Abnormal functional connectivity and cortical integrity influence dominant hand motor disability in multiple sclerosis: a multimodal analysis.

Functional reorganization and structural damage occur in the brains of people with multiple sclerosis (MS) throughout the disease course. However, the relationship between resting-state functional connectivity (FC) reorganization in the sensorimotor network and motor disability in MS is not well understood. This study used resting-state fMRI, T1-weighted and T2-weighted, and magnetization transfer (MT) imaging to investigate the relationship between abnormal FC in the sensorimotor network and upper limb motor disability in people with MS, as well as the impact of disease-related structural abnormalities within this network. Specifically, the differences in FC of the left hemisphere hand motor region between MS participants with preserved (n = 17) and impaired (n = 26) right hand function, compared with healthy controls (n = 20) was investigated. Differences in brain atrophy and MT ratio measured at the global and regional levels were also investigated between the three groups. Motor preserved MS participants had stronger FC in structurally intact visual information processing regions relative to motor impaired MS participants. Motor impaired MS participants showed weaker FC in the sensorimotor and somatosensory association cortices and more severe structural damage throughout the brain compared with the other groups. Logistic regression analysis showed that regional MTR predicted motor disability beyond the impact of global atrophy whereas regional grey matter volume did not. More importantly, as the first multimodal analysis combining resting-state fMRI, T1-weighted, T2-weighted and MTR images in MS, we demonstrate how a combination of structural and functional changes may contribute to motor impairment or preservation in MS. Hum Brain Mapp 37:4262-4275, 2016. © 2016 Wiley Periodicals, Inc.

Improving the Measurement of Cognitive Ability in Geriatric Patients.

BACKGROUND/AIMS: No single tool is available in geriatric clinical settings to quantitatively measure global cognitive ability at different stages ranging from normal functioning to severe impairment. We developed an adaptive test to measure cognitive ability in geriatric populations (Geriatric Rapid Adaptive Cognitive Estimate, GRACE); however, the test failed to discriminate between high-functioning individuals. This study aimed to estimate the extent to which adding more difficult items to the GRACE would improve measurement precision in the upper range of cognitive ability. METHODS: The original data used to develop the GRACE was merged with newly collected data of patients who presented at local geriatric clinics. The Rasch analysis was used to estimate the difficulty level of the newly added items and evaluate whether the psychometric properties of the GRACE were improved. RESULTS: One newly added item (Sequencing 5) had a higher difficulty level than all of the previous items in the GRACE. The rest of the new items were located in the high difficulty range. CONCLUSION: The psychometric properties of our adaptive screening tool were improved, and we were able to distinguish between individuals who had higher levels of cognitive functioning.

Abacavir/lamivudine fixed-dose combination with ritonavir-boosted darunavir: a safe and efficacious regimen for HIV therapy.

BACKGROUND: Current treatment guidelines recommend the use of tenofovir (TDF) and emtricitabine (FTC) along with a third agent to treat HIV-positive adults. However, other treatment options, including the use of abacavir (ABC) and lamivudine (3TC) when used with ritonavir-boosted darunavir (DRV/r), have rarely been studied. OBJECTIVE: We evaluated the safety and efficacy of the coformulation of ABC/3TC administered with DRV/r in treatment-naïve and treatment-experienced patients. METHODS: HIV-infected adults who received an open-label combination of ABC/3TC/ DRV/r were followed in a community clinic in Montréal. Patients had no resistance to any of the compounds in their regimen. Viral load (VL), CD4 cell count, AST, ALT, and creatinine levels were examined throughout the 48 weeks of follow-up. RESULTS: Sixty-seven patients with a mean age of 45 years were enrolled. Two did not return for follow-up and were excluded. Thirty-five (52%) were treatment- experienced and the remaining were treatment-naïve. HLA-B*5701 test results were available for 56 patients and none were positive. At baseline, mean VL was 4.8 log for treatment-naïve and 2.3 log for experienced patients. Twelve patients discontinued the study regimen prior to reaching the endpoint. At week 48, 79% had a VL <50. Median CD4 cell gain was higher among treatment-naïve patients (273 cells) than among treatment-experienced patients (102 cells) (P = .002). No patient experienced any grade 2 or higher liver enzyme elevation throughout the study. CONCLUSIONS: The new combination of ABC/3TC/DRV/r demonstrates a high rate of antiviral activity with no major toxicity. The drug combination appears to be generally safe and well tolerated.

[Learning together to work together: interprofessional education, a myth or reality?]. / Apprendre ensemble pourtravailler ensemble: l'education interprofessionnelle, un mythe ou une réalité?

This article offers a review of the literature on interprofessional education (EIP), a form of education which brings together members of two or more professions in a joint training. In this course, participants gain knowledge through other professionals and about them. The goal of EIP is to improve collaboration between health professionals and the quality of patient care. The EIP is booming worldwide and seems for from a mere fad. This expansion can be explained by several factors: the increasing importance attributed to the quality of care and patient safety, care changes (aging population and increasing chronic diseases) and the shortage of health professionals. The expectations of the EIP are large, while the evidence supporting its effectiveness is being built.

[Chronic wound management in hospital care units--a literature review]. / Pansement de plaies chroniques en milieu hospitalier une revue critique de la littérature.

Chronic wounds are a major health problem, which nurses are dealing with daily. However, weak agreement exists with the dressing technique on chronic wounds. The practices described are often imprecise and even controversial. At least four procedures are depicted for this practice in Switzerland. This search of evidence is conduct on the dressing technique on chronic wounds in hospital care units. The debate on this issue is depicted and the terms of sterile and non sterile bandage are defined. The scientific and professional literature analyzed to determine the level of proof of the existing data does not state that one of both techniques--sterile versus non sterile--is more adequate than the other, for the chronic wounds management in hospital environment. The principles formulated on the basis of this literature review are therefore based on the experts' opinion.

[A consulting partnership: a relationship to be defined]. / Entre consultance et partenariat: une relation à définir.

AIM: The goal was to explore the factors that influence adherence by internal medicine nurses (IMNs) to recommendations provided by a palliative care consult nurses (PCN) in a Swiss teaching hospital. METHOD: A qualitative phenomenological approach was applied. Following convenience sampling, IMNs were interviewed one-on-one (semi-structured questions). Two conceptual frameworks (Zay et at 1997; Sauve 2001) were used as a starting point for data coding. New categories and themes then emerged. RESULTS: Data saturation was achieved after 5 interviews. 5 categories emerged, including alterity; transparency; communication; time; and sense of ownership. Adherence requires a personal rapport and trust between the IMNs and PCNs. A focus on supporting the IMNs rather than focussing only on the patient enhances adherence. CONCLUSIONS: Our PC team needs to review its model of consultation, possibly adopting one that focuses more on supporting the primary teams. Formal and informal strategies to improve the rapport with IMN will be sought. Awareness by the PCN of the inferiority felt by the IMNs may enhance rapport building.

Spare non-occupational HIV post-exposure prophylaxis by active contacting and testing of the source person.

OBJECTIVE: HIV-1 post-exposure prophylaxis (PEP) is frequently prescribed after exposure to source persons with an undetermined HIV serostatus. To reduce unnecessary use of PEP, we implemented a policy including active contacting of source persons and the availability of free, anonymous HIV testing ('PEP policy'). METHODS: All consultations for potential non-occupational HIV exposures i.e. outside the medical environment) were prospectively recorded. The impact of the PEP policy on PEP prescription and costs was analysed and modelled. RESULTS: Among 146 putative exposures, 47 involved a source person already known to be HIV positive and 23 had no indication for PEP. The remaining 76 exposures involved a source person of unknown HIV serostatus. Of 33 (43.4%) exposures for which the source person could be contacted and tested, PEP was avoided in 24 (72.7%), initiated and discontinued in seven (21.2%), and prescribed and completed in two (6.1%). In contrast, of 43 (56.6%) exposures for which the source person could not be tested, PEP was prescribed in 35 (81.4%), P < 0.001. Upon modelling, the PEP policy allowed a 31% reduction of cost for management of exposures to source persons of unknown HIV serostatus. The policy was cost-saving for HIV prevalence of up to 70% in the source population. The availability of all the source persons for testing would have reduced cost by 64%. CONCLUSION: In the management of non-occupational HIV exposures, active contacting and free, anonymous testing of source persons proved feasible. This policy resulted in a decrease in prescription of PEP, proved to be cost-saving, and presumably helped to avoid unnecessary toxicity and psychological stress.

Clinical efficacy of early initiation of HAART in patients with asymptomatic HIV infection and CD4 cell count > 350 x 10(6) /l.

OBJECTIVE: To evaluate the efficacy of early initiation of highly active antiretroviral therapy (HAART), we compared the clinical course of two nested, matched cohorts within the Swiss HIV Cohort Study. METHODS: We selected all asymptomatic patients who started HAART between 1 January 1996 and 31 December 1999 with a CD4 cell count > 350 x 10(6)/l. We then matched them with asymptomatic participants who were seen at around the same time and who remained untreated during the following 12 months. This control group was further matched for age, sex, CD4 cell count, viral load, and HIV risk category, generating 283 pairs of treated versus untreated patients. RESULTS: During observation of median 3.19 versus 2.66 years, CDC stage B/C occurred in 6.4% versus 21.2%, AIDS in 1.8% versus 5.3%, death in 2.1% versus 6.4%, and AIDS or death of 'natural' causes in 2.8% versus 6.7% of the treated versus untreated patients. In multivariable Cox regression analysis, treatment reduced the risk of clinical progression by a factor of four- to five fold. During follow-up, the treated group had significantly higher CD4 counts and lower HIV-1 RNA levels. Intolerance/adverse events led to change or stop of at least one drug in 35% of treated patients. The entire regimen was interrupted at least once by 41% of patients, and 24% had no treatment anymore at the end of follow-up. CONCLUSIONS: The initiation of HAART in asymptomatic patients with CD4 cell count > 350 x 10(6)/l significantly delayed clinical progression. However, the risk of severe clinical events with deferred therapy was low and must be counter balanced against the burden and toxicity of HAART.