning

The appearance of a surface can be controlled by creating periodic microstructures designed to diffract light and produce structural colors. Nevertheless, since structural coloration is based on diffraction, the produced colors have a strong dependence on the viewing angle and absence of coloration takes place while tilting the samples. In this work direct laser interference patterning is used to firstly provide transparent polymer sheets a structural coloration with a high‐range observation angle, and secondly to demonstrate the combination of structural colors, producing a white coloring effect. The employed approaches are based on the fabrication of micro‐gratings with multiple periods in the same structured area and on the engineering of the diffraction orders of the diffraction spectrum. The patterned surfaces are characterized by confocal microscopy and angular spectrometry in reflection mode. The morphological characterization shows homogeneous surface patterns, while the spectral results demonstrate that combining four spatial periods on a single patterned surface, a white appearance is obtained over an angular observation range higher than 30°. The experimental results are supported by theoretical predictions by means of generalized formulas based on the diffraction of light.     

Prevalence and risk factors of clopidogrel non-response among Saudi patients undergoing coronary angiography

Objectives:

To estimate the prevalence of clopidogrel non-response and identify its risk factors among Saudi patients.

Methods:

This cross-sectional study was conducted at Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia between January and June 2013, to assess the degree of platelet inhibition using the VerifyNow assay (Accumetrics, San Diego, CA, USA) after receiving clopidogrel standard loading dose. Clopidogrel resistance was defined as ≤15% platelet inhibition or >213 P2Y12 reaction units (PRU).

Results:

Three hundred and four patients were included in the study. The mean age was 60.3 ± 11.4 years, and 73% were males. Clopidogrel doses were 300 mg (57%), 600 mg (27%), and 75 mg (16%). All patients used aspirin (81 mg in 94%). Approximately 66% (200/304) showed in vitro clopidogrel non-response, 54% had low platelet inhibitions, and 61% had high post-loading PRU. Using multivariate regression analysis that included all significant characteristics; only diabetes (odds ratio [OR]: 2.36, 95% confidence interval [CI]: 1.30-4.27, p=0.005) and higher preloading PRU (OR: 2.39, 95% CI: 1.40-4.11, p=0.002) remained significantly associated with higher clopidogrel non-response while myocardial infarction (OR: 0.34, 95% CI: 0.15-0.81, p=0.014) remained significantly associated with lower clopidogrel non-response. The associations of morbid obesity and diuretics use with higher clopidogrel non-response were slightly attenuated.

Conclusion:

Our findings indicate a high rate of clopidogrel in-vitro non-response among Saudi patients undergoing coronary angiography.Platelets play a critical role in the pathogenesis of atherothrombotic diseases such as coronary artery disease (CAD). The rupture of atherosclerotic plaques initiates a complex process of platelet adhesion, activation, and aggregation.1 Recently, clopidogrel and aspirin were the cornerstones of oral antiplatelet therapy for preventing ischemic events of atherothrombotic disease such as myocardial infarction and stroke.2,3 Clopidogrel was shown to be even more effective than aspirin in preventing such events of atherothrombotic disease.4 Clopidogrel is a prodrug and the active metabolite is generated by the cytochrome P450 system.5 The active metabolite acts by inhibiting platelet aggregation in response to adenosine diphosphate (ADP) through binding and blocking the platelet P2Y12 receptors.5 Variability in individual responsiveness to the antiplatelet effects of clopidogrel may lead to the occurrence of thromboembolic events despite regular antiplatelet therapy.6,7 This may be clinically translated into poor procedural and long-term morbidity and mortality outcomes.8,9 The prevalence of clopidogrel non-response (resistance) is highly variable in different studies and populations. A review10 estimated the non-response rate to range from 4-30%. This variability is partly caused by the lack of standard definition and the different assessment methods of clopidogrel non-response.11,12 A number of studies examined the patients characteristics associated with clopidogrel non-response but failed to identify any, probably due to small sample sizes and the presence of multiple confounding factors.13-15 Although, approximately 84% of Saudi patients admitted with acute coronary syndrome are treated with clopidogrel,16 there is lack of estimates of clopidogrel non-response and the associated risk factors in this population. The objective of the current study was to estimate the prevalence of clopidogrel non-response and to identify its risk factors among Saudi patients undergoing coronary angiography at a specialized cardiac center in Kingdom of Saudi Arabia (KSA).     

High dielectric constant and high breakdown strength polyimide via tin complexation of the polyamide acid precursor

Polymer dielectrics with ultra-high charge–discharge rates are significant for advanced electrical and electronic systems. Despite the fact that polymers possess high breakdown strength, the low dielectric constant (k) of polymers gives rise to low energy densities. Incorporating metal into polyimides (PI) at the polyamic acid (PAA) precursor stage of the synthetic process is a cheap and versatile way to improve the dielectric constant of the hybrid system while maintaining a high breakdown strength. Here, we explore inclusion of different percentages of Sn as a coordinated complex in a polyimide matrix to achieve metal homogeneity within the dielectric film to boost dielectric constant. Sn–O bonds with high atomic polarizability are intended to enhance the ionic polarization without sacrificing bandgap, a measurable property of the material to assess intrinsic breakdown strength. Enhancements of k from ca. 3.7 to 5.7 were achieved in going from the pure PI film to films containing 10 mol% tin.

Polyimide with high dielectric constant and breakdown strength is synthesized via tin complexation of the polyamide acid precursor. Sn–O bonds with high atomic polarizability are intended to enhance the ionic polarization without sacrificing bandgap.     

Clinical practice guidelines in multisystem inflammatory syndrome(MIS-C) related to COVlD-19:a critical review and recommendations

Background Multisystem inflammatory syndrome in children (MIS-C) is a serious health condition that develops from and is linked to coronavirus disease 2019.MIS-...     

Sir Victor Horsley (1857-1916): lessons for the modern clinician

Sir Victor Horsley is well known for his pioneering work as a neurological surgeon but his vital contributions to the regulation and advancement of the medical profession are less well understood. This archived literature review of The Horsley collection of papers (UCL Special Collections Library) documents Sir Victor's campaign for the autonomy of the stagnating medical profession of over a century ago. These lessons should empower modern clinicians to retain the professionalism they worry about losing.