A structured, journal-led peer-review mentoring program enhances peer review training.

BACKGROUND: Peer review is essential to the advancement of knowledge. However, training on how to conduct peer review is limited, unorganized, and not well studied. Thus, we sought to determine if a structured mentored peer-review program improved peer review training as measured by multiple quantitative and qualitative assessments. METHODS: This pre-post intervention study enrolled 55 mentees across 5 cohorts from 2020 to 2023. Each cohort completed pre-program evaluations, participated in 2 mentored reviews, and completed post-program evaluations over 6 months. Mentors and mentees completed pre-program demographic and review experience questionnaires. Outcome measures included (1) total and sub-scores on the modified Review Quality Index (mRQI) applied to the same pre-selected research manuscript reviewed by mentees both pre and post intervention, (2) mentee self-perceived comfort with and understanding of the review process using a custom questionnaire, and (3) mentor satisfaction surveys. Pre- and post-program measures were compared using the Wilcoxon signed-rank test. RESULTS: Post-program total modified RQI score (median (IQR) = 31 (26.3-35.8)) was higher than pre-program total score (26.6 (19.7-29.7)) for the 42 mentees who completed both pre- and post-program reviews. Mentees reported improved perception of review (median (IQR) pre = 4 (3-4), post = 5 (4-5)) and editorial processes (pre = 3 (2-4), post = 4 (4-5)) as well as self-perceived confidence in completing an independent review of both scientific (median (IQR) pre = 2 (2-3), post = 4 (4-4)) and non-scientific (pre = 3 (2-4), post = 4 (4-5)) manuscripts following program participation. p < 0.0001 for all scores noted. Mentors reported high scores for enjoyment (median (range) 5/5 (3-5)) and interest in repeat participation (5/5 (2-5)). CONCLUSIONS: A 6-month structured mentored-review program including 2 mentored reviews improves peer review training as measured by the modified RQI as well as participant self-perceived understanding of publication science with high mentor satisfaction.

Social Determinants of Health in Idiopathic Intracranial Hypertension.

BACKGROUND: Idiopathic intracranial hypertension (IIH) disproportionately affects women from socioeconomically disadvantaged communities, but specific social determinants of health have not been examined. METHODS: We used data from the National Institutes of Health's All of Us Research Program, an ongoing nationwide study of more than 300,000 diverse individuals in the United States. Height and weight were measured at baseline, and participants completed questionnaires about demographics, health care access, and quality of life. Women aged 18-50 years with IIH were identified through electronic health record data, excluding those with venous thrombosis, meningitis, hydrocephalus, or central nervous system neoplasms. We used logistic regression to compare questionnaire responses for IIH cases and controls, adjusting for age, race, ethnicity, annual income, and body mass index (BMI). RESULTS: We included 416 women with IIH and 107,111 women without IIH. The mean age was 38 years, and 49.3% identified as non-White. After adjusting for age, race/ethnicity, and BMI, women with IIH were more likely to be unemployed (odds ratio [OR] 1.40, 95% confidential interval [CI]: 1.14-1.71) and report delaying care because of difficulty affording copays (OR 1.47, 95% CI: 1.02-2.10) or specialist care (OR 1.52, 95% CI: 1.06-2.18). They also delayed care because of rural residence (OR 2.08, 95% CI: 1.25-3.47) and transportation limitations (OR 2.23, 95% CI: 1.55-3.20). Although women with IIH were more likely to be non-Hispanic Black (OR 1.66, 95% CI: 1.32-2.09), this association lost significance when controlling for BMI and income (OR 1.27, 95% CI: 0.96-1.68). CONCLUSIONS: Women with IIH experience adverse social determinants of health beyond those associated with obesity alone.

Caregiver Burden in Parkinson Disease: A Scoping Review of the Literature from 2017-2022.

Caregiver burden is a term that refers to the adverse effect of caregiving on the physical, emotional, social, spiritual, and financial well-being of the caregiver. Caregiver burden is associated with providing care to an individual with a chronic illness or disability, and the unique symptoms of Parkinson disease (PD) can amplify a patient's needs and reliance on others, leading to adverse outcomes for patients and their caregivers. In this scoping review of the literature from January 2017 through April 2022 that included 114 studies, we provide an updated, evidence-based summary of patient and caregiver-related factors that contribute to caregiver burden in PD. We also describe the impact of caregiver stress and burden on caregivers based on qualitative research studies and review recent interventions to mitigate burden. By providing clinical updates for practitioners, this review is designed to improve recognition of caregiver burden in the post-pandemic era and foster the development of targeted interventions to reduce caregiver burden in PD.

Unique characteristics of end-of-life hospitalizations in Parkinson disease.

Introduction: Persons with Parkinson disease (PD) are hospitalized at higher rates, have longer lengths of stay, and are more likely to die in the hospital than age-matched peers. Although prior studies have compared inpatient outcomes between persons with and without PD, little is known about inpatient outcomes across the PD trajectory, or whether hospitalizations occurring in the last 6 months of life differ from earlier hospitalizations. Methods: This cross-sectional study compared Medicare Part A and B beneficiaries aged 65 and older with a qualifying PD diagnosis who were hospitalized in 2017: decedents who died between 7/1/2017 and 12/31/2017 from all causes and were hospitalized at least once in their last 6 months of life, and non-decedents who were hospitalized between 1/1/2017 and 6/30/2017 and lived 6 or more months after discharge. End-of-life (EoL) hospitalizations were defined as those occurring in the last 6 months of life. Descriptive analyses compared patient-level variables (e.g., demographics, comorbidities, treatment intensity) and encounter-level variables (e.g., length of stay, total charges) between groups. Multivariable logistic regression models also compared rates of intensive care unit (ICU) admission and 30-day readmission between hospitalized decedents and hospitalized non-decedents, adjusting for age, sex, race/ethnicity, rural residence, and Charlson Comorbidity Index Score. Results: Of 26,492 Medicare decedents with PD, 16,187 (61.1%) were hospitalized in their last 6 months of life. Of 347,512 non-decedents with PD, 62,851 (18.1%) were hospitalized in a 6-month period. Hospitalized decedents were slightly older than hospitalized non-decedents (82.3 [SD 7.40] vs. 79.5 [SD 7.54] years) and had significantly more comorbidities. Compared to non-EoL hospitalizations, EoL hospitalizations were slightly longer (5 [IQR 3-9] vs. 4 [IQR 3-7] days) and more expensive based on total charges per admission ($36,323 [IQR 20,091-69,048] vs. $32,309 [IQR 18,789-57,756]). In covariate-adjusted regression models using hospitalized non-decedents as the reference group, hospitalized decedents were more likely to experience an ICU admission (AOR 2.36; CI 2.28-2.45) and 30-day readmission (AOR 2.43; CI 2.34-2.54). Discussion: Hospitalizations occurring in the last 6 months of life among persons with PD in the United States are longer, more costly, and more resource intensive than earlier hospitalizations and may stem from medical comorbidities. Once hospitalized, ICU admission and 30-day readmission may aid in prognostication and serve as markers of transition to the EoL period.

Weight and survival after deep brain stimulation for Parkinson's disease.

BACKGROUND: Weight loss in Parkinson's disease (PD) is common and associated with increased mortality. The clinical significance of weight changes following deep brain stimulation (DBS) of the subthalamic nucleus (STN) and globus pallidus internus (GPi) is unclear. OBJECTIVES: To address (1) whether PD patients exhibit progressive weight loss, (2) whether staged DBS surgery is associated with weight changes, and (3) whether survival after DBS correlates with post-DBS weight. METHODS: This is a single-center, longitudinal, retrospective cohort study of 1625 PD patients. We examined trends in weight over time and the relationship between weight and years survival after DBS using regression and mixed model analyses. RESULTS: There was a decline in body weight predating motor symptom onset (n = 756, 0.70 ± 0.03% decrease per year, p < 0.001). Weight decline accelerated in the decade preceding death (n = 456, 2.18 ± 0.31% decrease per year, p < 0.001). DBS patients showed a weight increase of 2.0 ± 0.33% at 1 year following the first DBS lead implant (n = 455) and 2.68 ± 1.1% at 3 years if a contralateral DBS lead was placed (n = 249). The bilateral STN DBS group gained the most weight after surgery during 6 years of follow up (vs bilateral GPi, 3.03 ± 0.45% vs 1.89 ± 0.31%, p < 0.01). An analysis of the DBS cohort with date of death available (n = 72) revealed that post-DBS weight (0-12 months after the first or 0-36 months after the second surgery) was positively associated with survival (R2 = 0.14, p < 0.001). DISCUSSION: Though PD is associated with significant weight loss, DBS patients gained weight following surgery. Higher post-operative weight was associated with increased survival. These results should be replicated in other cohorts.

Spirituality and Spiritual Distress in Parkinson's Disease Caregivers: A Scoping Review.

Despite recognition that spiritual concerns contribute to caregiver burden, little is known about spirituality, spiritual well-being, and spiritual distress in Parkinson's disease caregivers. In this scoping review of the literature through October 2022, we searched PubMed, PsychINFO, Embase, and CINAHL. From an initial pool of 328 studies, 14 were included. Caregiver factors (e.g., depression, age) and patient factors (e.g., faith, motor function) affected caregiver spirituality and spiritual well-being. Caregivers experienced loss of meaning, existential guilt, and loneliness, and coped through acquiescence, cultural beliefs, prayer, and gratitude. Future research should focus on the specific spiritual needs of Parkinson's disease caregivers and interventions to address them.

Parkinson's Pals: A Student-Led Program to Facilitate Intergenerational Connections and Promote Psychosocial Well-Being Among Persons with Parkinson's Disease.

Parkinson's disease (PD) causes unique motor and non-motor symptoms. Despite symptomatic treatment with pharmacotherapies, many persons with PD report feelings of loneliness and demoralization as their disease progresses. These symptoms greatly interfere with quality of life, necessitating novel treatment strategies. In this report, we introduce a new student-led program to improve psychosocial well-being among persons with PD by pairing them with college students. Through weekly one-on-one meetings, students gain a deeper understanding of PD, while patients gain a new social outlet and purpose. Based on the program's initial successes, we advocate for the adoption of similar programs at universities worldwide.

Clinical Reasoning: A 48-Year-Old Man With Spasticity and Progressive Ataxia.

A 48-year-old man was referred to the movement disorders clinic for 10 years of progressive slurred speech, spasticity, limb incoordination, and wide-based gait. Extensive neurologic workup was inconclusive, including serum and CSF testing, neuroimaging, EMG/NCS, exome sequencing, and mitochondrial testing. An ataxia repeat expansion panel ultimately revealed the final diagnosis. In this report, we review the clinical characteristics of a rare, late-onset, autosomal recessive cerebellar ataxia and discuss the importance of pursuing targeted gene testing to avoid diagnostic delays, especially as new treatments for this and other genetic diseases become available.

Association of Caregiver Depression Risk With Patient Outcomes in Parkinson Disease.

Importance: Caregivers are integral to Parkinson disease (PD) care, but little information exists regarding how caregivers impact patient outcomes. Objective: To assess the association between caregivers reporting depression symptoms and patient quality of life (QOL), emergency department (ED) visits, and hospitalizations. Design, Setting, and Participants: This retrospective cohort study was conducted at 15 Parkinson's Foundation Centers of Excellence within the US. The Parkinson's Foundation Parkinson Outcomes Project registry was used to collect baseline data from January 1, 2016, to December 31, 2018, with subsequent annual study visits through July 31, 2020. Data were analyzed from August 5, 2020, to June 9, 2023. A convenience sample of 454 patients with PD and their caregivers was recruited during routine clinical visits with movement disorder specialists. Patients with a physician diagnosis of idiopathic PD who lived at home and had 1 or more follow-up study visits were included. Exposure: Caregiver depression symptoms using the Center for Epidemiologic Studies Depression Scale. Main Outcomes and Measures: Patient health-related QOL (measured by the 39-item Parkinson Disease Questionnaire), number of annual ED visits, and number of annual hospitalizations were measured. The independent association between caregivers reporting depression symptoms and patient outcomes was assessed using linear mixed-effects and Poisson regression models. The a priori hypotheses were that a greater number of depression symptoms reported via the Center for Epidemiologic Studies Depression Scale would be associated with worse patient QOL and a greater number of ED visits and hospitalizations. Results: Among 454 patient-caregiver dyads (patients: mean [SD] age, 67.3 [8.4] years; 320 men [70.5%]; caregivers: mean [SD] age, 65.9 [8.7] years; 326 women [71.8%]), the mean (SD) follow-up was 2.0 (1.4) study visits. Greater depression symptoms among caregivers were associated with worse patient QOL as measured by the Parkinson Disease Questionnaire (mean [SD] score, 33.78 [17.71], on a scale of 0-100, with higher scores indicating worse QOL, among patients with caregivers who had depression symptoms vs 24.50 [14.19] among patients with caregivers who did not have depression symptoms; ß = 0.43; 95% CI, 0.28-0.58; P < .001) and more annual ED visits (ß = 0.02; 95% CI, 0 to 0.04; P = .03) but not more hospitalizations (ß = 0.02; 95% CI, -0.01 to 0.03; P = .10). Conclusions and Relevance: In this cohort study, patients with PD who had caregivers at higher risk of depression were more likely to have worse QOL and higher ED use than patients who had caregivers not at higher risk of depression. Additional caregiving resources and interventions to reduce caregiver depression symptoms could potentially improve patient outcomes.

Sociodemographic and Geographic Disparities in End-of-Life Health Care Intensity Among Medicare Beneficiaries With Parkinson Disease.

Background and Objective: Current studies of end-of-life care in Parkinson disease (PD) do not focus on diverse patient samples or provide national views of end-of-life resource utilization. We determined sociodemographic and geographic differences in end-of-life inpatient care intensity among persons with PD in the United States (US). Methods: This retrospective cohort study included Medicare Part A and Part B beneficiaries 65 years and older with a qualifying PD diagnosis who died between January 1, 2017, and December 31, 2017. Medicare Advantage beneficiaries and those with atypical or secondary parkinsonism were excluded. Primary outcomes included rates of hospitalization, intensive care unit (ICU) admission, in-hospital death, and hospice discharge in the last 6 months of life. Descriptive analyses and multivariable logistic regression models compared differences in end-of-life resource utilization and treatment intensity. Adjusted models included demographic and geographic variables, Charlson Comorbidity Index score, and Social Deprivation Index score. The national distribution of primary outcomes was mapped and compared by hospital referral region using Moran I. Results: Of 400,791 Medicare beneficiaries with PD in 2017, 53,279 (13.3%) died. Of decedents, 33,107 (62.1%) were hospitalized in the last 6 months of life. In covariate-adjusted regression models using White male decedents as the reference category, odds of hospitalization was greater for Asian (AOR 1.38; CI 1.11-1.71) and Black (AOR 1.23; CI 1.08-1.39) male decedents and lower for White female decedents (AOR 0.80; CI 0.76-0.83). ICU admissions were less likely in female decedents and more likely in Asian, Black, and Hispanic decedents. Odds of in-hospital death was greater among Asian (AOR 2.49, CI 2.10-2.96), Black (AOR 1.11, CI 1.00-1.24), Hispanic (AOR 1.59; CI 1.33-1.91), and Native American (AOR 1.49; CI 1.05-2.10) decedents. Asian and Hispanic male decedents were less likely to be discharged to hospice. In geographical analyses, rural-dwelling decedents had lower odds of ICU admission (AOR 0.77; CI 0.73-0.81) and hospice discharge (AOR 0.69; CI 0.65-0.73) than urban-dwelling decedents. Nonrandom clusters of primary outcomes were observed across the US, with highest rates of hospitalization in the South and Midwest (Moran I = 0.134; p < 0.001). Discussion: Most persons with PD in the US are hospitalized in the last 6 months of life, and treatment intensity varies by sex, race, ethnicity, and geographic location. These group differences emphasize the importance of exploring end-of-life care preferences, service availability, and care quality among diverse populations with PD and may inform new approaches to advance care planning.

Racial and Ethnic Disparities in Parkinson Disease: A Call to Action.

Health disparities are pervasive in the United States. In the field of Parkinson disease (PD), profound racial and ethnic disparities exist in diagnosis, treatment, and research participation, leading to differential health outcomes and lack of generalizable research data. Racial and ethnic disparities not only limit our understanding of this complex heterogeneous disorder but also hamper our ability to provide new evidence-based care for America's most vulnerable populations. In this report, we summarize findings from our comprehensive white paper for the Michael J. Fox Foundation that reviews the current state of knowledge on racial and ethnic disparities in PD care in the following areas: epidemiology, etiology, phenotype and diagnosis, treatment, and research. We also identify knowledge gaps and necessary policy changes to ensure equitable, high-value care for all persons with PD. These strategies are designed to help identify and reduce health disparities among persons with PD and may serve as a model for other neurologic diseases.

Gait abnormalities and non-motor symptoms predict abnormal dopaminergic imaging in presumed drug-induced Parkinsonism.

Drug-induced parkinsonism (DIP) can be clinically indistinguishable from degenerative parkinsonism, and bedside assessments are needed to differentiate between these conditions. We examined 34 U.S. Veterans with DIP using 123I-FP-CIT (DAT-SPECT) to identify underlying nigrostriatal degeneration. Participants were 94% male with mean age of 64.5 ± 7.1 years. DAT-SPECT was abnormal in 12/34 (35%). Comparing normal and abnormal imaging groups, there were no differences in age, sex, race/ethnicity, psychiatric diagnosis, motor severity, or RBD Screening Questionnaire scores. Those with underlying neurodegeneration reported significantly more non-motor symptoms (NMS), worse olfactory function on the University of Pennsylvania Smell Identification Test, and greater turning duration/steps on the instrumented Timed Up and Go. Area under the curve (AUC) combining poor olfaction and total NMS burden was 0.84 (CI 0.71-0.97), while AUC for turn steps was 0.91 (CI 0.81-1.00). Gait impairment, hyposmia, and NMS may be useful alone and in combination to identify DIP patients with underlying dopaminergic degeneration.

Neurofilament Light Chain as a Biomarker for Cognitive Decline in Parkinson Disease.

BACKGROUND: Neurofilament light chain protein (NfL) is a promising biomarker of neurodegeneration. OBJECTIVES: To determine whether plasma and CSF NfL (1) associate with motor or cognitive status in Parkinson's disease (PD) and (2) predict future motor or cognitive decline in PD. METHODS: Six hundred and fifteen participants with neurodegenerative diseases, including 152 PD and 200 healthy control participants, provided a plasma and/or cerebrospinal fluid (CSF) NfL sample. Diagnostic groups were compared using the Kruskal-Wallis rank test. Within PD, cross-sectional associations between NfL and Unified Parkinson's Disease Rating Scale Part III (UPDRS-III) and Mattis Dementia Rating Scale (DRS-2) scores were assessed by linear regression; longitudinal analyses were performed using linear mixed-effects models and Cox regression. RESULTS: Plasma and CSF NfL levels correlated substantially (Spearman r = 0.64, P < 0.001); NfL was highest in neurocognitive disorders. PD participants with high plasma NfL were more likely to develop incident cognitive impairment (HR 5.34, P = 0.005). CONCLUSIONS: Plasma NfL is a useful prognostic biomarker for PD, predicting clinical conversion to mild cognitive impairment or dementia. © 2021 International Parkinson and Movement Disorder Society.

Hospital Magnet Status Associates With Inpatient Safety in Parkinson Disease.

ABSTRACT: BACKGROUND: Persons with Parkinson disease (PD) have complex care needs that may benefit from enhanced nursing care provided in Magnet-designated hospitals. Our primary objective was to determine whether an association exists between hospital Magnet status and patient safety events for PD inpatients in the United States. METHODS: We conducted a retrospective cohort study using the Nationwide Inpatient Sample and Agency for Healthcare Research and Quality databases from 2000 to 2010. Parkinson disease diagnosis and demographic variables were retrieved, along with Magnet designation and other hospital characteristics. Inpatient mortality and preventable adverse events in hospitals with and without Magnet status were then compared using relevant Agency for Healthcare Research and Quality patient safety indicators. RESULTS: Between 2000 and 2010, 493 760 hospitalizations among PD patients were identified. Of those, 40 121 (8.1%) occurred at one of 389 Magnet hospitals. When comparing PD patients in Magnet versus non-Magnet hospitals, demographic characteristics were similar. Multivariate regression models adjusting for patient and hospital characteristics identified a 21% reduction in mortality among PD inpatients in Magnet hospitals (adjusted odds ratio [AOR], 0.79; 95% confidence interval [CI], 0.74-0.85). PD inpatients in Magnet hospitals also had a lower odds of experiencing any patient safety indicator (AOR, 0.74; 95% CI, 0.68-0.79), pressure ulcers (AOR, 0.60; 95% CI, 0.55-0.67), death from a low mortality condition (AOR, 0.74; 95% CI, 0.68-0.79), and a higher odds of postoperative bleeding (AOR, 1.45; 95% CI, 1.04-2.04). CONCLUSIONS: PD patients had a reduced risk of inpatient mortality and several nursing-sensitive patient safety events, highlighting the possible benefits of Magnet status on inpatient safety in PD.

Cerebral fat embolism syndrome in sickle cell disease without evidence of shunt.

Fat embolism syndrome (FES) is a known complication of sickle cell disease (SCD) that occurs secondary to vaso-occlusive crises, bone marrow infarction, and the subsequent release of fat globules into the venous circulation. Although neurologic involvement is common, the pathophysiology of cerebral fat emboli remains controversial. While fat microemboli can enter the arterial circulation through right-to-left shunts, the systemic release of free fatty acids may also cause indirect endothelial damage and disruption of the blood-brain-barrier. We present an unusual case of cerebral fat emboli in SCD that occurred in the absence of acute chest syndrome or right-to-left shunt, favoring a biochemical etiology. Treatment of FES includes supportive care and emergent red cell exchange transfusions.

Late onset progressive multifocal leukoencephalopathy in Hodgkin lymphoma.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease resulting from infection of oligodendrocytes in the central nervous system with John Cunningham virus. Although PML is commonly diagnosed in immunocompromised patients with human immunodeficiency virus, it can also arise in other immunodeficient states. In this report, we present an unusual case of PML occurring 40years after chemoradiation therapy for Hodgkin lymphoma in a patient with normal total lymphocyte counts on annual surveillance. Although current guidelines recommend annual complete blood counts for patients in remission, this testing may be insufficient to monitor patients with chronic CD4+ lymphopenia.