A comparison of an implanted accelerometer with a wearable accelerometer for closed-loop DBS.

Sensing technology, as well as cloud communication, is enabling the development of closed-loop deep brain stimulation (DBS) for Parkinson's disease. The accelerometer is a practical sensor that can provide information about the disease/health state of the patient as well as physical activity levels, all of which in the long-term can provide feedback information to an adaptive closed-loop control algorithm for more effective and personalized DBS therapy. In this paper, we present for the first time, acceleration streamed from Medtronic's RC+S device in patients with Parkinson's disease while at home, and compare it to accel-eration acquired concurrently from the patient's Apple Watch. We examined correlation between the accelerometer signals at varying time scales. We also compared the spectral band power obtained from the two accelerometers. While there was an average correlation of 0.37 for subject 1 and 0.50 for subject 2 between the two acceleration signals on a time scale of 10 minutes, the correlation was lower for shorter time scales on the order of seconds. There was greater spectral power in the Parkinsonian tremor band of 4-7 Hz for the externally worn accelerometer than the internal accelerometer, but the internal accelerometer showed greater relative power distributed in the higher frequencies (7-30 Hz). Thus, based on this preliminary analysis, we expect that the internal accelerometer may be used to assess patient activity and state for closed loop DBS but tremor detection may require more sophisticated signal processing. Furthermore, the internal accelerometer may contain information in higher frequency bands that reveal information about the patient state. Clinical relevance - Closed-loop DBS is expected to improve patient outcomes for the tens of thousands of Parkinson's disease patients using DBS [1], [2]. Eliminating an additional external device in order to implement closed-loop adaptive deep brain stimulation would benefit DBS patients however an understanding of what information is lost by doing so is needed to justify the ultimate design of closed-loop DBS.

The Effect of Medical Home on Shared Decision-Making for Caregivers of Children with Emotional, Developmental, or Behavioral Health Conditions.

INTRODUCTION: Known as the "pinnacle of patient-centered care," shared decision-making (SDM) is the process that enables and encourages the health care provider, the patient, and/or their caregiver (parent or guardian) to participate collaboratively in medical decisions. Prior research indicates that children with emotional, developmental, or behavioral health conditions (EDB) are less likely to attain SDM than children with other special health care needs (SHCNs). This study investigates whether the presence of a medical home reduces disparities in SDM among children with EDB when compared to children with other SHCNs and the general pediatric population. METHODS: Using the 2016 National Survey of Children's Health, we conducted weighted descriptive statistics to investigate the prevalence of medical home and SDM for children with (1) EDB, (2) other SHCNs, and (3) no SHCNs. We then employed a nested multivariate logistic regression model to examine whether the presence of a medical home reduced the disparity between children with EDB and their counterparts. RESULTS: Nationally, 21% of children with EDB (n = 647,274), 14.0% of children with other SHCNs (n = 1,086,068), and 13% of children with no SHCNs (n = 883,969) did not attain caregiver-reported SDM in medical care. In each of the health condition groups, the presence of a medical home significantly improved the odds of SDM (p < 0.001). Presence of a medical home also reduced the disparities observed in caregiver-reported SDM among children with EDB as compared to those with other SHCNs and no SHCNs. DISCUSSION: Ongoing investment in medical homes may reduce disparities in SDM experienced by children with EDB.

Correlation Between the Posterior Mandibular Width and the Lingual Gap Caused by Symphyseal Fractures Using a Virtual Model.

PURPOSE: The objective was to determine the dimensional impact, on the occlusal and articular level, of the gap produced in the lingual plate from symphyseal fractures, correlated with the dimensional change in the posterior mandibular width. MATERIALS AND METHODS: We performed an observational experimental study based on 30 computed tomography scans of patients treated by the Maxillofacial Surgery Service, Hospital Clínico Mutual de Seguridad, Santiago, Chile, between 2012 and 2016. The inclusion criteria were jaws without evidence of fractures or pathology, with an absence of orthodontic appliances, and with complete dentition to the first mandibular molar. By use of Digital Dental Service 3-dimensional planning software (DDS-Pro; Digital Dental Service, London, UK), a vertical mandibular fracture was made, leaving lingual gaps of 1, 2, and 3 mm, and the dimensional changes were recorded with regard to the posterior facial width. RESULTS: The mandibular height did not vary with regard to the lingual gap; the mandibular length was inversely proportional to the lingual gap; and the intermolar, intergonial, and intercondylar distances were directly proportional to increases in the lingual gap. CONCLUSIONS: The larger the lingual gap, the shorter the mandibular length and the larger the mandibular transverse dimensions. Special attention must be paid to the occlusal and articular level.

Stakeholders' Perspectives on Stakeholder-engaged Research (SER): Strategies to Operationalize Patient-centered Outcomes Research Principles for SER.

BACKGROUND: US federal funding agencies increasingly incentivize stakeholder-engaged research which represents a paradigm shift toward incorporating a range of stakeholders in research design, conduct, and dissemination. OBJECTIVES: We use qualitative methods to capture experience-based recommendations on how to operationalize 4 Patient-Centered Outcomes Research (PCOR) principles in stakeholder-engaged research, specifically: (1) reciprocal relationships; (2) colearning; (3) partnership; and (4) trust, transparency, and honesty. RESEARCH DESIGN: We conducted semistructured interviews with members of a stakeholder panel who participated in a 2-year comparative effectiveness study of cholesterol screening and treatment among young adults. SAMPLE: Participants included 8 young adults and parent panelists and 11 professional panelists (clinicians, researchers, policy developers, and disseminators). MEASURES: The interview guide included questions about the 4 PCOR principles and queried preferred strategies to attain them. Interview transcripts were analyzed using an a priori and emergent coding structure. RESULTS: Participants provided strategies to promote the 4 PCOR principles. Although some stakeholder-identified strategies were complementary, others conflicted due to (1) competing ideologies identified among the principles, and (2) distinct stakeholder preferences. Illustrative of competing ideologies, participants simultaneously preferred receiving relevant articles before calls (to facilitate colearning) but also minimal outside reading (to achieve partnership). Illustrative of distinct stakeholder preferences, young adult and parent panelists generally preferred calls to occur on weekends/evenings, whereas professional panelists preferred mid-week work hours. CONCLUSIONS: Our exploratory study provides stakeholder-identified strategies to achieve the 4 PCOR principles, and demonstrates the need to identify, acknowledge, and address potentially conflicting strategies due to the potential for competing ideologies or variation in stakeholder preferences.

Pénfigo herpetiforme: reporte de caso / Pemphigus herpetiformis: case report

El pénfigo herpetiforme es una variante clínica infrecuente del pénfigo, que presenta similitud clínica con la dermatitis herpetiforme, con presencia histológica de acantólisis y de ampolla intrapidermica. Se presenta el caso de un paciente de 61 años, con lesiones vesiculares pruriginosas, de 3 a 8 mm un, de conformación arciforme y herpetiforme, localizadas en el tórax y las extremidades. La histopatología y la inmunofluorescencia directa fueron compatibles con pénfigo. El paciente tuvo mejoría luego del tratamiento con inmunoglobulina intravenosa.

The pemphigus herpetiformis is a rare clinical variant of pemphigus, which presents clinical similarity with dermatitis herpetiformis, but with the histological presence of acantholysis and intraepidermal blister. We present the case of a 61 year old male patient with pruritic vesicular lesions of 3-8 mm of acute and herpetiform configuration over his thorax and extremities. The histopathology and direct immunofluorescence were consistent with pemphigus. The patient had improvement after treatment with intravenous immunoglobulin.

Does higher cost mean better quality? evidence from highly-regarded adolescent drug treatment programs.

We conducted a survey to examine whether reimbursement levels are associated with the quality of adolescent substance use treatment programs in the United States. Between March and September 2005, telephone and written surveys were administered to program, clinical, and finance directors of previously surveyed highly regarded programs. Differences in quality scores were compared for programs with above versus below median reimbursement levels and examined in multivariate regression models constructed separately for programs offering residential and outpatient treatment. In residential treatment multivariate regression models, higher quality scores were associated with higher reimbursement, but this relationship was not observed for outpatient treatment. Even the highest level of outpatient reimbursement received may be too low to support quality improvement initiatives. Our results suggest that higher reimbursement may be a necessary component of quality improvement for residential adolescent drug treatment programs, and emphasize the need for further research to determine what levels of reimbursement and insurance coverage policies will encourage the expansion of high quality outpatient programs.