Predictive clinical factors for penetration and aspiration in Parkinson's disease.

BACKGROUND: Do the current swallow-specific subquestions of neurological diagnostic tools reflect the objective swallowing function in Parkinson's disease (PD) patients or are clinical factors superior to predict critical aspiration? METHODS: In a cross-sectional, observational study a total of 119 Parkinson outpatients were examined clinically and by flexible-endoscopic evaluation of swallowing (FEES). Self-reported dysphagia by subquestions of the MDS-UPDRS and NMS questionnaire and history of subjective aspiration signs were collected. KEY RESULTS: Nearly, all PD patients showed deglutition abnormalities in FEES (113/119) while only 12%-27% of them reported swallowing problems in the swallow-specific subquestions of neurological standard diagnostic tools (MDS-UPDRS and NMS-Quest), and the answers were heterogeneous and poorly reproducible. With a sensitivity of up to a maximum of 50%, self-reported dysphagia is therefore no reliable tool for identifying dysphagia in PD. While most clinical parameters were linked to dysphagia to some extent, logistic regression analysis revealed high age (Odds Ratio (OR) 1.1 in years, 95% CI 1.03-1.18, P < 0.01), gender (OR 0.3 for females, 95% CI 0.08-0.97, P = 0.04), and affirmed subjective aspiration signs (OR 8.6, 95% CI 3.05-26.52, P < 0.001) as the most significant predictors for critical dysphagia. CONCLUSIONS AND INFERENCES: Self-perception of swallowing is no reliable tool for identifying dysphagia and questionnaires are insufficient for detecting previous aspiration. Consequent and specific asking for previous subjective aspiration signs is the single most important measure for identifying PD patients at risk for critical aspiration.

ACUDIN - ACUpuncture and laser acupuncture for treatment of DIabetic peripheral Neuropathy: a randomized, placebo-controlled, partially double-blinded trial.

BACKGROUND: Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes mellitus with significant clinical sequelae that can affect a patient's quality of life. Metabolic and microvascular factors are responsible for nerve damage, causing loss of nerve function, numbness, painful sensory symptoms, and muscle weakness. Therapy is limited to anti-convulsant or anti-depressant drugs for neuropathic pain and paresthesia. However, reduced sensation, balance and gait problems are insufficiently covered by this treatment. Previous data suggests that acupuncture, which has been in use in Traditional Chinese Medicine for many years, may potentially complement the treatment options for peripheral neuropathy. Nevertheless, more objective data on clinical outcome is necessary to generally recommend acupuncture to the public. METHODS: We developed a study design for a prospective, randomized (RCT), placebo-controlled, partially double-blinded trial for investigating the effect of acupuncture on DPN as determined by nerve conduction studies (NCS) with the sural sensory nerve action potential amplitude as the primary outcome. The sural sensory nerve conduction velocity, tibial motor nerve action potential amplitude, tibial motor nerve conduction velocity, the neuropathy deficit score, neuropathy symptom score, and numeric rating scale questionnaires are defined as secondary outcomes. One hundred and eighty patients with type 2 diabetes mellitus will be randomized into three groups (needle acupuncture, verum laser acupuncture, and placebo laser acupuncture). We hypothesize that needle and laser acupuncture have beneficial effects on electrophysiological parameters and clinical and subjective symptoms in relation to DPN in comparison with placebo. DISCUSSION: The ACUDIN trial aims at investigating whether classical needle acupuncture and/or laser acupuncture are efficacious in the treatment of DPN. For the purpose of an objective parameter, NCS were chosen as outcome measures. Acupuncture treatment may potentially improve patients' quality of life and reduce the socio-economic burden caused by DPN. TRIAL REGISTRATION: German Clinical Trial Register (DRKS), No. DRKS00008562 , trial search portal of the WHO ( http://apps.who.int/trialsearch/ ).

Critical Dysphagia is Common in Parkinson Disease and Occurs Even in Early Stages: A Prospective Cohort Study.

To assess the prevalence of dysphagia and its typical findings in unselected "real-world" Parkinson patients using an objective gold-standard method. This was a prospective, controlled, cross-sectional study conducted in 119 consecutive Parkinson patients of all stages independent of subjective dysphagia. Patients and 32 controls were clinically and endoscopically examined by flexible endoscopic evaluation of swallowing (FEES) to evaluate the deglutition with regard to three consistencies (water, biscuit, and bread). Typical findings of dysphagia like penetration and aspiration, residues, and leakage were assessed. Dysphagia was common in Parkinson patients and occurred in all, even early, disease stages. Only 5% (6/119) of patients showed a completely unremarkable deglutition. Aspiration was seen in 25% (30/119) of patients and always related to water. Residues occurred in 93% (111/119), most commonly for bread. Leakage was much less frequent and was found in only 3-18%, depending on consistency. In a significant fraction of patients, objective dysphagia was not subjectively perceived. A total of 16% of asymptomatic patients suffered from critical aspiration. Significant swallowing deficiencies already occurred in early disease. Aspiration was found in 4 of 20 (20%) patients with disease duration of less than 2 years. Seven of 57 patients (12%) with Hoehn and Yahr stage 2 suffered from severe aspiration. Given the high frequency of critical aspiration in Parkinson disease, these patients should be evaluated early for dysphagia to avoid complications and recommend an adequate therapy. FEES is a simple, cost efficient, minimally invasive method that is ideally suited for this purpose.

Systematic Comparison of IgM and IgG ABO Antibody Titers by Using Tube and Gel Card Techniques and its Relevance for ABO-Incompatible Kidney Transplantation.

BACKGROUND: Although the determination of the ABO antibody titers is necessary for the decision-making in ABOincompatible (ABOi) kidney transplantations, various methods for the determination of the ABO antibody titers are being used. However, the absence of uniform standards makes their comparability far more difficult. Two of the most commonly used methods are the tube method and the gel card method. In this study, we systematically investigate to what extent these two methods affect the result of ABO antibody titers. METHODS: ABO antibodies were determined from plasmas of 90 donors (30 individuals each with blood group A, B, and O). Seven further donors with blood group A, B, and AB provided erythrocytes for the testing. A total of 360 ABO antibody titers were determined; 180 tests for each method, each with 90 determinations of immunoglobulin G (IgG) and immunoglobulin M (IgM) antibody titers. In addition, we also made a differentiation by blood groups to find out if and to what extent the blood groups have an impact on the results. RESULTS: Our analysis shows that the choice of method has a highly significant (p < 0.0001) impact on the titer level of the ABO antibodies. The median values of ABO antibody titers determined by using the gel card method are two titer steps lower than the titers, which are determined when using the tube method. Moreover, our data shows that there are major differences in the ABO antibody titer level among the blood groups, regardless of the choice of methods. CONCLUSIONS: We consider changing to the gel card method for determining the ABO antibody titers as a simple and effective way to achieve a standardized and uniform method. Here, too, the clinicians should be provided with sufficient information by the laboratories, in order to draw the right consequence from this change, while considering all the relevant data. As a consequence of this study, the transplant center of the University of Hamburg-Eppendorf paired a change from tube to gel card regarding the ABO antibody titer determination of ABOi kidney transplantations with an intensification of the preoperative target titer from ≤ 1:8 to ≤ 1:4.

Immediate Pain Relief in Adhesive Capsulitis by Acupuncture-A Randomized Controlled Double-Blinded Study.

OBJECTIVE: Primary adhesive capsulitis (AC), or frozen shoulder, is an insidious and idiopathic disease. Severe pain is predominant in the first two of the three stages of the condition, which can last up to 21 months. DESIGN, SETTING, AND SUBJECTS: Sixty volunteers with primary AC were randomly assigned to acupuncture with press tack needles compared with press tack placebos in a patient- and observer-blinded placebo-controlled study. The participants were subsequently offered classical needle acupuncture in an open follow-up clinical application. Thirty-four volunteers received conservative therapy, including 10 classical needle acupuncture treatments over 10 weeks, 13 volunteers received conservative therapy without classical needle acupuncture. All subjects agreed to follow-up after one year. METHODS: Acupuncture treatment was performed using a specific distal needling concept, using reflex areas on distant extremities avoiding local treatment. RESULTS: An immediate improvement of 3.3 ± 3.2 points in Constant-Murley Shoulder Score (CMS) pain subscore was seen in the press tack needles group and of 1.6 ± 2.8 points in the press tack placebos group (P <0.02). Conservative therapy including classical needle acupuncture significantly improved the pain subscore within 14.9 ± 15.9 weeks compared with 30.9 ± 15.8 weeks with only conservative therapy (P < 0.001). CONCLUSION: The efficiency of distal needling acupuncture on immediate pain reduction was demonstrated in patients with AC and confirmed the applicability of press tack needles and press tack placebos for double-blind studies in acupuncture. Subsequent clinical application observation proved that results obtained with press tack needles/press tack placebos can be transferred to classical needle acupuncture. Integrating acupuncture with conservative therapy showed superior effectiveness with respect to the time course of the recovery process in AC compared with conservative therapy alone.

Impact of spinal cord compression from intradural and epidural spinal tumors on perioperative symptoms-implications for surgical decision making.

Spinal cord or cauda equina compression (SCC) is an increasing challenge in clinical oncology due to a higher prevalence of long-term cancer survivors. Our aim was to determine the clinical relevance of SCC regarding patient outcome depending on different tumor entities and their anatomical localization (extradural/intradural/intramedullary). We retrospectively analyzed 230 patients surgically treated for SCC. Preoperative status for pain and neurological impairment were correlated to the degree of compression, tumor location, and early as well as short-term follow-up outcome parameters. Interestingly, we did not observe any differences between intradural-extramedullary compared to extradural tumors. Unilaterally localized tumors were likely to present with pain (72.9 %, p < 0.01), whereas concentric growth was associated with motor deficits (41.0 %, p < 0.01, as primary symptom, 49.3 % on admission, p < 0.05). In concentric tumors, the pain pattern was diffuse (40.5 % vs. 17.5 in unilateral disease, p < 0.01), whereas unilateral tumors resulted in localized pain (61.4 % local axial or radicular, p < 0.01). Diffuse pain, patients without a sensory or motor deficit, progressive disease, cervical localization, and a higher degree of stenosis were identified as beneficial for an early improvement in pain (p < 0.05). Notably, 29 % of patients with unchanged pain and 30.8 % with unchanged neurologic function at day 7 postoperative improved during follow-up (p < 0.001). Our data demonstrate that the preoperative tumor anatomy in patients with SCC was closely related to their presenting symptoms and early clinical outcome. The detailed analysis elucidates the biology of SCC and might thereby aid in determining which patients will benefit from surgery.

Practical barriers and ethical challenges in genetic data sharing.

The underlying ethos of dbGaP is that access to these data by secondary data analysts facilitates advancement of science. NIH has required that genome-wide association study data be deposited in the Database of Genotypes and Phenotypes (dbGaP) since 2003. In 2013, a proposed updated policy extended this requirement to next-generation sequencing data. However, recent literature and anecdotal reports suggest lingering logistical and ethical concerns about subject identifiability, informed consent, publication embargo enforcement, and difficulty in accessing dbGaP data. We surveyed the International Genetic Epidemiology Society (IGES) membership about their experiences. One hundred and seventy five (175) individuals completed the survey, a response rate of 27%. Of respondents who received data from dbGaP (43%), only 32% perceived the application process as easy but most (75%) received data within five months. Remaining challenges include difficulty in identifying an institutional signing official and an overlong application process. Only 24% of respondents had contributed data to dbGaP. Of these, 31% reported local IRB restrictions on data release; an additional 15% had to reconsent study participants before depositing data. The majority of respondents (56%) disagreed that the publication embargo period was sufficient. In response, we recommend longer embargo periods and use of varied data-sharing models rather than a one-size-fits-all approach.

PedMerge: merging pedigrees to facilitate family-based genetic statistical analyses.

SUMMARY: PedMerge allows users to accurately and efficiently merge separately ascertained pedigrees that belong to the same extended family. In addition to validation checks of pedigree structure, the software provides files in LINKAGE or PEDSYS format that easily allow to be used by a variety of genetic statistical software packages including LINKAGE, SOLAR, SLINK or can be further manipulated with Mega2. AVAILABILITY: http://sites.google.com/site/rosemarieplaetke/home/s/pedmerge

Relationships between plasma adiponectin and body fat distribution, insulin sensitivity, and plasma lipoproteins in Alaskan Yup'ik Eskimos: the Center for Alaska Native Health Research study.

Adiponectin, a protein secreted by adipose tissue, has antiatherogenic, anti-inflammatory, and insulin-sensitizing actions. We examined the relationship between plasma adiponectin and adiposity, insulin resistance, plasma lipids, glucose, leptin, and anthropometric measurements in 316 adult men and 353 adult women Yup'ik Eskimos in Southwest Alaska. Adiponectin concentration was negatively associated with body mass index, percentage of body fat, sum of skin folds, waist circumference, triglycerides, insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR]), fasting insulin, and leptin in both men and women, and also with glucose in women. Adiponectin concentration correlated positively with high-density lipoprotein cholesterol concentration, and also with low-density lipoprotein cholesterol in women. Insulin-sensitive individuals (HOMA-IR <3.52, n = 442) had higher plasma adiponectin concentrations than more insulin-resistant individuals (HOMA-IR >or=3.52, n = 224): 11.02 +/- 0.27 microg/mL vs 8.26 +/- 0.32 microg/mL, P < .001. Adiponectin concentrations did not differ between groups of participants with low and high level of risk for developing coronary heart disease. No difference in plasma adiponectin levels was found among Yup'ik Eskimos and whites matched for sex, age, and body mass index. In conclusion, circulating adiponectin concentrations were most strongly associated with sum of skin folds in Yup'ik men and with high-density lipoprotein cholesterol levels, sum of skin folds, waist circumference, and insulin and triglycerides concentrations in Yup'ik women.

Metabolic syndrome in Yup'ik Eskimos: the Center for Alaska Native Health Research (CANHR) Study.

OBJECTIVE: This study investigated the prevalence of metabolic syndrome and its defining components among Yup'ik Eskimos. RESEARCH METHODS AND PROCEDURES: A cross-sectional study design that included 710 adult Yup'ik Eskimos >or=18 years of age residing in 8 communities in Southwest Alaska. The prevalence of metabolic syndrome was determined using the recently updated Adult Treatment Panel III criteria. RESULTS: The prevalence of metabolic syndrome in this study cohort was 14.7%, and varied by sex with 8.6% of the men and 19.8% of the women having metabolic syndrome. This is lower than the prevalence of 23.9% in the general U.S. adult population. The most common metabolic syndrome components/risk factors were increased waist circumference and elevated blood glucose. High-density lipoprotein (HDL) cholesterol levels in Yup'ik Eskimos were significantly higher, and triglycerides lower than levels reported in National Health and Nutritional Examination III. DISCUSSION: Compared with other populations, metabolic syndrome is relatively uncommon in Yup'ik Eskimos. The higher prevalence among Yup'ik women is primarily explained by their large waist circumference, suggesting central body fat accumulation. Further increases in metabolic syndrome risk factors among Yup'ik Eskimos could lead to increases in the prevalence of type 2 diabetes and cardiovascular disease, once rare in this population.

The Center for Alaska Native Health Research Study: a community-based participatory research study of obesity and chronic disease-related protective and risk factors.

OBJECTIVES: To describe the background, approach and general results of the Center for Alaska Native Health Research (CANHR) study. STUDY DESIGN: This was a cross-sectional Community-Based Participatory Research (CBPR) study with one tribal group to assess risk and protection for obesity and the risk factors related to chronic disease, diabetes and cardiovascular disease. METHODS: A combination of biological, genetic, nutritional and psychosocial measurements were taken on 922 Alaska Native participants in ten communities in Southwestern Alaska. The paper reports on data from 753 adult participants. RESULTS: The prevalence of type 2 diabetes is 3.3% in the sample population. Metabolic syndrome is significantly lower among the males and equal for females when compared with Caucasians in the NHANES III sample. Obesity among adults is now at the national average. Risk factors for chronic disease include a shift to a Westernized diet, stress, obesity and impaired fasting glucose and protective factors include high levels of polyunsaturated fatty acid dietary intake. Articles in this issue present specific results in these areas. CONCLUSIONS: The data strongly indicate that, in general, Yup'ik people in our study are metabolically healthy and that diet and life style provide a delicate combination of protective and risk factors. The results strongly indicate that solution focused research utilizing primary and secondary prevention strategies may provide evidence for how to intervene to prevent further increases of chronic diseases. Research that focuses on relating the intrinsic strengths of indigenous worldviews and practices with basic research may contribute to positive transformations in community health.

Building a community-based participatory research center to investigate obesity and diabetes in Alaska Natives.

The Center for Alaska Native Health Research (CANHR) is a community-based participatory research project aimed at understanding current risk factors for obesity, diabetes, and cardiovascular disease in Alaska Natives living in Southwest Alaska. We utilize a multidisciplinary approach that includes assessment of genetic, nutritional and behavioral risk factors and their interrelationships with one another in the overall development of disease. The design of the CANHR project involved community participation in the development, implementation and interpretation of research results. We have developed a participatory research program that is designed to be culturally appropriate, relevant to community needs and interests, and respectful to our participants. This manuscript describes the organizational development of our CANHR study and the procedures employed in its progression to date.

The Family Investigation of Nephropathy and Diabetes (FIND): design and methods.

BACKGROUND: The Family Investigation of Nephropathy and Diabetes (FIND) is a multicenter study designed to identify genetic determinants of diabetic nephropathy. It is conducted in eight U.S. clinical centers and a coordinating center, and with four ethnic groups (European Americans, African Americans, Mexican Americans, and American Indians). Two strategies are used to localize susceptibility genes: a family-based linkage study and a case-control study using mapping by admixture linkage disequilibrium (MALD). METHODS: In the family-based study, probands with diabetic nephropathy are recruited with their parents and selected siblings. Linkage analyses will be conducted to identify chromosomal regions containing genes that influence the development of diabetic nephropathy or related quantitative traits such as serum creatinine concentration, urinary albumin excretion, and plasma glucose concentrations. Regions showing evidence of linkage will be examined further with both genetic linkage and association studies to identify genes that influence diabetic nephropathy or related traits. Two types of MALD studies are being done. One is a case-control study of unrelated individuals of Mexican American heritage in which both cases and controls have diabetes, but only the case has nephropathy. The other is a case-control study of African American patients with nephropathy (cases) and their spouses (controls) unaffected by diabetes and nephropathy; offspring are genotyped when available to provide haplotype data. CONCLUSIONS: Identification of genes that influence susceptibility to diabetic nephropathy will lead to a better understanding of how nephropathy develops. This should eventually lead to improved treatment and prevention.

Do middle school students really have fixed images of elders?

OBJECTIVE: The purpose of this study was to determine whether combinations of characteristics, abstracted from drawings of elders made by middle school students, grouped together to form cohesive perceptions, or stereotypes, of human aging. METHODS: We abstracted 49 characteristics from drawings of elders made by 1,944 students at two middle schools in San Antonio, Texas, at the beginning of the 1998-1999 school year. Correlational and factor analyses were used to determine if there was an underlying structure or grouping to the characteristics. Logistic regression was used to determine the variables associated with the investigators' classification of the images as positive, neutral, or negative. RESULT: The standardized alpha coefficient for the 49 variables was low (alpha = 0.37). The Spearman rho correlations between the variables were also low, with 90.2% of the 1,176 comparisons being < 0.10. Exploratory factor analyses did not provide a useful grouping of characteristics drawn by the students, including analyses stratified by gender and restricted to the most common 34 characteristics. Among the 49 characteristics that emerged from the drawings, 11, 4, and 11 traits were directly associated with classifying the drawings as positive, neutral, or negative, respectively. DISCUSSION: These analyses indicate that middle school students have not formed strong images regarding aging: No clear cohesive stereotypes of elders emerged from the images drawn by these children. Absence of stereotypic views implies that middle school students may not have a built-in bias toward older people and age-associated changes. This suggests that young adolescents are at a point where instruction including gerontological content can be used to effectively teach about aging and health promotion.

Sentence completion to assess children's views about aging.

PURPOSE: Sentence completion exercises require students to give open-ended responses to prompts. The first purpose of this article is to describe the method of sentence completion to assess middle-school children's attitudes and beliefs about aging. The second purpose is to describe the patterns of characteristics that children associate with aging. DESIGN AND METHODS: Two middle schools in San Antonio, TX agreed to have their students participate in the sentence completion exercises at the beginning of the 1998-1999 school year. Teachers asked students to write responses to the following prompts: "Old is.," "You know you are old when.," "You know your parents are old when.," "When I am old, I.," and "Old people." We coded the responses for their characteristics and whether they were positive, negative, or neutral. RESULTS: Of the 2,476 students, 1,874 (75.6%) wrote responses to at least one prompt. Overall, we collected 3,700 responses and coded 9,438 characteristics (2.6 characteristics per response). The most common characteristics of aging were having wrinkles (21.1%), having gray hair or being bald (20.0%), and being less active (17.5%). Students had a much more positive view of their future (55.4%) compared with their view of aging elicited by the other prompts (range of 4.9-25.7% positive responses). Students infrequently associated old age with specific conditions; only 4.6% mentioned diseases, 6.0% mentioned being ill or taking medications, and 5.7% mentioned sensory problems. IMPLICATIONS: Middle-school students view their futures much more positively than the changes they observe in their parents and other elders. Students infrequently identified specific diseases or impairments as responsible for the changes they observe with aging. These observed responses provide a starting point for educators to develop and deliver gerontologically based materials that teach about healthful habits to maintain independence across a life span.

Genetic fieldwork for hereditary prostate cancer studies.

The success of a genetic family study depends on the recruitment of a sufficient number of unaffected family members. We present our experiences from interviews performed in two family studies, a genetic family study of prostate cancer (PC) and a medical, anthropological, qualitative study. In the genetic family study, 949 PC patients were contacted, and 29% responded. Response rates were higher (44%) among subjects contacted by health providers participating in the study, compared to only 18% of those contacted by letter. Thirty-six pedigrees were ascertained. On average, each family had 3.3 affected relatives. Average age at time of diagnosis was 61.9 years in the probands. 58% of the families reported additional cancers. Breast cancer was reported in 12 families; colon cancer was the second most reported cancer, followed by lung, stomach, and throat cancers. Beliefs about the inheritance of PC were explored with 20 participants. The parental origin of the proband's PC in each family did not significantly affect participants' beliefs about the inheritance of PC. 95% agreed that PC could be inherited from a father to a son. Participants thought that a mother (n = 12) or daughter of a patient (n = 11) could not give PC to their sons. This misperception of the inheritance of PC can result in (1) an underreporting of PC cases in a kindred, and (2) healthy men underestimating their risk of developing PC when the disease runs in the mother's family. Thus health educators and genetic counselors might consider these findings when teaching patients and their relatives about hereditary PC.

Incorporating the Contextual Assessment Approach to regimens used in genetic family studies.

PURPOSE: To develop a procedure that enhances enrollment and addresses ethical issues associated with participation in genetic family studies. METHODS: The Contextual Assessment Approach (CAA) was standardized to the recruitment procedures in the Family Investigation of Nephropathy and Diabetes (FIND) study at the University of Texas Health Science Center at San Antonio. Structured interviews with the CAA questionnaire (CAA-Q) were conducted with 50 low-income Mexican-American probands. The CAA allows systematic interpretation of health beliefs, family dynamics, and attitudes regarding participation in FIND. Data analyses included qualitative and quantitative methods. RESULTS: CAA analyses of probands' perspectives regarding relatives' enrollment in FIND facilitated recruiting 34 probands from whom 30 families were enrolled (family enrollment rate: 88%). CAA reduced recruitment efforts by 32% and avoided exerting undue pressure on unwilling participants to ensure voluntary participation. Remarkably, 76% of the subjects were unaware of any risk associated with participation in genetic family studies. CONCLUSIONS: Administering the CAA-Q before enrolling subjects in FIND increased our enrollment rate by targeting efforts toward the willing subjects and addressing ethical issues associated with their participation.