Search

Stroke remains a leading cause of disability, with survivors experiencing long-term decrements in independence and quality of life. Occupational therapists (OTs) employ numerous neurorehabilitative treatment approaches to remediate impairments that are impeding performance. OTs also use physical agent modalities to facilitate increased participation and success in therapy. One such modality is transcranial direct current stimulation (tDCS), a form a noninvasive brain stimulation that can be overlaid onto task practice and delivers a constant, low intensity current into the brain. tDCS is safe, portable, and efficacious in remediating a variety of deficits, yet is not consistently incorporated into clinical practice. The authors discuss the mechanisms, safety, evidence, and potential applications of tDCS to enhance outcomes for this growing population.

Background The National Institutes of Health Stroke Scale (NIHSS) is purported to be associated with long-term outcomes. This study determined the concurrent validity of the NIHSS with the Stroke Impact Scale (SIS), a previously validated measure of health status in chronic stroke survivors. Methods The NIHSS and the SIS were administered to 147 subjects before participation in a multicenter, randomized, controlled trial. A Spearman's rho was used to determine correlations between NIHSS total score and (1) SIS physical dimension scores, (2) SIS overall perception of recovery scores, and (3) the SIS activities and independent activities of daily living (ADL/IADL) scores. SIS score variation and medians between subjects who scored a zero versus a nonzero on the NIHSS was also assessed. Results There was no association between total NIHSS scores and SIS physical dimension scores, SIS overall perception of recovery scores, and SIS ADL/IADL scores ( P = −.036, P = .782; P = −.039, P = .640; P = −.054, P = .520; respectively). Lastly, significant variation and similar median scores on the SIS were found between those scoring a zero on the NIHSS versus those who did not score a zero. Conclusions The NIHSS has no association with health status in chronic stroke and lacks association with measures of impairment and functional limitation. From these findings, we conclude that the NIHSS has poor validity to discern long-term poststroke outcomes and is not associated with health status. Because of possible limitation in the NIHSS's ability to accurately determine outcomes in this population, we recommend restriction of its use to the acute stage of recovery.

OBJECTIVE. To determine the impact of transcranial direct current stimulation (tDCS) combined with repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with moderate impairment. METHOD. The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session. RESULTS. Immediately after intervention, the participant demonstrated marked score increases on the UE section of the Fugl–Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of Movement subscales). CONCLUSION. These data support the use of tDCS combined with RTP to decrease impairment and increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity of efficacious treatment approaches in this impairment level.

The vast majority of stroke survivors exhibit residual impairments,1,2 with most reporting-associated quality of life decrements.3,4 The prevalence of these poststroke motor deficits and the overall burden of stroke are likely to rise exponentially attributable to an aging population and increases in the prevalence of many risk factors (eg, obesity, diabetes mellitus, smoking).5,6 In light of these trends, several promising motor interventions have been introduced, with many targeting upper extremity (UE) hemiparesis, given its widely appreciated impact. Yet, although several of these approaches appear efficacious, few therapeutic approaches showing promise in animal or early human trials are fully translated to regular clinical practice.7 Consistently, many contemporary motor rehabilitation strategies require high duration contact time8 and costly equipment,9 preventing their widespread clinical application, except among specialized rehabilitation and academic medical centers. Mental practice involves repetitive cognitive rehearsal of physical movements in the absence of physical, voluntary attempts. From a practical perspective, mental practice constitutes an attractive alternative to other rehabilitative approaches because it does not require physical rehearsal, can be performed without direct supervision, and requires minimal expense and equipment, facilitating ease of use. The brain’s ability to respond to repetitive, learning-based strategies even years after injury and well into adulthood also makes mental practice a favorable match for stroke, which tends to be a disease of the aged and because survivors frequently exhibit residual impairments for years postictus. We speculated that repetitive mental practice use, shown to trigger the same neural areas and musculature as physical practice of the same tasks,10–14 would cause substantive neural and motor changes in stroke survivors with UE deficits. Although used for decades in sport and exercise settings, this laboratory was the first to apply mental practice to increase learning …

Objectives. (a) To determine associations among motor evoked potential (MEP) amplitude, MEP latency, lower extremity (LE) impairment, and gait velocity and (b) determine the association between the presence of a detectable MEP signal with LE impairment and with gait velocity.Method. 35 subjects with chronic, stable LE hemiparesis were undergone TMS, the LE section of the Fugl-Meyer Impairment Scale (LE FM), and 10-meter walk test. We recorded presence, amplitude, and latency of MEPs in the affected tibialis anterior (TA) and soleus (SO).Results. MEP presence was associated with higher LEFM scores in both the TA and SO. MEP latency was larger in subjects with lower LEFM and difficulty walking.Conclusion. MEP latency appears to be an indicator of LE impairment and gait.Significance. Our results support the precept of using TMS, particularly MEP latency, as an adjunctive LE outcome measurement and prognostic technique.

Objective To determine the immediate effect of a portable, myoelectric elbow-wrist-hand orthosis on paretic upper extremity (UE) impairment in chronic, stable, moderately impaired stroke survivors. Design Observational cohort study. Setting Outpatient rehabilitation clinic. Participants Participants exhibiting chronic, moderate, stable, poststroke, UE hemiparesis (N=18). Interventions Subjects were administered a battery of measures testing UE impairment and function. They then donned a fabricated myoelectric elbow-wrist-hand orthosis and were again tested on the same battery of measures while wearing the device. Main Outcome Measures The primary outcome measure was the UE Section of the Fugl-Meyer Scale. Subjects were also administered a battery of functional tasks and the Box and Block (BB) test. Results Subjects exhibited significantly reduced UE impairment while wearing the myoelectric elbow-wrist-hand orthosis (FM: t 17 =8.56, P z =2.251, P =.024; feeding [elbow]: z =2.966, P =.003; drinking [grasp]: z =3.187, P =.001). Additionally, subjects showed significant decreases in time taken to grasp a cup ( z =1.286, P =.016) and increased gross manual dexterity while wearing a myoelectric elbow-wrist-hand orthosis (BB test: z =3.42, P Conclusions Results suggest that UE impairment, as measured by the Fugl-Meyer Scale, is significantly reduced when donning a myoelectric elbow-wrist-hand orthosis, and these changes exceeded the Fugl-Meyer Scale's clinically important difference threshold. Further, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Future work will integrate education sessions to increase subjects' ability to perform multijoint functional movements and attain consistent functional changes.

Enterovirus (EV) 68 was originally isolated in California in 1962 from four children with respiratory illness. Since that time, reports of EV68 isolation have been very uncommon. Between 1989 and 2003, 12 additional EV68 clinical isolates were identified and characterized, all of which were obtained from respiratory specimens of patients with respiratory tract illnesses. No EV68 isolates from enteric specimens have been identified from these same laboratories. These recent isolates, as well as the original California strains and human rhinovirus (HRV) 87 (recently shown to be an isolate of EV68 and distinct from the other human rhinoviruses), were compared by partial nucleotide sequencing in three genomic regions (partial sequencing of the 5'-non-translated region and 3D polymerase gene, and complete sequencing of the VP1 capsid gene). The EV68 isolates, including HRV87, were monophyletic in all three regions of the genome. EV68 isolates and HRV87 grew poorly at 37 degrees C relative to growth at 33 degrees C and their titres were reduced by incubation at pH 3.0, whereas the control enterovirus, echovirus 11, grew equally well at 33 and 37 degrees C and its titre was not affected by treatment at pH 3.0. Acid lability and a lower optimum growth temperature are characteristic features of the human rhinoviruses. It is concluded that EV68 is primarily an agent of respiratory disease and that it shares important biological and molecular properties with both the enteroviruses and the rhinoviruses.

While enteroviruses have been the most commonly identified cause of aseptic meningitis in the United States, the role of the emerging, neurotropic West Nile virus (WNV) is not clear. In summer 2001, an aseptic meningitis epidemic occurring in an area of a WNV epizootic in Baltimore, Maryland, was investigated to determine the relative contributions of WNV and enteroviruses. A total of 113 aseptic meningitis cases with onsets from June 1 to September 30, 2001, were identified at six hospitals. WNV immunoglobulin M tests were negative for 69 patients with available specimens; however, 43 (61%) of 70 patients tested enterovirus-positive by viral culture or polymerase chain reaction. Most (76%) of the serotyped enteroviruses were echoviruses 13 and 18. Enteroviruses, including previously rarely detected echoviruses, likely caused most aseptic meningitis cases in this epidemic. No WNV meningitis cases were identified. Even in areas of WNV epizootics, enteroviruses continue to be important causative agents of aseptic meningitis.

Objectives. We evaluated the implementation of three commericially available neuraminidase inhibition assays in a public health laboratory (PHL) setting. We also described the drug susceptibility patterns of human influenza A and B circulating in Maryland during the 2011–2012 influenza season. Methods. From January to May 2012, 169 influenza virus isolates were tested for phenotypic susceptibility to oseltamivir, zanamivir, and peramivir using NA-Fluor™, NA-Star®, and NA-XTD™ concurrently. A 50% neuraminidase inhibitory concentration (IC50) value was calculated to determine drug susceptibility. We used the standard deviation based on the median absolute deviation of the median analysis to determine the potential for reduced drug susceptibility. We evaluated each assay for the use of resources in high- and low-volume testing scenarios. Results. One of the 25 2009 influenza A (H1N1) pandemic isolates tested was resistant to oseltamivir and peramivir, and sensitive to zanamivir, on all three platforms. Eighty-two influenza A (H3N2) and 62 B isolates were sensitive to all three drugs in all three assays. For a low-volume scenario, NA-Star and NA-XTD took 120 minutes to complete, while NA-Fluor required 300 minutes to complete. The lowest relative cost favored NA-Star. In a high-volume scenario, NA-Fluor had the highest throughput. Reagent use was most efficient when maximizing throughput. Cost efficiency from low- to high-volume testing improved the most for NA-Star. Conclusions. Our evaluation showed that both chemiluminescent and fluorescent neuraminidase inhibition assays can be successfully implemented in a PHL setting to screen circulating influenza strains for neuraminidase inhibitor resistance. For improved PHL influenza surveillance, it may be essential to develop guidelines for phenotypic drug-resistance testing that take into consideration a PHL's workload and available resources.

Member of the Autism Genome Project Consortium: Astrid M. Vicente Although autism is a highly heritable neurodevelopmental disorder, attempts to identify specific susceptibility genes have thus far met with limited success. Genome-wide association studies using half a million or more markers, particularly those with very large sample sizes achieved through meta-analysis, have shown great success in mapping genes for other complex genetic traits. Consequently, we initiated a linkage and association mapping study using half a million genome-wide single nucleotide polymorphisms (SNPs) in a common set of 1,031 multiplex autism families (1,553 affected offspring). We identified regions of suggestive and significant linkage on chromosomes 6q27 and 20p13, respectively. Initial analysis did not yield genome-wide significant associations; however, genotyping of top hits in additional families revealed an SNP on chromosome 5p15 (between SEMA5A and TAS2R1) that was significantly associated with autism (P = 2 x 10(-7)). We also demonstrated that expression of SEMA5A is reduced in brains from autistic patients, further implicating SEMA5A as an autism susceptibility gene. The linkage regions reported here provide targets for rare variation screening whereas the discovery of a single novel association demonstrates the action of common variants.

A street nurse position in the rural and small-town interior of British Columbia has been addressing the needs of street-involved or otherwise marginalized client populations by bringing healthcare services to wherever those clients are, rather than waiting for the clients to seek care. The primary reason for a street outreach approach is that marginalized populations face a variety of barriers to accessing traditional healthcare services--barriers such as homelessness, mental health problems, criminal involvement, lack of transportation, lack of ability to pay for prescriptions, lack of specialized or knowledgeable providers and provider discrimination. In the rural street nurse program, the target population includes the usual street nurse populations of illegal drug users and sex trade workers, which are more hidden in small communities than in larger urban centres, creating the community denial that is a barrier to healthcare access. Yet another barrier is the co-locaton of services common in small communities, where public health clinics might share a building with police services, making marginalized clients reluctant to attend clinics. The rural street nurse collaborates with public health nurses and other care providers (mental health workers, social workers, etc) with collegial advice and support, making and receiving referrals, and generally assisting one another--the street nurse through his rapport with the marginalized individuals and the others with their specialized knowledge. Rural street services are delivered whereverthe clientsfeel comfortable: a school, a drop-in centre, a mall, a youth centre or simplythe street. Services provided include sexually transmitted infection testing, chlamydia treatments, pregnancy testing emergency contraception pills and assistance with filling out forms for financial support. Accordingly, the street nurse's truck is equipped as a mobile treatment centre and office, with a cellphone and a stock of testing and treatment supplies.

This study examines relationships between an intensive care unit and the general practitioners within a local health authority in respect of bereavement care. A questionnaire to all 113 local general practitioners generated a response from 67 (59.3%). While about two-fifths of respondents reported at least one of their patients dying on the intensive care unit, half said that they were often first informed by relatives. Although four-fifths of inner city general practitioners offered some form of bereavement service, it ranked lowest in terms of priority on time, and a further one-seventh provided no service at all. Half the respondents thought that hospital staff could do more to help. The implications for practice are discussed.

Marijuana was the drug of the 1960s and heroin the drug of the 1970s. Cocaine was the popular drug of the 1980s, and cocaine's popularity appears to have continued into the 1990s. Cocaine use increased dramatically between 1974 and 1985. This article reviews the trends of cocaine use, fetal and maternal pharmacodynamics of cocaine, intrauterine effects of cocaine on the fetus, and the neonatal manifestations of cocaine exposure.