Outcome of Hospitalized Parkinson's Disease Patients with and without COVID-19.

Background: The Parkinson's disease (PD) patient population, with an already reduced life expectancy, is rendered particularly vulnerable by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Objectives: We determined the risk factors that increase the risk of death in patients with Parkinson's disease who are infected by SARS-CoV-2. Methods: Patients with a diagnosis of PD admitted to Montefiore Hospital (Bronx, New York) and tested for SARS-CoV-2 were identified. Retrospective review of electronic medical records confirmed the diagnosis; patients were classified by severity of PD. PD severity, demographic, socioeconomic factors, and co-morbidities were correlated with mortality rates in patients with SARS-CoV-2. Results: We identified 162 patients meeting criteria; chart review confirmed a diagnosis of PD in 70 patients. Of the 70 patients, 53 were positive for SARS-CoV-2 and 17 were negative. PD patients with SARS-CoV-2 infection had a higher mortality rate (35.8%) compared to PD patients without the infection (5.9%, P = 0.028). PD patients older than 70 years of age, those with advanced Parkinson's disease, those with reductions in their medications, and non-Hispanics (largely comprised of Black/African- Americans) had a statistically significant higher mortality rate, if infected. Conclusions: PD did not increase mortality rates from SARS-CoV-2 infection when age was controlled. However, certain unalterable factors (advanced disease and age greater than 70 years) and alterable ones (reductions in PD medications) placed PD patients at increased risk for mortality. Also several socioeconomic factors contributed to mortality, for example, non-Hispanic patients with SARS-CoV-2 infection fared worse, likely driven by poorer outcomes in the Black/African-American cohort.

Diagnosis and Supportive Management of Fucosidosis: A Case Report.

Fucosidosis is a lysosomal storage disease, resulting from a deficiency of the enzyme alpha-L-fucosidase. We present the case of an affected female with numerous manifestations, clinically and radiographically. In fucosidosis, advanced interventions are not always necessary to have rewarding outcomes. In fact, early diagnosis and management of the symptoms with a multi-systemic supportive care approach can improve the quality of life and may also prolong the life of those patients diagnosed with fucosidosis.

Association between response to pentosan polysulfate sodium therapy for interstitial cystitis and patient questionnaire-based treatment satisfaction.

OBJECTIVE: To evaluate the relationship between symptom reduction and satisfaction with pentosan polysulfate sodium (PPS) therapy in subjects with interstitial cystitis (IC). METHODS: A secondary analysis was conducted in 128 subjects treated with PPS 300 mg/day (US Food and Drug Administration-approved dose) from a 32-week multicenter, randomized, double-blind study of 380 subjects with IC who were treated with PPS 300 mg/day, 600 mg/day, or 900 mg/day. Self-rated outcome measures included the O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and a treatment satisfaction questionnaire. Treatment responders were defined as subjects having > or =30% reduction in ICSI from baseline to study end point. RESULTS: A reduction in IC symptoms was associated with significantly higher satisfaction with PPS (p < 0.05). Compared with nonresponders, subjects achieving a > or = 30% reduction in ICSI were more likely to be pleased with PPS for IC symptoms, to have benefited from PPS for their IC symptoms, to recommend PPS for IC symptoms to others with the same condition, and to say that PPS provides better relief, based on prior experience with other IC treatments. Among all subjects at week 32, 75% said they would recommend PPS therapy for IC symptoms to others with the condition. CONCLUSION: Despite limitations (lack of placebo control, use of a nonvalidated instrument), this analysis demonstrated significantly increased treatment satisfaction with PPS therapy among treatment responders versus nonresponders. There was a significant positive correlation between ICSI scores and response on the treatment satisfaction questionnaire. Treatment response and patient satisfaction with treatment are important clinical considerations in the management of patients with IC.

Time to initiation of pentosan polysulfate sodium treatment after interstitial cystitis diagnosis: effect on symptom improvement.

OBJECTIVES: Interstitial cystitis (IC) is a chronic, debilitating condition that is often associated with late diagnosis and a delay in initiation of appropriate IC-specific therapy. The purpose of this study was to determine whether the length of time from initial diagnosis to start of treatment impacts subsequent symptom improvement. METHODS: A retrospective analysis was conducted in 128 patients with IC who had been treated with pentosan polysulfate sodium (PPS) 300 mg/day for 32 weeks in a multicenter, randomized, double-blind, parallel-group clinical trial. Outcome measures included the O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and the O'Leary-Sant Interstitial Cystitis Problem Index (ICPI). Early treatment was defined as treatment initiation 6 months or less after IC diagnosis, whereas late treatment was defined as treatment initiation 24 months or more after IC diagnosis. Efficacy data were analyzed by using the intent-to-treat, last-observation-carried-forward population. RESULTS: At the end of the study, mean changes from baseline in total ICSI and ICPI scores (+/- SEM) for early treatment (6 months or less) versus late treatment (24 months or more) were 3.97 +/- 0.59 versus 2.15 +/- 0.70 (P = 0.0472) and 3.94 +/- 0.56 versus 1.77 +/- 0.63 (P = 0.0117), respectively. Similar trends for both measures were observed when examining other times from IC diagnosis (3 months or less versus 24 months or more, 3 months or less versus 36 months or more, and 6 months or less versus 36 months or more). CONCLUSIONS: Initiation of PPS treatment within 6 months of establishing the diagnosis of IC may be associated with greater improvement in patient symptoms and symptom bother.

What makes a physician an exemplary communicator with patients?

OBJECTIVE: A pilot study was conducted to examine the characteristics, capacities (beliefs, values and intentions) and skills that distinguish exemplary communicators from less exemplary communicators in patient-physician encounters. METHODS: Forty physicians participated in a four-station videotaped OSCE focusing on a variety of adolescent sexual health issues and assessed using seven quantitative measures. Results determined the top 15%, and the bottom 15%. An interviewer reviewed and discussed two of the videotaped scenarios with physicians in both groups. Interviews were analyzed to determine differences between groups. RESULTS: Results consistently identified the top 15% (6) and bottom 15% (6) physicians. The t-tests showed statistically significant differences on all skills and capacity measures. "Notable" differences (25% or higher) were found on two quantitative instruments assessing skills. There were no notable differences in capacities. The qualitative inquiry confirmed notable differences in skills and identified capacities of empathy, non-judgement and self-reflection as restricted to the exemplary group. CONCLUSION: Using quantitative and qualitative measures, it is possible to determine skills and capacities that distinguish exemplary communicators from less exemplary communicators. PRACTICE IMPLICATIONS: In addition to effective skills, physician empathy, non-judgement and self-reflection appear to be necessary components for exemplary physician communication with adolescents.

Chorea-acanthocytosis: a mimicker of Huntington disease case report and review of the literature.

BACKGROUND: Neuroacanthocytosis consists of a group of rare heterogeneous neurodegenerative disorders associated with acanthocytosis. Chorea-acanthocytosis, a variety of neuroacanthocytosis, is an autosomal recessive condition with clinical and radiologic features similar to Huntington disease. Although difficult, distinguishing between these entities is crucial as the implications for genetic counseling are significant. REVIEW SUMMARY: We report the case of a 33-year-old female who presented to our institution with a 3-year history of chorea. The patient's prominent orofacial symptoms and the presence of acanthocytes on peripheral blood smear led to the correct diagnosis of chorea-acanthocytosis. CONCLUSIONS: The significant similarities between chorea-acanthocytosis and Huntington disease at the clinical and radiologic levels can lead to an initial misdiagnosis. Clinical clues suggestive of chorea-acanthocytosis include prominent orofacial dyskinesias, often causing dysarthria and dysphagia. Acanthocytosis, when present on peripheral blood smear, can confirm the diagnosis.

Relationship of resident characteristics, attitudes, prior training and clinical knowledge to communication skills performance.

PURPOSE: A substantial body of literature demonstrates that communication skills in medicine can be taught and retained through teaching and practice. Considerable evidence also reveals that characteristics such as gender, age, language and attitudes affect communication skills performance. Our study examined the characteristics, attitudes and prior communication skills training of residents to determine the relationship of each to patient-doctor communication. The relationship between communication skills proficiency and clinical knowledge application (biomedical and ethical) was also examined through the use of doctor-developed clinical content checklists, as very little research has been conducted in this area. METHODS: A total of 78 first- and second-year residents across all departments at Dalhousie Medical School participated in a videotaped 4-station objective structured clinical examination presenting a range of communication and clinical knowledge challenges. A variety of instruments were used to gather information and assess performance. Two expert raters evaluated the videotapes. RESULTS: Significant relationships were observed between resident characteristics, prior communication skills training, clinical knowledge and communication skills performance. Females, younger residents and residents with English as first language scored significantly higher, as did residents with prior communication skills training. A significant positive relationship was found between the clinical content checklist and communication performance. Gender was the only characteristic related significantly to attitudes. CONCLUSIONS: Gender, age, language and prior communication skills training are related to communication skills performance and have implications for resident education. The positive relationship between communication skills proficiency and clinical knowledge application is important and should be explored further.

Anticipating smallpox and monkeypox outbreaks: complications of the smallpox vaccine.

BACKGROUND: The recent outbreak in the Midwest of monkeypox, as well as the continued fears of a terrorist-induced epidemic of smallpox, prompted the authors' review of the literature regarding past and current experiences with smallpox vaccination. The smallpox vaccine, which is highly effective in preventing the spread of both these orthopoxvirus infectious illnesses, might be administered to numerous health care workers and, in the event of a smallpox attack, millions of other citizens. However, vaccinees would be at risk for several vaccine-related neurologic complications. REVIEW SUMMARY: According to prior reports, neurologic complications have occurred in 2.5 per million US individuals, with the most common being postvaccinal encephalomyelitis (PVEM). In older children and adults, PVEM causes stupor and coma, seizures, paraparesis, and other neurologic and mental abnormalities, and, in 16% of cases, permanent neurologic sequelae. The overall mortality rate of neurologic complications is approximately 1.5 per million vaccinees. Risk factors for PVEM were age younger than 1 year and no previous smallpox vaccination, but not a prior episode of PVEM or other preexisting neurologic illnesses. Neither the current smallpox vaccination campaigns in Israel nor the one in the United States has had comparable complications, but the US campaign has been associated with myocarditis and myopericarditis. CONCLUSION: Although the potential neurologic complications of the smallpox vaccine must be weighed against the threat of monkeypox and smallpox, current experience with vaccination suggests it carries a very low risk of neurologic complications and does not lead to exacerbations of chronic neurologic illnesses.

Effect of pentosan polysulfate therapy on intravesical potassium sensitivity.

OBJECTIVES: To evaluate further the intravesical potassium sensitivity test (PST) as an indicator of the epithelial leak of interstitial cystitis (IC) and determine whether successful pentosan polysulfate (PPS; Elmiron) treatment is associated with a change in PST results. Most individuals with IC appear to have an abnormally permeable epithelium that allows urinary solutes such as potassium to penetrate to the bladder interstitium, provoking symptoms. METHODS: Data were from an optimal dose trial of PPS in IC. Patients underwent a PST before and after a 32-week trial of 300, 600, or 900 mg PPS/day. The response to PPS treatment was measured using the Patient Overall Rating of Improvement in Symptoms scale. The before and after treatment PSTs and Patient Overall Rating of Improvement of Symptoms scores were compared. RESULTS: Of 377 patients with IC at 28 centers, 302 (80%) had a positive PST at entry. Of the 198 patients who completed the study, 153 were PST positive at entry and 92 (60%) showed clinical improvement at exit. Clinically improved patients had significant improvement on the PST analog pain and urgency scales (3.2 to 1.3 and 3.6 to 1.9, respectively; P <0.0001). In contrast, patients with no clinical improvement had no significant change in pain (3.1 to 2.7) or urgency (3.6 to 3.2). CONCLUSIONS: PST shows abnormal epithelial permeability in most patients with IC and a significant reduction in this permeability after successful PPS therapy. PST appears to be a valid indicator of epithelial abnormality and a reliable test in the diagnosis of IC.

Implementing a communication skills programme in medical school: needs assessment and programme change.

INTRODUCTION: Communication skills training (CST) in medicine, once considered a minor subject, is now ranked a core clinical skill. To assess the state of formal and informal CST at Dalhousie Medical School a needs assessment was undertaken in 1997 with the goal of using these findings to plan and implement a new communication skills curriculum. OBJECTIVES: This article briefly describes the relevant findings of the needs assessment, the subsequent development of an integrated cross curriculum CST programme, and early programme evaluation results. METHOD: Surveys were completed by undergraduates at the end of pre-clinical (n=65), and clinical phases (n=82), residents (n=54), and faculty (n=117). Results revealed learners' and faculty's appreciation of the importance of CST, learners' assessment of training weaknesses in the delivery of CST, learners' weakness in higher order patient--doctor communication skills, and faculty weakness in assessing learners' communication skills competency. The results also indicated that CST was generally not being addressed either formally or informally in clinical medical education. RESULTS: The paper describes and discusses the subsequent implementation (beginning in 1998) of CST into the medical school curriculum. There is a description of programme development and evaluation at the pre-clinical, clerkship and postgraduate levels, a description and discussion of faculty development, and discussion of the importance of financial and administrative support for the programme. CONCLUSION: Programme evaluation results at all levels are positive.

Achievement of Students in a Conventional and Problem-Based Learning (PBL) Curriculum.

This study compared student performance in problem-based (PBL) and conventional curricula on: 1) basic science knowledge following two preclinical years; 2) the Medical Council of Canada Qualifying Examination (MCC) Part I, written upon completion of the four year MD, and 3) Part II of the MCC Qualifying Examination, an assessment of clinical performance after 17 months of postgraduate education. Students in the conventional class of 1995 (n = 81) and the PBL classes of 1996 (n = 84) and 1997 (n = 78) participated. The 1995 conventional class scored significantly higher on the knowledge test than did the 1996 PBL class. The 1997 PBL class performed similarly to the 1995 class. The MCC Part I total examination scores of the three classes were similar. However, the PBL classes of 1996 and 1997 outperformed the class of 1995 in Psychiatry (p = 0.01); also, the PBL class of 1997 outscored the classes of 1995 and 1996 in Preventive Medicine and Community Health (p = 0.001). Two classes have completed the Part II examination. The 1995 and 1996 classes scored similarly in data-gathering, problem-solving and overall. The 1995 class scored significantly higher in communication skills (p = 0.01). We conclude that the performance of PBL and conventional classes is equivalent after medical school, and during postgraduate education, and that knowledge differences found in the first PBL class after two preclinical years have disappeared at the end of fourth year. Basic science knowledge may continue to grow throughout the clinical experience. Differences in communication skills, which favoured the conventional class, require further study.