Predictors of Mortality in Veterans with Amyotrophic Lateral Sclerosis: Respiratory Status and Speech Disorder at Presentation.

BACKGROUND There is a lack of accurate models to predict amyotrophic lateral sclerosis (ALS) disease course and outcomes. As a result, risk assessment and counseling, the timing of interventions, and their stratification in clinical trials are difficult. This study aimed to evaluate the association between symptoms at presentation and mortality. MATERIAL AND METHODS A single veterans hospital reviewed the electronic records of 105 veterans with ALS who were periodically followed in our ALS clinic between 2010 and 2021. A survival decision tree (≤3 or >3 years) was generated based on the statistical median survival of our data. The variables known to influence survival when alive were compared to patients who died. RESULTS The (mean±SD) age at onset was 62±11 years, M/F ratio 101: 4, and 90% were non-Hispanic whites. The initial score for the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) was 31±8.3. Dysarthria and shortness of breath (SOB) were present on initial presentation in 52 (49.5%) and 32 (30.5%) patients, respectively. Deaths occurred in 80 (76.2%) patients during the study period. The main cause of death was respiratory disease (failure and pneumonia, n=43 53.75%). Patients survived for >3 years on initial presentation with normal respiration and speech, compared to ≤3 years of survival in patients with dysarthria and SOB, irrespective of age. CONCLUSIONS This study suggests that for veterans with ALS, the main predictors of shorter survival were respiratory status and speech disorder on initial presentation to the clinic.

Corrigendum to "Fever in a paraplegia patient with a pressure ulcer" [Radiology Case Reports 16 (2021) 2434-2436].

[This corrects the article DOI: 10.1016/j.radcr.2021.05.065.].

Patient with basilar artery occlusion related to metastatic melanoma.

Posterior circulation stroke accounts for approximately 20% of all ischemic strokes. The basilar artery, which is the main vessel of the posterior circulation, supplies most of the brainstem, occipital lobes and part of the cerebellum and thalami. We present a case of a 73-year-old man with known metastatic melanoma while undergoing immunotherapy presented to the emergency department with a history of progressive shortness of breath, generalize weakness, and dysphagia. The patient's imaging workup revealed brain metastasis. While hospitalized had a sudden onset of loss of consciousness which lasted a few minutes and was back to baseline. An hour later he had another episode of loss of consciousness with absence of brainstem signs. Urgent head computerized tomography showed basilar artery occlusion. Patient was transferred to the intensive care unit and started on intravenous heparin (DVT/PE dosing protocol) and supportive care. At present there is lack of high-quality evidence from randomized controlled trial to guide as how best manage patients with basilar artery occlusion.

Impact of Adherence with Disease-Modifying Therapies on All-Cause Mortality Rates Among Veterans with Multiple Sclerosis.

BACKGROUND Adherence to disease-modifying therapies (DMTs) is essential for reducing multiple sclerosis (MS)-related relapses and disability. However, no known data exist regarding rates of adherence to DMTs and their impact on mortality. The present study aimed to determine the effect of adherence to DMTs on all-cause mortality in patients with MS in a real-world setting. MATERIAL AND METHODS We reviewed electronic records of 279 patients with MS and followed them longitudinally in our MS clinic between Januray1, 2000 and December 31, 2019. The inclusion criteria were complete electronic records along with documentation of initial and final functional outcome measures, including mortality. The exclusion criteria were incomplete electronic records and lack of documentation of initial and final functional outcome measures. RESULTS Of 279 patients with MS, 148 (53.0%) were non-adherent to any DMT medication(s). Of the 131 (47.0%) MS patients who were adherent, 13 (4.7%) had poor adherence and 118 (42.3%) had good adherence. More patients in the good-adherence group survived (94.9%) compared to the non-adherence group (66.9%, P<0.001). The odds of being alive were 12 times higher among those who adhered to their DMT compared to those who did not. CONCLUSIONS This study indicates that veterans who adhere to their DMTs are 12 times more likely to be alive than those who are non-adherent, even after adjusting for variables known to affect S-related mortality such as age at entry, MS type, MS duration, body mass index, and diabetes.

Impact of adherence to disease-modifying therapies on employment among veterans with multiple sclerosis.

PURPOSE: Patients who adhere to their disease-modifying therapies (DMTs) have a lower rate of MS-related relapses and disability. We sought to determine the adherence rate to DMTs and the association between adherence to DMTs and employment in patients with multiple sclerosis (MS). METHOD: One hundred and forty-two patients with MS who were periodically followed in our clinic between January 2000 and January 2020. We compared three groups of patients, defined according to their adherence to DMTs (non-adherent; poorly adherent; adherent), on their obtaining paid employment. RESULTS: Forty-seven MS patients (33.1%) were non-adherent to any DMT medication, while 88 MS patients (62.0%) demonstrated good and 7 (4.9%) poor adherences. More patients in the good-adherence group were in paid employment 42.0% compared to 23.4% in the non-adherent group (p = 0.587) after controlling for potential co-founders. CONCLUSION: In this study veterans who adhered to their DMTs were 2.4 times more likely to be in paid-employment compared to non- or poorly-adherent patients. The clinical significance of this study is to encourage MS patients to adhere to their DMTs as a motivating factor of being in paid-employment.Implications for rehabilitationWhat is known about this subject? In the setting of a randomized controlled trial adherence rates reported for different injectable DMTs vary from 79-85% for once a week interferon beta-1a (IM IFNb-1a) to 49-78% for other injectable DMTs.•What are the new findings and/or impact on clinical practice?•Paid employment was more common among veterans whose adherence to DMTs was good (42.0% employed) or poor (42.9%) than among those who were non-adherent (23.4%). Veterans who adhered to DMTs were also younger, had less severe MS, and displayed less cognitive and physically impairment than those who did not adhere.•Being employed can act as a motivating factor to encourage adherence to treatment aimed at preventing accumulation of mental and physical disabilities.

The Impact of Adherence to Disease-Modifying Therapies on Functional Outcomes in Veterans with Multiple Sclerosis.

BACKGROUND: Patients who adhere to their DMTs have lower rate of MS-related relapses and disability. OBJECTIVE: We sought to determine the adherence rate to disease-modifying therapies (DMTs) and its impact on functional outcome(s) in veterans with multiple sclerosis (MS). METHOD: We reviewed the electronic records of 279 veterans with MS who were periodically followed in our MS clinic. We compared 3 groups of patients, defined according to their adherence to DMTs (non-adherent; poorly adherent; adherent) on their effect on disability progression and time to sustained EDSS score of 6. RESULTS: There were 148 (53%) veterans with MS who were non-adherent to any DMT medication(s) while of the 131 (47%) veterans who were taking medications, 118 (42%) had a good- and 13 (5%) had poor-adherence. The mean age at MS onset was 36.6 (± 11.2) and mean duration of MS for the sample was 24 ± 13.5 years. The mean initial EDSS and TFIM scores were 4.09 ± 2.9 SD and 104 ± 25.7 for the study sample. The change in MMSE, TFIM scores, and time to sustained EDSS score of 6 significantly favored the good- compared to the non-adherence group (P < .01). CONCLUSION: This study suggests that veterans with MS who adhered to their DMTs had less decline in their MS-related cognition, disease severity and disability compared to non- and poorly-adherent groups even after adjusting for age, gender, MS duration, and type. Time to EDSS score of 6 was significantly prolonged in the good-adherence group.

Fever in a paraplegia patient with a pressure ulcer.

The incidence rates of pressure ulcers (PUs) in patients with SCI in the United States varies by clinical setting, ranging from 0.4%-38% in acute care, 2.2%-23.9% in long-term care, and 0%-17% in home care [1,2]. Unrelieved pressure is the most important factor in the development of PUs. Other factors associated with PUs in patients with SCI include age at the time of injury, men, blacks, completeness of the injury, functional dependence, behavioral protective factors such as frequent pressure relief, self-positioning, daily skin monitoring, nutritional state, cigarette smoking, alcohol (ab)use, and being depressed [3]. Presence of PUs affects functional physical outcomes; thus, prevention of PUs is the key [4]. Infection is a common complication of PUs which can be local such as cellulitis or osteomyelitis or systemic such as septicemia with a greater than 50% mortality. We present a case of a 58-year-old paraplegic man with pressure ulcer who presented with fever in the presence of an osteomyelitis and had a pelvic abscess on magnetic resonance imaging which needed surgical drainage.

Psoas muscle hematoma presenting as painful monoplegia.

I present here a case of psoas (retroperitoneal) hematoma; which is a rare, but potentially life-threatening acute condition, with a 30-day mortality of 10% from bleeding in the retroperitoneal space without associated trauma or iatrogenic intervention. A 59-year-old man who was on long-term anticoagulation for his atrial fibrillation presented to our facility with worsening pain in the left groin and being unable to move the left leg and walk. Computed tomography showed a large left psoas hematoma. He was treated conservatively which included reversal of his anticoagulation state. This case highlights the need for early diagnosis of psoas hematoma by computed tomography scan of the abdomen and pelvis to promptly initiate treatment to improve functional outcome.

Progressive lip numbness due to numb chin and cheek syndrome in a patient with prostate cancer.

Numb chin syndrome (NCS) is characterized by numbness in an area of the chin and lower lip along the distribution of the mental or inferior alveolar nerves, a branch of the mandibular division of the trigeminal nerve. Most cases of NCS are due to diffuse metastatic disease, especially associated with underlying lymphoproliferative and breast cancer. Other less like causes are dental, traumatic, toxic, drug-induced, or infectious. NCS may be the initial symptom of malignancy or metastasis in patients with cancer. Axial and vertebral bone metastases are common in patients with carcinoma of the prostate; however, involvement of the branches of the trigeminal nerve is rare. We present a case of the NCS in a 59-year-old man with metastatic prostate adenocarcinoma to the base of the skull.

Predictors of Mortality in Veterans with Multiple Sclerosis in an Outpatient Clinic Setting.

BACKGROUND: Examining factors that increase risk of death in veterans with multiple sclerosis (MS) may help reduce MS-related mortality. We sought to determine predictors of mortality in veterans with MS attending an outpatient clinic. METHODS: Review of electronic medical records of 226 veterans with MS regularly followed up from January 1, 2000, through December 31, 2014. RESULTS: Mortality at the end of the 15-year study period was 14%. Patients with MS died prematurely, with a standardized mortality rate of 1.35 relative to the general (Oklahoma) population. The main causes of death documented were MS disease itself (57% of cases), infection (43%), and cancer and respiratory failure (18% each). Cox regression analysis using the whole cohort showed that progressive MS type; older age at entry into the study; presence of sensory, cerebellar, or motor (weakness and/or ataxia) concerns on presentation; more disability on presentation; higher body-mass index; being diabetic; never received disease-modifying therapy; and presence of pressure ulcers or neurogenic bladder were significant predictors of higher mortality. CONCLUSIONS: Initial presentation by MS type (progressive MS), higher level of disability, and associated motor, sensory, and cerebellar concerns are significant predictors of MS-related mortality. The main causes of death were MS disease itself, infection, respiratory disease, and cancer. More attention should be given to preventive strategies that delay mortality, such as yearly immunization and aggressively treating MS-related complications and diabetes mellitus.

Effect of Transcranial Direct Current Stimulation on Severely Affected Arm-Hand Motor Function in Patients After an Acute Ischemic Stroke: A Pilot Randomized Control Trial.

OBJECTIVE: The aim of this article was to determine whether cathodal transcranial direct current stimulation (c-tDCS) to unaffected primary motor cortex (PMC) plus conventional occupational therapy (OT) improves functional motor recovery of the affected arm hand in patients after an acute ischemic stroke compared with sham transcranial direct current stimulation plus conventional OT. DESIGN: In this prospective, randomized, double-blinded, sham-controlled trial of 16 severe, acute ischemic stroke patients with severe arm-hand weakness were randomly assigned to either experimental (c-tDCS plus OT; n = 8) or control (sham transcranial direct current stimulation plus OT; n = 8) groups. All patients received a standard 3-hr in-patient rehabilitation therapy, plus an additional ten 30-min sessions of tDCS. During each session, 1 mA of cathodal stimulation to the unaffected PMC is performed followed by the patient's scheduled OT. The primary outcome measure was change in Action Research Arm Test (ARAT) total and subscores on discharge. RESULT: Application of c-tDCS to unaffected PMC resulted in a clinically relevant 10-point improvement in the affected arm-hand function based on ARAT total score compared with a 2-point improvement in the control group. CONCLUSIONS: Application of 30-min of c-tDCS to the unaffected PMC showed a 10-point improvement in the ARAT score. This corresponds to a large effect size in improvement of affected arm-hand function in patients with severe, acute ischemic stroke. Although not statistically significant, this suggests that larger studies, enrolling at least 25 patients in each group, and with a longer follow-up are warranted.

Effect of Chronic Medical Conditions in Veterans with Multiple Sclerosis on Long-Term Disability.

BACKGROUND The goal of this observational study was to examine the effect of common chronic medical conditions (CMCs) on long-term disability (activity limitation) in veterans already diagnosed with multiple sclerosis (MS). MATERIAL AND METHODS We retrospectively reviewed the electronic charts of 124 veterans with MS who have been regularly followed in our MS clinic for 10 or more years. General linear model analysis examined whether MS-related severity as measured by the Expanded Disability Status Scale (EDSS) and the presence of CMCs affected long-term disability as measured by the total score on the Functional Independence Measure (TFIM). RESULTS Commonly encountered CMCs were increased BMI (61%), hyperlipidemia (78%), hypertension (65%), current smokers (47%), and arthritis/arthralgia (24%). Results suggest that the number of CMCs was not predictive of final TFIM scores; of the variables examined, only initial EDSS score was predictive of final TFIM scores. CONCLUSIONS The presence of CMCs did not affect the long-term disability in veterans diagnosed with MS, this was due mainly to CMCs being closely monitored and co-treated with other medical specialties.

Compare serum creatinine versus Renal 99mTc-DTPA scan determined glomerular filtration rates in veterans with traumatic spinal cord injury and meurogenic bladder.

OBJECTIVE: This observational study: (a) compared serum creatinine (estimated glomerular filtration rate (EGFR)) to renal isotope 99mTc-DTPA (GFR) determined glomerular filtration rate, and evaluated whether either method (b) better determined the state of renal function, and (c) predict urinary tract infection (UTI), renal and urological structural lesions or mortality in veterans with traumatic spinal cord injury (SCI) and neurogenic bladder (NGB). DESIGN: Observational study. SETTING: VA Medical Center affiliated with Oklahoma University. PARTICIPANTS: Veterans with SCI and regularly followed in SCI clinic. Demographic and clinical data, as well as, EGFR, GFR, blood urea nitrogen (BUN) and serum creatinine levels, and presence of UTI, renal and urinary bladder lesions on renal nuclear scan, renal ultrasound, and cystoscopy studies were recorded. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Urological lesions, UTI, and Mortality. RESULTS: For 161 patients with SCI and NGB the mean ± SD for EGFR was 104 ± 36 and 84 ± 32 for GFR. EGFR and GFR were positively correlated (r = 0.34, P = 0.015). GFR was significantly (P < 0.05) more sensitive and specific in determining renal functional state. Neither measures were significant indicator for UTI, renal or urological lesions; GFR was a significant predictor of risk of death (1.2 times increase in risk per 10 unit drop in GFR) even after adjusting for age (P = 0.040). CONCLUSION: While GFR and EGFR are comparable measures of glomerular filtration, GFR was a more informative measure of renal functional state and risk of mortality than EGFR. Neither method predicted the presence of UTI related renal or urological lesions.

Evaluate the impact of neurogenic bladder in veterans with traumatic spinal cord injury.

OBJECTIVE: This observational study aimed to determine the prevalence of neurogenic bladder (NGB), and its impact (frequency of urinary tract infection [UTI], autonomic dysreflexia (AD) pressure ulcers, spasticity, and hospitalization rates) on veterans with traumatic spinal cord injury (SCI). BACKGROUND: NGB (detrusor muscle and urethral sphincter dysfunction with loss of bladder sensation to void), secondary to SCI, is commonly encountered in daily practice; however, its impact on veterans' overall health has been less well studied. METHOD: We retrospectively reviewed the electronic charts of veterans with SCI enrolled in our program and regularly followed in our SCI clinic. Demographic data collected included: age, sex, race/ethnicity, and age, level, severity and cause of spinal injury. Also noted was presence of NGB, episodes of UTI, presence of pressure ulcers, AD, spasticity, and hospitalization rate. Differences between those with and without NGB were evaluated using Generalized Linear Models. RESULTS: Of 161 veterans with SCI, symptoms of NGB was present in 133 (83%). Presence of NGB was associated with severe spinal cord injury. Veterans with NGB had more frequent UTI and presence of pressure ulcers (P < 0.05). They also were more likely to need hospitalization and were at an increased risk of dying. CONCLUSION: Incidence of NGB in veterans with SCI is high, is mainly associated with severe spinal cord injury, and severely impacts veterans' health by frequently causing UTIs, increasing hospitalization rate, and increases risk of death.

Factors predictive of type of powered mobility received by veterans with disability.

BACKGROUND: The goal of this observational study was to determine factors predictive of the type of powered mobility prescribed to veterans with disability. MATERIAL/METHODS: A retrospective chart review was conducted for all veterans (n=170) who received powered mobility from a designated power mobility clinic. Logistic regression analysis was used to determined factors predictive of the type of powered mobility provided. RESULTS: Sixty-four (38%) veterans were provided powered wheelchairs and 106 (62%) were provided powered scooters. Of the variables examined, only primary medical conditions for referral and disability severity (as measured by the 2-minute timed walk test; 2-MWT) were predictive of the types of powered mobility prescribed. Veterans who were able to walk longer distances were more likely to be prescribed powered scooters. Age, gender, race, level of education, marital and employment status, number of chronic medical conditions, and upper and lower limb muscle strength were not significant predictors. CONCLUSIONS: This study suggests that the primary medical conditions for referral and 2-MWT can assist clinicians in the determination of the type of powered mobility to prescribe to veterans with disability.