Investigation of the posterior parietal cortex to ventral premotor connection in writer's cramp using transcranial magnetic stimulation.

The posterior parietal, premotor and motor cortices are brain regions relevant in the planning of movement. Previous transcranial magnetic stimulation (TMS) studies have shown ipsilateral premotor-to-motor inhibition in healthy subjects at rest. This premotor-to-motor inhibition has been found to be altered in patients with writer's cramp (WC), a common type of focal hand dystonia. We aimed to investigate the influence of the posterior parietal cortex on the ipsilateral ventral premotor cortex using a three single-pulse TMS paradigm. Nineteen right-handed subjects (eleven healthy volunteers and eight WC patients) completed the study. A three single-pulse TMS paradigm (preconditioning, conditioning, and test stimuli) was used to sequentially stimulate the left posterior parietal, ventral premotor, and primary motor cortices. We found that in both healthy subjects and patients, stimulating the ipsilateral posterior parietal cortex resulted in reversal of the resting premotor-to-motor inhibition. Resting premotor-to-motor inhibition was also found, with no statistically significant group difference. Furthermore, a facilitatory effect of the posterior parietal cortex on the primary motor cortex was found in both groups. Our results suggest that in the resting state, the inhibitory effect of the left posterior parietal cortex on the ipsilateral ventral premotor cortex found in healthy subjects is also intact in WC patients. While we are unable to identify any parietal-to-premotor connectivity abnormality in the resting state, an abnormality during a specific task cannot be excluded. Previously reported conductivity abnormalities in resting fMRI do not appear to translate into a TMS physiological abnormality.

Patient reported outcomes of emergency general surgery procedures.

BACKGROUND: Emergency general surgery (EGS) involves care of a patient's often previously unknown disease in the setting of an unplanned interaction with the healthcare system. This leads to challenges collecting and interpreting patient reported outcome measures (PROMs). METHODS: We performed a qualitative and mixed methods study using semi-structured interviews during the index hospitalization and at 6-12 months to capture peri-operative patient experiences. We compared interview findings to clinical characteristics. RESULTS: Among 30 patients, two-thirds reported feeling no choice but to pursue emergency surgery with many reporting exclusion from decision-making. Females reported these themes more commonly. Patients with minor complications less frequently reported trust in their team and discussed communication issues and delays in care (all p â€‹< â€‹0.05). Patients with major complications more frequently reported confidence in their team and gratefulness, but also communication limitations (all p â€‹< â€‹0.05). Patients not admitted to the ICU more frequently discussed good communication and expeditious treatment. CONCLUSIONS: PROMs developed for EGS patients should consider patient outcomes and reflections that they felt excluded from decision-making. Severity of complications may also differentially impact PROMs.

A personalized approach empowering successful aging: Patient perspective on fall prevention education.

BACKGROUND: Falls are the leading cause of fatal injury, and the most common cause of nonfatal trauma, among older adults. However, patient perspectives on preferences for obtaining fall education are not well reported. OBJECTIVE: To identify components of successful fall prevention education. DESIGN: Prospective qualitative study. SETTING: Tertiary care center; institutional. PARTICIPANTS: Adults aged 65 years or older with a history of falls who received services from inpatient trauma or outpatient geriatric services. INTERVENTIONS: One-hour face-to-face semistructured interview. MAIN OUTCOME MEASURE: Semistructured interviews sought to determine participants' history of fall education and perceived strengths and weaknesses of various formats of fall education. RESULTS: Nearly all participants (9/10) indicated they had not received fall prevention education of any kind. Many participants (6/10) reported that, despite not receiving any formal education about falls, they had either given or received information about falls from other older adults in their communities. Participants indicated that framing fall education as a part of healthy aging would be more desirable and mentioned involving participants' families as part of the education. The majority of participants (7/10) suggested fall education be delivered through in-person discussion with providers, and most (9/10) indicated this would provide a personalized approach with opportunity for questions. Participants specified fall education should consist of both environmental modifications (5/10) and awareness of one's surroundings (4/10). CONCLUSIONS: Despite histories of falls, nearly all participants reported they had not received formal fall education. However, many indicated they received fall information informally through their communities. Participants agreed successful fall prevention education would be delivered in an empowering way by a trusted member of the care team.

Evidence for increased intraabdominal pressure as a cause of recurrent migration of the distal catheter of a ventriculoperitoneal shunt: illustrative case.

BACKGROUND: Placement of a ventriculoperitoneal (VP) shunt is an effective treatment for several disorders of cerebrospinal fluid flow. A rare complication involves postoperative migration of the distal catheter out of the intraperitoneal compartment and into the subcutaneous space. Several theories attempt to explain this phenomenon, but the mechanism remains unclear. OBSERVATIONS: The authors report the case of a 37-year-old nonobese woman who underwent placement of a VP shunt for idiopathic intracranial hypertension. Postoperatively, the distal catheter of the VP shunt migrated into the subcutaneous space on three occasions despite the use of multiple surgical techniques, including open and laparoscopic methods of abdominal catheter placement. Notably, the patient repeatedly displayed radiographic evidence of chronic bowel distention consistent with increased intraperitoneal pressure. LESSONS: In this case, the mechanism of catheter migration into the subcutaneous space did not appear to be caused by pulling of the catheter from above but rather by expulsion of the catheter from the peritoneum. Space in the subcutaneous tissues caused by open surgical placement of the catheter was permissive for this process. Patients with chronic increased intraabdominal pressure, such as that caused by bowel distention, obesity, or Valsalva maneuvers, may be at increased risk for distal catheter migration.

Idiopathic Normal Pressure Hydrocephalus With Stuttering: Report of Two Cases and Review of the Literature.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a disorder of aging that is characterized by enlarged cerebral ventricles, gait apraxia, dementia, and urinary incontinence. iNPH is frequently misdiagnosed, in part because the symptoms resemble other neurological disorders, and because other associated symptoms have not been fully characterized. Importantly, iNPH has not previously been associated with stuttering, and shunting has not been shown to alleviate the symptom of stuttering. CASE DESCRIPTIONS: Here, we report 2 cases of patients with iNPH presenting with stuttering that resolved after ventriculoperitoneal (VP) shunt placement. Each patient presented with gait difficulty, incontinence, cognitive impairment, and stuttering. Lasting improvements of the symptoms (including stuttering) were seen in both patients after cerebrospinal fluid (CSF) drainage procedures that included lumbar puncture, extended lumbar CSF drainage, placement of a VP shunt, and VP shunt revision. CONCLUSIONS: These findings suggest that iNPH can present with stuttering or dysarthria. The significant improvement in stuttering and dysarthria, along with the improvements in gait difficulty, incontinence, and cognitive impairment that occurred after CSF drainage, suggests that the motor apraxia observed in iNPH can affect speech production. Practitioners should be aware that iNPH can present with stuttering, and that CSF drainage can improve stuttering in select circumstances.

The Rose-Colored Glasses of Geriatric Fall Patients: Inconsistencies Between Knowledge of Risk Factors for and Actual Causes of Falls.

BACKGROUND: Falls are the leading cause of fatal injury, and most common cause of non-fatal trauma, among older adults. We sought to elicit older patient's perspectives on fall risks for the general population as well as contributions to any personal falls to identify opportunities to improve fall education. METHODS: Ten patients with a history of falls from inpatient trauma and outpatient geriatric services were interviewed. Transcripts were analyzed independently by five individuals using triangulation and constant comparison (NVivo11, QSR International) to compare fall risks to fall causes. RESULTS: All patients reported that either they (9/10 participants) or someone they knew (8/10) had fallen. Despite this, only two personally worried about falling. Patient perceptions of fall risks fell into seven major themes: physiologic decline (8/10); underestimating limitations (7/10); environmental hazards (7/10), lack of awareness/rushing (4/10), misuse/lack of walking aids (3/10); positional transitions (2/10), and improper footwear (1/10). In contrast, the most commonly reported causes of personal falls were lack of awareness/rushing (7/10), environmental hazards (3/10), misuse/lack of walking aids (2/10), improper footwear (2/10), physiologic decline (2/10), underestimating limitations (1/10) and positional transitions (1/10). In general tended to attribute their own falls to their surroundings and were less likely to attribute physical or psychological limitations. CONCLUSION: Despite participants identifying falls as a serious problem, they were unlikely to worry about falling themselves. Participants were able to identify common fall risks. However, when speaking about personal experience, they were more likely to blame environmental hazards or rushing, and minimized the role of physiologic decline and personal limitations.

Botulinum toxin and occupational therapy for Writer's cramp.

BACKGROUND: Writer's cramp (WC) is a form of focal hand dystonia, for which focal botulinum neurotoxin (BoNT) injections are the current best therapy. Past studies have shown that some types of rehabilitative therapy can be useful. We hypothesized that BoNT together with a specific type of occupational therapy would be better than BoNT alone for treating WC patients comparing the effects with a patient-rated subjective scale. METHODS: Twelve WC patients were randomized to two groups. Six received only BoNT therapy and 6 received BoNT & occupational therapy. The occupational therapy involved specific exercises of finger movements in the direction opposite to the dystonic movements during writing. BoNT was injected by movement disorders neurologists in the affected muscles under electromyography-guidance. The primary outcome was the patient-rated subjective scale at 20 weeks. Secondary exploratory outcomes included the writer's cramp rating scale (WCRS), writer's cramp impairment scale (WCIS), the writer's cramp disability scale (WCDS), handgrip strength and kinetic parameters. RESULTS: The patient-rated subjective scale scores at 20 weeks were not significantly different between the two groups. Significant objective improvement was noted in the BoNT & occupational therapy group, as noted by the decrease (28%) in WCIS scores. CONCLUSIONS: Improvement of the primary outcome measure, the patient-rated subjective scale, was not achieved. However, significant improvement was found in the BoNT & occupational therapy group in a secondary measure of impairment. Our hypothesis-driven study results are likely limited by small sample size, and further large-scale studies of occupational therapy methods to improve the efficacy of BoNT seems worthwhile.