Content Validity of the Modified Functional Scale for the Assessment and Rating of Ataxia (f-SARA) Instrument in Spinocerebellar Ataxia.

The functional Scale for the Assessment and Rating of Ataxia (f-SARA) assesses Gait, Stance, Sitting, and Speech. It was developed as a potentially clinically meaningful measure of spinocerebellar ataxia (SCA) progression for clinical trial use. Here, we evaluated content validity of the f-SARA. Qualitative interviews were conducted among individuals with SCA1 (n = 1) and SCA3 (n = 6) and healthcare professionals (HCPs) with SCA expertise (USA, n = 5; Europe, n = 3). Interviews evaluated symptoms and signs of SCA and relevance of f-SARA concepts for SCA. HCP cognitive debriefing was conducted. Interviews were recorded, transcribed, coded, and analyzed by ATLAS.TI software. Individuals with SCA1 and 3 reported 85 symptoms, signs, and impacts of SCA. All indicated difficulties with walking, stance, balance, speech, fatigue, emotions, and work. All individuals with SCA1 and 3 considered Gait, Stance, and Speech relevant f-SARA concepts; 3 considered Sitting relevant (42.9%). All HCPs considered Gait and Speech relevant; 5 (62.5%) indicated Stance was relevant. Sitting was considered a late-stage disease indicator. Most HCPs suggested inclusion of appendicular items would enhance clinical relevance. Cognitive debriefing supported clarity and comprehension of f-SARA. Maintaining current abilities on f-SARA items for 1 year was considered meaningful for most individuals with SCA1 and 3. All HCPs considered meaningful changes as stability in f-SARA score over 1-2 years, 1-2-point change in total f-SARA score, and deviation from natural history. These results support content validity of f-SARA for assessing SCA disease progression in clinical trials.

Artificial intelligence-enabled detection and assessment of Parkinson's disease using nocturnal breathing signals.

There are currently no effective biomarkers for diagnosing Parkinson's disease (PD) or tracking its progression. Here, we developed an artificial intelligence (AI) model to detect PD and track its progression from nocturnal breathing signals. The model was evaluated on a large dataset comprising 7,671 individuals, using data from several hospitals in the United States, as well as multiple public datasets. The AI model can detect PD with an area-under-the-curve of 0.90 and 0.85 on held-out and external test sets, respectively. The AI model can also estimate PD severity and progression in accordance with the Movement Disorder Society Unified Parkinson's Disease Rating Scale (R = 0.94, P = 3.6 × 10-25). The AI model uses an attention layer that allows for interpreting its predictions with respect to sleep and electroencephalogram. Moreover, the model can assess PD in the home setting in a touchless manner, by extracting breathing from radio waves that bounce off a person's body during sleep. Our study demonstrates the feasibility of objective, noninvasive, at-home assessment of PD, and also provides initial evidence that this AI model may be useful for risk assessment before clinical diagnosis.

Coding and Reimbursement for Vestibular Tests by the U.S. Centers for Medicare and Medicaid Services (CMS).

Coding and insurance reimbursement is a part of the healthcare system in the United States but is subject to periodic modifications. In addition to changes in the evaluation and management (E/M) codes that took effect in 2021, there are some differences in coding for some diagnostic vestibular function test procedures. Two new codes for vestibular myogenic evoked potential testing were added and previous codes for auditory evoked potential codes 92585 and 92586, which some facilities had used to bill for vestibular myogenic evoked potential testing, have been eliminated. This article outlines the current state of coding and reimbursement by CMS for vestibular procedures.

Pulmonary function decline in amyotrophic lateral sclerosis.

Background: There has been no comprehensive longitudinal study of pulmonary functions (PFTS) in ALS determining which measure is most sensitive to declines in respiratory muscle strength. Objective: To determine the longitudinal decline of PFTS in ALS and which measure supports Medicare criteria for NIV initiation first. Methods: Serial PFTs (maximum voluntary ventilation (MVV), maximum inspiratory pressure measured by mouth (MIP) or nasal sniff pressure (SNIP), maximum expiratory pressure (MEP), and Forced Vital Capacity (FVC)) were performed over 12 months on 73 ALS subjects to determine which measure showed the sentinel decline in pulmonary function. The rate of decline for each measure was determined as the median slope of the decrease over time. Medicare-based NIV initiation criteria were met if %FVC was ≤ 50% predicted or MIP was ≤ 60 cMH2O. Results: 65 subjects with at least 3 visits were included for analyses. All median slopes were significantly different than zero. MEP and sitting FVC demonstrated the largest rate of decline. Seventy subjects were analyzed for NIV initiation criteria, 69 met MIP criteria first; 11 FVC and MIP criteria simultaneously and none FVC criteria first. Conclusions: MEP demonstrated a steeper decline compared to other measures suggesting expiratory muscle strength declines earliest and faster and the use of airway clearance interventions should be initiated early. When Medicare criteria for NIV initiation are considered, MIP criteria are met earliest. These results suggest that pressure-based measurements are important in assessing the timing of NIV and the use of pulmonary clearance interventions.

Oil immersed lossless total analysis system for integrated RNA extraction and detection of SARS-CoV-2.

The COVID-19 pandemic exposed difficulties in scaling current quantitative PCR (qPCR)-based diagnostic methodologies for large-scale infectious disease testing. Bottlenecks include lengthy multi-step processes for nucleic acid extraction followed by qPCR readouts, which require costly instrumentation and infrastructure, as well as reagent and plastic consumable shortages stemming from supply chain constraints. Here we report an Oil Immersed Lossless Total Analysis System (OIL-TAS), which integrates RNA extraction and detection onto a single device that is simple, rapid, cost effective, and requires minimal supplies and infrastructure to perform. We validated the performance of OIL-TAS using contrived SARS-CoV-2 viral particle samples and clinical nasopharyngeal swab samples. OIL-TAS showed a 93% positive predictive agreement (n = 57) and 100% negative predictive agreement (n = 10) with clinical SARS-CoV-2 qPCR assays in testing clinical samples, highlighting its potential to be a faster, cheaper, and easier-to-deploy alternative for infectious disease testing.

Parentage-based tagging combined with genetic stock identification is a cost-effective and viable replacement for coded-wire tagging in large-scale assessments of marine Chinook salmon fisheries in British Columbia, Canada.

Wild Pacific salmon, including Chinook salmon Oncorhynchus tshawytscha, have been supplemented with hatchery propagation for over 50 years in support of increased ocean harvest, mitigation for hydroelectric development, and conservation of threatened populations. In Canada, the Wild Salmon Policy for Pacific salmon was established with the goal of maintaining and restoring healthy and diverse Pacific salmon populations, making conservation of wild salmon and their habitats the highest priority for resource management decision-making. For policy implementation, a new approach to the assessment and management of Chinook salmon and the associated hatchery production and fisheries management are needed. Implementation of genetic stock identification (GSI) and parentage-based tagging (PBT) for marine fisheries assessment may overcome problems associated with coded-wire tag-based (CWT) assessment and management of Chinook salmon fisheries, providing at a minimum information equivalent to that derived from the CWT program. GSI and PBT were used to identify Chinook salmon sampled in 2018 and 2019 marine fisheries (18,819 individuals genotyped) in British Columbia to specific conservation units (CU), populations, and broodyears. Individuals were genotyped at 391 single nucleotide polymorphisms via direct sequencing of amplicons. Very high accuracy of assignment to population and age (>99.5%) via PBT was observed for 1994 Chinook salmon of ages 2-4 years, with a 105,722-individual, 380-population baseline available for assignment. Application of a GSI-PBT system of identification to individuals in 2019 fisheries provided high-resolution estimates of stock composition, catch, and exploitation rate by CU or population, with fishery exploitation rates directly comparable to those provided by CWTs for 13 populations. GSI and PBT provide an alternate, cheaper, and more effective method in the assessment and management of Canadian-origin Chinook salmon relative to CWTs, and an opportunity for a genetics-based system to replace the current CWT system for salmon assessment.

Lack of Diversity in Simulation Technology: An Educational Limitation?

STATEMENT: Despite increased attention on diversity in medicine and healthcare, heterogeneity in simulation technology has been slow to follow suit. In a nonsystematic review of simulation technology available in 2018 with respect to skin tone, age and sex, we found limited diversity in these offerings, suggesting limitations to educators' abilities to represent the full array of patients, conditions, and scenarios encountered in medicine and training. We highlight these limitations and propose basic strategies by which educators can increase awareness of and incorporate diversity into the simulation arena.

Best practice recommendations for bladder management in spinal cord-afflicted patients in South Africa.

Recent research on the standard of care and related quality of life of the spinal cord-afflicted community in South Africa (SA) has revealed significant gaps in practice, and challenges regarding levels of care and access to services and supplies specifically related to the neurogenic bladder.

"Anywhere but here": Querying spatial stigma as a social determinant of health among youth of color accessing LGBTQ services in Chicago's Boystown.

The link between stigma and negative health outcomes is established, yet available research infrequently considers the complex intersection of place, race, and class-based stigma and how this stigma shapes opportunities and health among marginalized groups. Furthermore, scholarship on the relationship between stigma and health often fails to include the voices of the stigmatized themselves. This exclusion renders their lived-experiences hidden and their insight devalued, producing findings with limited validity to promote health equity and social change. In this article, we explore intersecting place, race, and class-based stigmas, or spatial stigma, as a social determinant of health among youth of color (YoC) accessing LGBTQ-specific services in the Chicago's White, middle-class gay enclave, Boystown. Qualitative data were collected within the context of a youth participatory action research study with 11 youth researchers (ages 18-24). Data sources included critical autoethnography, focus groups with current and former LGBTQ service patrons, and individual interviews with LGBTQ service providers. Emergent thematic patterns illuminate how the stigmatization of YoC based on place, race, and class (i.e., being from poor and low-income, racialized South and West sides communities) impacts their opportunities in the neighborhood and access to health-supporting resources. These findings may be useful for practitioners and policy makers who aim to promote health equity among marginalized young people and add to the growing body of literature on health effects of spatial stigma among marginalized communities.

Biomechanical mechanisms underlying exosuit-induced improvements in walking economy after stroke.

Stroke-induced hemiparetic gait is characteristically asymmetric and metabolically expensive. Weakness and impaired control of the paretic ankle contribute to reduced forward propulsion and ground clearance - walking subtasks critical for safe and efficient locomotion. Targeted gait interventions that improve paretic ankle function after stroke are therefore warranted. We have developed textile-based, soft wearable robots that transmit mechanical power generated by off-board or body-worn actuators to the paretic ankle using Bowden cables (soft exosuits) and have demonstrated the exosuits can overcome deficits in paretic limb forward propulsion and ground clearance, ultimately reducing the metabolic cost of hemiparetic walking. This study elucidates the biomechanical mechanisms underlying exosuit-induced reductions in metabolic power. We evaluated the relationships between exosuit-induced changes in the body center of mass (COM) power generated by each limb, individual joint power and metabolic power. Compared with walking with an exosuit unpowered, exosuit assistance produced more symmetrical COM power generation during the critical period of the step-to-step transition (22.4±6.4% more symmetric). Changes in individual limb COM power were related to changes in paretic (R2=0.83, P=0.004) and non-paretic (R2=0.73, P=0.014) ankle power. Interestingly, despite the exosuit providing direct assistance to only the paretic limb, changes in metabolic power were related to changes in non-paretic limb COM power (R2=0.80, P=0.007), not paretic limb COM power (P>0.05). These findings contribute to a fundamental understanding of how individuals post-stroke interact with an exosuit to reduce the metabolic cost of hemiparetic walking.

Detection and Assessment of the Distribution of Infectious Agents in Juvenile Fraser River Sockeye Salmon, Canada, in 2012 and 2013.

Infectious diseases may contribute to declines in Fraser River Sockeye salmon (Oncorhynchus nerka) stocks, but a clear knowledge gap exists around which infectious agents and diseases are important. This study was conducted to: (1) determine the presence and prevalence of 46 infectious agents in juvenile Fraser River Sockeye salmon, and (2) evaluate spatial patterns in prevalence and burden over initial seaward migration, contrasting patterns between 2 years of average and poor productivity. In total, 2,006 out-migrating Sockeye salmon were collected from four regions along their migration trajectory in British Columbia, in 2012 and 2013. High-throughput microfluidics quantitative PCR was employed for simultaneous quantitation of 46 different infectious agents. Twenty-six agents were detected at least once, including nine with prevalence >5%. Candidatus Brachiomonas cysticola, Myxobolus arcticus, and Pacific salmon parvovirus were the most prevalent agents. Infectious agent diversity and burden increased consistently upon smolts entry into the ocean, but they did not substantially change afterwards. Notably, both freshwater- and saltwater-transmitted agents were more prevalent in 2013 than in 2012, leading to an overall higher infection burden in the first two sampling regions. A reduction in the prevalence of two agents, erythrocytic necrosis virus and Paraneuclospora theridion, was observed between regions 2 and 3, which was speculated to be associated with mortality during the 1st month at sea. The most prevalent infectious agents were all naturally occurring. In a small number of samples (0.9%), seven agents were only detected around and after salmon farming regions, including four important pathogens: piscine orthoreovirus, Piscirickettsia salmonis, Tenacibaculum maritimum, and Moritella viscosa. As the first synoptic survey of infectious agents in juvenile Sockeye salmon in British Columbia, this study provides the necessary baseline for further research on the most prevalent infectious agents and their potential pathogenicity, which may adversely affect the productivity of valuable Sockeye salmon stocks. In addition, our findings are informative to the decision makers involved in conservation programs.

The cost of a recalcitrant intravenous drug user with serial cases of endocarditis: Need for guidelines to improve the continuum of care.

We report a case of an intravenous drug user (IVDU) patient who had 4 episodes of endocarditis within a 2-year time period in rural Georgia. The institutional cost was approximately $380,000. The lack of an established transitional care plan for IVDUs to outpatient care is a common phenomenon at institutions. Guidelines are essential to optimize the quality of care rendered to IVDUs with such infections, to assist providers in utilizing limited resources, and to limit the cost to the institutions.

Safety Evaluation of Parastar® Plus in Dogs and Assessment of Transferable Residue of Fipronil and Cyphenothrin from Dogs to Humans.

Dogs are easily infested with fleas, ticks, and other ectoparasites serving as vectors for transmitting bacterial, viral, and parasitic diseases. Therefore, the use of ectoparasiticides is inevitable and important. The present investigation was undertaken with two specific objectives: one, to evaluate the safety of fipronil and cyphenothrin in dogs after topical application of Parastar® Plus, and two, to determine the transferable residue of these insecticides from dogs to humans. Six healthy, adult dogs (medium length hair, weighing between 20.5 and 27.3 kg) received topical application of Parastar® Plus (2.68 mL; fipronil, 9.8%, and cyphenothrin, 5.2%) on the back between the shoulder blades. At predetermined intervals, dogs were given a full physical exam, and residues of fipronil and cyphenothrin were determined in dog blood and cotton glove extracts using GC/MS. Fipronil and cyphenothrin peaks eluted at 7.453 and 9.913 min, correspondingly, and the compounds were confirmed based on characteristic ions. At no time was fipronil or cyphenothrin residue detected in blood samples. In glove extracts, residues of fipronil and cyphenothrin were maximally present at 24-h posttreatment (43.84 ± 5.69 and 59.26 ± 8.97 ppm, respectively). By 48 h, the residue levels sharply declined (16.89 ± 2.82 and 17.98 ± 2.07 ppm, respectively). The insecticides' residues were detected in insignificant amounts after 1 week (5.69 ± 2.16 and 10.00 ± 1.51 ppm, respectively), and only in trace amounts after 2 weeks. At no time did any dog show side effects, except itching at the site of Parastar® Plus application. The findings suggest that Parastar® Plus was safe for dogs, and transferable residues of fipronil and cyphenothrin were minimal, posing very little or no health concern to pet owners or veterinary personnel. Of course, veterinary personnel, who handle many dogs daily, may require proper protection to avoid cumulative exposure.

The Psychosocial Assessment of Candidates for Transplantation: A Cohort Study of its Association With Survival Among Lung Transplant Recipients.

BACKGROUND: The United Network for Organ Sharing mandates a psychosocial assessment of transplant candidates before listing. A quantified measure for determining transplant candidacy is the Psychosocial Assessment of Candidates for Transplant (PACT) scale. This instrument's predictive value for survival has not been rigorously evaluated among lung transplantation recipients. METHODS: We reviewed medical records of all patients who underwent lung transplantation at Mayo Clinic, Rochester from 2000-2012. A transplant psychiatrist had assessed lung transplant candidates for psychosocial risk with the PACT scale. Recipients were divided into high- and low psychosocial risk cohorts using a PACT score cutoff of 2. The main outcome variable was posttransplant survival. Mortality was analyzed using the Kaplan-Meier estimator and Cox proportional hazard models. RESULTS: This study included 110 lung recipients: 57 (51.8%) were females, 101 (91.8%) Whites, mean age: 56.4 years. Further, 7 (6.4%) recipients received an initial PACT score <2 (poor or borderline candidates) and later achieved a higher score, allowing transplant listing; 103 (93.6%) received initial scores ≥2 (acceptable, good or great candidates). An initial PACT score < 2 was modestly associated with higher mortality (adjusted hazard ratio = 2.73, p = 0.04). CONCLUSIONS: Lung transplant recipients who initially received a low score on the PACT scale, reflecting poor or borderline psychosocial candidacy, experienced greater likelihood of mortality. This primary finding suggests that the psychosocial assessment, as measured by the PACT scale, may provide additional mortality risk stratification for lung transplant candidates.

Improving Resident Performance in Knee Arthroscopy: A Prospective Value Assessment of Simulators and Cadaveric Skills Laboratories.

BACKGROUND: Cadaveric skills laboratories and virtual reality simulators are two common methods used outside of the operating room to improve residents' performance of knee arthroscopy. We are not aware of any head-to-head comparisons of the educational values of these two methodologies. The purpose of this prospective randomized trial was to assess the efficacy of these training methods, compare their rates of improvement, and provide economic value data to programs seeking to implement such technologies. METHODS: Orthopaedic surgery residents were randomized to one of three groups: control, training on cadavera (cadaver group), and training with use of a simulator (simulator group). Residents completed pretest and posttest diagnostic knee arthroscopies on cadavera that were timed and video-recorded. Between the pretest and posttest, the control group performed no arthroscopy, the cadaver group performed four hours of practice on cadavera, and the simulator group trained for four hours on a simulator. All tests were scored in a blinded, randomized fashion using the validated Arthroscopy Surgical Skill Evaluation Tool (ASSET). The mean improvement in the ASSET score and in the time to complete the procedure were compared between the pretest and posttest and among the groups. RESULTS: Forty-five residents (fifteen per group) completed the study. The mean difference in the ASSET score from the pretest to the posttest was -0.40 (p = 0.776) in the control group, +4.27 (p = 0.002) in the cadaver group, and +1.92 (p = 0.096) in the simulator group (p = 0.015 for the comparison among the groups). The mean difference in the test-completion time (minutes:seconds) from the pretest to the posttest was 0:07 (p = 0.902) in the control group, 3:01 (p = 0.002) in the cadaver group, and 0:28 (p = 0.708) in the simulator group (p = 0.044 for the comparison among groups). Residents in the cadaver group improved their performance at a mean of 1.1 ASSET points per hour spent training whereas those in the simulator group improved 0.5 ASSET point per hour of training. CONCLUSIONS: Cadaveric skills laboratories improved residents' performance of knee arthroscopy compared with that of matched controls. Residents practicing on cadaveric specimens improved twice as fast as those utilizing a high-fidelity simulator; however, based on cost estimation specific to our institution, the simulator may be more cost-effective if it is used at least 300 hours per year. Additional study of this possibility is warranted.

Assessment of prevalence and distribution of spotted fever group rickettsiae in Manitoba, Canada, in the American dog tick, Dermacentor variabilis (Acari: Ixodidae).

Little is known about the distribution and prevalence of the spotted fever group rickettsiae in Canada. We conducted active surveillance for tick-associated rickettsiae in 10 localities in Manitoba. A total of 1044 adult American dog ticks, Dermacentor variabilis (Acari: Ixodidae), were collected and screened for spotted fever group rickettsiae. Rickettsia montanensis was the only species of rickettsia detected. The mean prevalence of infection was 9.8% (range, 0.00-21.74% among localities). The proportion of infected male and female ticks was not significantly different; however, tick populations near the northern limit of D. variabilis distribution in Manitoba had a lower prevalence of infection compared to tick populations from more southern localities in the province.

End-of-life and palliative care curricula in internal medicine clerkships: a report on the presence, value, and design of curricula as rated by clerkship directors.

PURPOSE: End-of-life and palliative care (EOL/PC) education is a necessary component of undergraduate medical education. The extent of EOL/PC education in internal medicine (IM) clerkships is unknown. The purpose of this national study was to investigate the presence of formal EOL/PC curricula within IM clerkships; the value placed by IM clerkship directors on this type of curricula; curricular design and implementation strategies; and related barriers and resources. METHOD: The Clerkship Directors in Internal Medicine conducted its annual survey of its institutional members in April 2012. The authors analyzed responses to survey items pertaining to formal EOL/PC curriculum and content using descriptive statistics. The authors used qualitative techniques to analyze free-text responses. RESULTS: The response rate was 77.0% (94/122). Of those responding, 75.8% (69/91) believed such training should occur in the IM clerkship, and 43.6% (41/94) reported formal curricula in EOL/PC. Multiple instructional modalities were used to deliver this content, with the majority of programs dedicating four or more hours to the curriculum. Curricula covered a wide range of topics, and student assessment tools were varied. Most felt that students valued this education. The qualitative analysis revealed differences in the values clerkship directors placed on teaching EOL/PC within the IM clerkship. CONCLUSIONS: Although many IM clerkship directors have implemented formal curricula in EOL/PC, a substantial gap remains between those who have implemented and those who believe it belongs in the clerkship. Time, faculty, cost, and competing demands are the main barriers to implementation.