Prevalence of Somatosensory Tinnitus in Veterans With Tinnitus.

OBJECTIVES: The primary objective was to estimate the prevalence of somatosensory tinnitus (ST) among Veterans with tinnitus. DESIGN: Three hundred four Veterans with tinnitus were phone screened for ST by performing and reporting on a series of head/neck/jaw maneuvers. A random sample of 12 individuals who screened positive and five who screened negative attended an in-person visit to confirm the presence/absence of ST. RESULTS: Of the 304 Veterans, 12 could not complete the screening maneuvers, 205 screened positive, and 87 screened negative. A Bayesian estimator that combines phone screening and in-person exam results establishes the prevalence of ST among Veterans with tinnitus at 56% with a 90% Bayesian confidence interval of 45% to 65%. CONCLUSIONS: At least half of Veterans with tinnitus have ST, suggesting that a sizable at-need population exists. Treatment addressing the biomechanical component has the potential to improve tinnitus symptoms.

New acquisition of antibiotic-resistant organisms in skilled nursing facilities.

The epidemiology of new acquisition of antibiotic-resistant organisms (AROs) in community-based skilled nursing facilities (SNFs) is not well studied. To define the incidence, persistence of, and time to new colonization with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CAZ(r)) and ciprofloxacin-resistant (CIP(r)) Gram-negative bacteria (GNB) in SNFs, SNF residents were enrolled and specimens from the nares, oropharynx, groin, perianal area, and wounds were prospectively cultured monthly. Standard microbiological tests were used to identify MRSA, VRE, and CAZ(r) and CIP(r) GNB. Residents with at least 3 months of follow-up were included in the analysis. Colonized residents were categorized as having either preexisting or new acquisition. The time to colonization for new acquisition of AROs was calculated. Eighty-two residents met the eligibility criteria. New acquisition of AROs was common. For example, of the 59 residents colonized with CIP(r) GNB, 28 (47%) were colonized with CIP(r) GNB at the start of the study (96% persistent and 4% intermittent), and 31 (53%) acquired CIP(r) GNB at the facility (61% persistent). The time to new acquisition was shortest for CIP(r) GNB, at a mean of 75.5 days; the time to new acquisition for MRSA was 126.6 days (P = 0.007 versus CIP(r) GNB), that for CAZ(r) was 176.0 days (P = 0.0001 versus CIP(r) GNB), and that for VRE was 186.0 days (P = 0.0004 versus CIP(r) GNB). Functional status was significantly associated with new acquisition of AROs (odds ratio [OR], 1.24; P = 0.01). New acquisition of AROs, in particular CIP(r) GNB and MRSA, is common in SNFs. CIP(r) GNB are acquired rapidly. Additional longitudinal studies to investigate risk factors for ARO acquisition are required.

A Technology-Enabled Concussion Care Pathway Reduces Costs and Enhances Care.

BACKGROUND: The standardization of care along disease lines is recommended to improve outcomes and reduce health care costs. The multiple disciplines involved in concussion management often result in fragmented and disparate care. A fundamental gap exists in the effective utilization of rehabilitation services for individuals with concussion. PURPOSE: The purpose of this project was to (1) characterize changes in health care utilization following implementation of a concussion carepath, and (2) present an economic evaluation of patient charges following carepath implementation. DESIGN: This was a retrospective cohort study. METHODS: A review of electronic medical and financial records was conducted of individuals (N = 3937), ages 18 to 45 years, with primary diagnosis of concussion who sought care in the outpatient or emergency department settings over a 7-year period (2010-2016). Outcomes including encounter length, resource utilization, and charges were compared for each year to determine changes from pre- to post-carepath implementation. RESULTS: Concussion volumes increased by 385% from 2010 to 2015. Utilization of physical therapy increased from 9% to 20% while time to referral decreased from 72 to 23 days post-injury. Utilization of emergency medicine and imaging were significantly reduced. Efficient resource utilization led to a 20.7% decrease in median charges (estimated ratio of means [CI] 7.72 [0.53, 0.96]) associated with concussion care. LIMITATIONS: Encounter lengths served as a proxy for recovery time. CONCLUSIONS: The implementation of the concussion carepath was successful in optimizing clinical practice with respect to facilitating continuity of care, appropriate resource utilization, and effective handoffs to physical therapy. The utilization of enabling technology to facilitate the collection of common outcomes across providers was vital to the success of standardizing clinical care without compromising patient outcomes.

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion.

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) demonstrate the process of integrating technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) present data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. A multi-disciplinary team of experts in concussion care was formed to develop an evidence-informed algorithm, outlining best practices for the clinical management of concussion along three phases of recovery - acute, subacute, and post-concussive. A custom mobile application, the Cleveland Clinic Concussion (C3) app was developed and validated to provide a platform for the systematic collection of objective, biomechanical outcomes and to provide guidance in clinical decision-making in the field and clinical environments. The Cleveland Clinic Concussion app included an electronic incident report, assessment modules to measure important aspects of cognitive and motor function, and a return to play module to systematically document the six phases of post-injury rehabilitation. The assessment modules served as qualifiers within the carepath algorithm, driving referral for specialty services as indicated. Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

Improving tinnitus with mechanical treatment of the cervical spine and jaw.

BACKGROUND: Tinnitus affects approximately 30-50 million Americans. In approximately 0.5-1.0% of the population, tinnitus has a moderate to severe impact on their quality of life. Musculature and joint pathologies of the head and neck are frequently associated with tinnitus and have been hypothesized to play a contributing role in its etiology. However, specific physical therapy interventions to assist in improving tinnitus have not yet been reported. PURPOSE: To describe the examination and treatment intervention of a patient with subjective tinnitus. PATIENT DESCRIPTION: The patient was a 42-yr-old male experiencing intermittent bilateral tinnitus, headaches, blurred vision, and neck tightness. His occupation required long-term positioning into neck protraction. Examination found limitations in cervical extension, bilateral rotation, and side bending. Asymmetry was also noted with temporomandibular joint (TMJ) movements. Upon initial evaluation the patient demonstrated functional, physical, and emotional deficits per neck, headache, and dizziness self-report scales and a score on the Tinnitus Handicap Inventory (THI) of 62. Resisted muscle contractions of the cervical spine in flexion, extension, and rotation increased his tinnitus. INTERVENTION: Treatment focused on normalizing cervical spine mobility through repetitive movements, joint mobilization, and soft tissue massage. RESULTS: At 2.5 mo, the patient demonstrated a complete reversal of his tinnitus after 10 physical therapy sessions as noted by his score of 0 on the THI upon discharge. He also demonstrated objective improvements in his cervical motion. This case reflected treatment targeted at cervical and TMJ impairments and notable improvements to tinnitus. Future studies should further explore the direct and indirect treatment of tinnitus by physical therapists through clinical trials.

Tinnitus: patients do not have to 'just live with it'.

Tinnitus is distressing and affects the quality of life for many patients. Because primary care physicians may be the entry point for patients seeking help for tinnitus, we urge them to acknowledge this symptom and its potential negative impact on the patient's health and quality of life. Physicians should actively listen to the patient and provide hope and encouragement, but also provide realistic expectations about the course of treatment. The patient must also understand that there may be no singular "cure" for tinnitus and that management may involve multidisciplinary assessment and treatment.

Transforming growth factor-beta induces cellular injury in experimental diabetic neuropathy.

The mechanism/s leading to diabetic neuropathy are complex. Transforming growth factor-beta1 (TGF-beta1) has been associated with diabetic nephropathy and retinopathy but not neuropathy. In this study, changes in TGF-beta isoforms were examined in vivo and in vitro. Two groups of animals, streptozotocin diabetic with neuropathy and non-diabetic controls were examined at 4 weeks (n=10/group) and 12 weeks (n=8/group). In diabetic DRG using quantitative real-time PCR (QRT-PCR), TGF-beta1 and TGF-beta2 mRNA, but not TGF-beta3, was increased at 4 and 12 weeks. In sciatic nerve TGF-beta3 mRNA was primarily increased. Immunohistochemistry (DRG) and immunoblotting (sciatic nerve) showed similar differential protein expression. In sciatic nerve TGF-beta formed homo- and hetero-dimers, of which beta(2)/beta(3), beta(1)/beta(1), and beta(1)/beta(3) were significantly increased, while that of the TGF-beta(2)/beta(2) homodimer was decreased, in diabetic compared to non-diabetic rats. In vitro, pretreatment of embryonic DRG with TGF-beta neutralizing antibody prevents the increase in total TGF-beta protein observed with high glucose using immunoblotting. In high glucose conditions, combination with TGF-beta2>beta1 increases the percent of cleaved caspase-3 compared to high glucose alone and TGF-beta neutralizing antibody inhibits this increase. Furthermore, consistent with the findings in diabetic DRG and nerve, TGF-beta isoforms applied directly in vitro reduce neurite outgrowth, and this effect is partially reversed by TGF-beta neutralizing antibody. These findings implicate upregulation of TGF-beta in experimental diabetic peripheral neuropathy and indicate a novel mechanism of cellular injury related to elevated glucose levels. In combination, these findings indicate a potential new target for treatment of diabetic peripheral neuropathy.

X11alpha impairs gamma- but not beta-cleavage of amyloid precursor protein.

The phosphotyrosine binding domain of the neuronal protein X11alpha/mint-1 binds to the C-terminus of amyloid precursor protein (APP) and inhibits catabolism to beta-amyloid (Abeta), but the mechanism of this effect is unclear. Coexpression of X11alpha or its PTB domain with APPswe inhibited secretion of Abeta40 but not APPsbetaswe, suggesting inhibition of gamma- but not beta-secretase. To further probe cleavage(s) inhibited by X11alpha, we coexpressed beta-secretase (BACE-1) or a component of the gamma-secretase complex (PS-1Delta9) with APP, APPswe, or C99, with and without X11alpha, in HEK293 cells. X11alpha suppressed the PS-1Delta9-induced increase in Abeta42 secretion generated from APPswe or C99. However, X11alpha did not impair BACE-1-mediated proteolysis of APP or APPswe to C99. In contrast to impaired gamma-cleavage of APPswe, X11alpha or its PTB domain did not inhibit gamma-cleavage of NotchDeltaE to NICD (the Notch intracellular domain). The X11alpha PDZ-PS.1Delta9 interaction did not affect gamma-cleavage activity. In a cell-free system, X11alpha did not inhibit the catabolism of APP C-terminal fragments. These data suggest that X11alpha may inhibit Abeta secretion from APP by impairing its trafficking to sites of active gamma-secretase complexes. By specifically targeting substrate instead of enzyme X11alpha may function as a relatively specific gamma-secretase inhibitor.