Papillitis associated with IgLON5 autoimmunity: A novel clinical phenotype.

OBJECTIVES: To describe papillitis as a clinical phenotype of IgLON5 autoimmunity. METHODS: We retrospectively reviewed patients with IgLON5 autoimmunity who had optic neuropathy, optic neuritis, or optic disc edema. Sera from patients with recurrent papillitis were tested for IgLON5 antibodies. RESULTS: We found two elderly males presenting with papillitis in the presence of IgLON5 antibodies. CSF pleocytosis was present and partial vision improvement occurred in one patient despite immunotherapy. Sera from 18 patients with recurrent papillitis were negative for IgLON5 antibodies. CONCLUSION: Papillitis could be a manifestation of IgLON5 disease, with or without accompanying cognitive, sleep, and movement disorders.

Corpus callosum lesions are not inextricably linked to CNS symptoms in reported cases of susac syndrome.

OBJECTIVE: To evaluate whether corpus callosum (CC) lesions are inextricably linked to CNS symptoms of Susac Syndrome (SuS) by reviewing published cases to find instances where: 1) CC lesions occur without CNS symptoms, and 2) whether patients with CNS symptoms lack CC lesions. METHODS: 100 reported cases of SuS were identified in PubMed. Clinical symptoms, para-clinical testing and MRI data were collected both at presentation and for any available follow-up and analyzed. Cases were reviewed to evaluate how they met European diagnostic criteria for SuS (EuSaC) both at first presentation and at most recent evaluation after followup, if available. RESULTS: Limited disease is a common finding in the 100 recently published cases and 56/100 cases did not meet EuSaC probable or definite criteria at first evaluation. CC lesions were not inextricably linked with encephalopathy, as 8 cases presented with CC lesions without CNS symptoms and 6 cases had encephalopathy without CC lesions. In five patients with both eye and ear involvement, isolated CC lesions or CNS symptoms could enhance diagnostic certainty. This may reduce specificity, but would increase sensitivity, ultimately benefitting patient care. CONCLUSION: Patients with early SuS rarely meet diagnostic criteria at presentation. Future diagnostic criteria could make use of unlinked CC lesions or CNS symptoms.

An Educational Video Improves Consent in Pediatric Lumbar Puncture: A Randomized Control Trial.

BACKGROUND: Lumbar puncture is a low-risk procedure performed on pediatric patients for a variety of indications. Parents give consent to this procedure but are often left with concerns. There are no published studies on the nature of the concerns of parents in North America and no studies examining a process to improve pediatric lumbar puncture consent. Here we identify parent concerns with lumbar puncture and determine the utility of an adjunctive educational video. METHODS: Seventy-two patient-parent dyads were enrolled in a randomized control trial to receive standard consent with or without an educational video. A survey was provided to determine parent self-rated understanding of the procedure, their perception of its safety, their perception of the painfulness, and their overall comfort with their child undergoing lumbar puncture. In addition, demographic characteristics and qualitative information about parent concerns were collected. TRIAL REGISTRATION: NCT03677219. RESULTS: The video resulted in significantly greater parent understanding of the procedure (P = 0.015) and perception of its safety (P = 0.021) compared with controls. Parent comfort with the procedure increased after viewing the video (P = 0.002). Parents' top three concerns were pain, infection, and neurological injury. CONCLUSIONS: Parent concerns in pediatric lumbar puncture include pain, infection, and neurological injury, and viewing an educational video improved parent perception of understanding and safety compared with controls. In addition, there was reduced variability of responses in those who viewed the video. Thus a short educational video on a handheld device is an effective means to address parent concerns and standardize the process of pediatric lumbar puncture consent.

Hospitalized head and spine injuries on Saskatchewan farms.

INTRODUCTION: With over 44,000 individual farms, farm dwellers account for 11% of the population of Saskatchewan. There is limited data on brain and spine injuries acquired on farms. The objective of this study was to evaluate the epidemiology of head and spine injuries on Saskatchewan farms to assist the development of injury prevention initiatives. METHODS: Using the Canadian Centre for Agricultural Health and Safety's Saskatchewan Farm Injury Surveillance Database, farm-related head and spine injuries hospitalized > 24 hours were examined (1990-2007). We collected information regarding the type and mechanism of injury as well as the geographic location of both the injury and treatment. RESULTS: The database captured 390 brain injuries and 228 spine injuries, including 16 spinal cord injuries. The majority of patients were male (73.3% of head injuries and 84.2% of spine injuries). The highest risk age groups were 50-59 years, with 24.1% of the spine injuries, and 40-49 years, with 19.2% of the head injuries. The most common causes of injury were falls and/or machinery-related. The average annual incidence of farm-related spine and head injury were 10.8 and 17.6 per 100,000 farm population, respectively. All patients included in this study were hospitalized for over 24 hours, with 44.7% of spine injuries spending over one week in hospital, and 20% of head injuries spending over three days in hospital. CONCLUSIONS: Injury prevention initiatives should be targeted towards males aged 40-59 years residing in the southern areas of the province, with increased awareness towards the dangers of falls and operating tractors.

The living with dysarthria group: implementation and feasibility of a group intervention for people with dysarthria following stroke and family members.

BACKGROUND: The broad life implications of acquired dysarthria are recognized, but they have received little attention in stroke management. Reports of group therapy, which may be a suitable approach to intervention, are not available for stroke-related dysarthria. AIMS: To examine the operational feasibility of and response to a new eight-session weekly group intervention programme, Living with Dysarthria, designed for people with chronic dysarthria following stroke and their main communication partners. METHODS & PROCEDURES: The target participation was for programme completion by two groups of eight people with dysarthria (PWD) and available family members (FMs) or carers. An active recruitment strategy was undertaken from the speech and language therapy case records for the previous 6 years in two hospitals with combined annual stroke admissions of over 500 people. Twelve PWD and seven FMs were recruited (group 1: seven PWD and four FMs; group 2: five PWD and three FMs). Speech intelligibility, communication effectiveness, general well-being, quality of communication life, and knowledge of stroke and dysarthria were assessed pre- and post-programme. Each PWD and FM also set an individual goal and rated their achievement of this on a 0-10 scale. OUTCOMES & RESULTS: Recruitment to the programme was lower than anticipated and below target. The 12 PWD were recruited from 62 initial contacts, which was the total number who according to available information met the criteria. The programme was viable: it ran to plan, with only minor content alterations, in community accommodation, and with good participant engagement. Group median score changes were in a positive direction for all measures and effect sizes ranged from 0.17 (quality of communication life) to 0.46 (intelligibility). Significant post-programme changes were present for intelligibility and knowledge of stroke and dysarthria (p= 0.05). Participants' ratings of goal achievements ranged from 6 (some change) to 10 (a lot of change). CONCLUSIONS & IMPLICATIONS: The recruitment experience revealed a take-up rate of around 20% from PWD following stroke, informing future planning. The participant engagement and performance results from the piloting of the programme indicate that the Living with Dysarthria programme is viable and has potential for effecting positive change. Further testing is justified.

Dysarthria following stroke: the patient's perspective on management and rehabilitation.

OBJECTIVE: To explore the perceptions of people with stroke-related dysarthria in relation to the management and rehabilitation of dysarthria. DESIGN: Qualitative semi-structured interviews. SETTING: Community setting Subjects: Twenty-four people with an acquired dysarthria as a result of a stroke in the previous three years. All were living at home at the time of the interview. None exhibited a co-existing impairment (for example, aphasia, apraxia or cognitive impairment) that might have contributed to their communicative experiences. RESULTS: Participants described the considerable efforts they made to maximize their communicative effectiveness prior to, and during, communicative interactions. Activities described included careful articulation and vocal projection as well as more inconspicuous strategies including pre-planning interactions, focused, effortful speech and word substitution. Communication was facilitated by a range of strategies including drafting, rehearsal, manoeuvring and ongoing monitoring and repair. Self-led speech rehabilitation activities were functionally based and often undertaken regularly. Some novel reading-aloud and speaking-aloud activities were described. CONCLUSION: The quantity and nature of inconspicuous, internalized, cognitive activities people with dysarthria engage in to maximize their communicative effectiveness should be considered in evaluating the impact of dysarthria following stroke. Focusing upon externally observable characteristics alone is insufficient. Challenging, functionally relevant, patient-focused activities, materials and targets are more likely to be perceived by the patient as relevant and worthwhile and are thus more likely to ensure adherence to recommended rehabilitation activities.

Contemporary treatment strategy for spinal metastasis: the "LMNOP" system.

The choice of treatment for spinal metastasis is complex because (1) it depends on several inter-related clinical and radiologic factors, and (2) a wide range of management options has evolved in recent years. While radiation therapy and surgery remain the cornerstones of treatment, radiosurgery and percutaneous vertebral augmentation have also established a role. Classification systems have been developed to aid in the decision-making process, and each has different strengths and weaknesses. The comprehensive scoring systems developed to date provide an estimate of life expectancy, but do not provide much advice on the choice of treatment. We propose a new decision model that describes the key factors in formulating the management plan, while recognizing that the care of each patient remains highly individualized. The system also incorporates the latest changes in technology. The LMNOP system evaluates the number of spinal Levels involved and the Location of disease in the spine (L), Mechanical instability (M), Neurology (N), Oncology (O), Patient fitness, Prognosis and response to Prior therapy (P).

The impact of stroke-related dysarthria on social participation and implications for rehabilitation.

INTRODUCTION: Each year an estimated 30,000-45,000 UK individuals experience stroke-related dysarthria (impairment of movements required to produce speech). Many will experience persistent dysarthria long after discharge from stroke services. Although we have some insight into the impact of other communication impairments, we have very limited information on the impact of dysarthria on social participation. PURPOSE: To explore the impact of dysarthria on social participation following stroke. METHODS: We report data from in-depth semi-structured interviews with 24 individuals with stroke-related dysarthria. RESULTS: Our findings suggest a complex association between the severity of an individual's dysarthria and the impact on their social participation. Participants' descriptions highlighted their experiences of social participation and isolation. We further suggest that, in some cases, the coping strategies adopted by the participants could be seen to further exacerbate this isolation. These results have important implications for the prioritisation, planning and delivery of therapeutic interventions for people with dysarthria. CONCLUSIONS: The impact of stroke-related dysarthria transcends the physiological impairment to impact upon individuals' social participation, which is key to the process of rehabilitation. The development and evaluation of the effectiveness of an intervention that addresses these impacts is the next challenge for therapists and researchers working in this area.

An exploration of lifestyle beliefs and lifestyle behaviour following stroke: findings from a focus group study of patients and family members.

BACKGROUND: Stroke is a major cause of disability and family disruption and carries a high risk of recurrence. Lifestyle factors that increase the risk of recurrence include smoking, unhealthy diet, excessive alcohol consumption and physical inactivity. Guidelines recommend that secondary prevention interventions, which include the active provision of lifestyle information, should be initiated in hospital, and continued by community-based healthcare professionals (HCPs) following discharge. However, stroke patients report receiving little/no lifestyle information.There is a limited evidence-base to guide the development and delivery of effective secondary prevention lifestyle interventions in the stroke field. This study, which was underpinned by the Theory of Planned Behaviour, sought to explore the beliefs and perceptions of patients and family members regarding the provision of lifestyle information following stroke. We also explored the influence of beliefs and attitudes on behaviour. We believe that an understanding of these issues is required to inform the content and delivery of effective secondary prevention lifestyle interventions. METHODS: We used purposive sampling to recruit participants through voluntary sector organizations (29 patients, including 7 with aphasia; 20 family members). Using focus group methods, data were collected in four regions of Scotland (8 group discussions) and were analysed thematically. RESULTS: Although many participants initially reported receiving no lifestyle information, further exploration revealed that most had received written information. However, it was often provided when people were not receptive, there was no verbal reinforcement, and family members were rarely involved, even when the patient had aphasia. Participants believed that information and advice regarding healthy lifestyle behaviour was often confusing and contradictory and that this influenced their behavioural intentions. Family members and peers exerted both positive and negative influences on behavioural patterns. The influence of HCPs was rarely mentioned. Participants' sense of control over lifestyle issues was influenced by the effects of stroke (e.g. depression, reduced mobility) and access to appropriate resources. CONCLUSIONS: For secondary prevention interventions to be effective, HCPs must understand psychological processes and influences, and use appropriate behaviour change theories to inform their content and delivery. Primary care professionals have a key role to play in the delivery of lifestyle interventions.

Patients' experiences of disruptions associated with post-stroke dysarthria.

BACKGROUND: Post-stroke dysarthria rehabilitation should consider social participation for people with dysarthria, but before this approach can be adopted, an understanding of the psychosocial impact of dysarthria is required. Despite the prevalence of dysarthria as a result of stroke, there is a paucity of research into this communication disorder, particularly studies that address the experiences of individuals. The available literature focuses mainly on the perceptions of others or includes groups of mixed aetiologies. AIMS: To investigate the beliefs and experiences of people with dysarthria as a result of stroke in relation to their speech disorder, and to explore the perceived physical, personal and psychosocial impacts of living with dysarthria. METHODS & PROCEDURES: Participants for this qualitative study were recruited from twelve hospitals in Scotland that served both rural and urban populations and afforded opportunity for comparison. Semi-structured, in-depth interviews were carried out over a 12-month period with 24 individuals with varying severity of dysarthria following stroke. The interviews were orthographically transcribed and coded using the NVivo package, which also facilitated identification of patterns using the constant comparative method. OUTCOMES & RESULTS: The results of the study indicate that the effects of dysarthria following stroke extend beyond the physiological characteristics of the impairment. In turn, the resulting communication difficulties lead to changes in self-identity, relationships, social and emotional disruptions, and feelings of stigmatization or perceived stigmatization. The impact of dysarthria was found to be disproportionate to the physiological severity, with participants continually striving to get their speech back to 'normal'. CONCLUSIONS & IMPLICATIONS: The findings provide insight into the psychosocial impact of dysarthria following stroke. Speech and language therapy interventions need to go beyond the speech impairment to address and promote psychosocial well being, reduce the likelihood of feelings of stigmatization and changes in self-identity, irrespective of the severity of dysarthria.