Complications and outcomes of hospitalizations for patients with and without Parkinson disease.

Objective: To examine complications and outcomes of hospitalizations for common indications for hospitalization among patients with Parkinson disease (PD). Methods: We identified and selected the ten most common indications for hospitalization among individuals ≥65 years of age using principal diagnoses from the California State Inpatient Database, 2018-2020. Patients with comorbid PD were identified using secondary diagnosis codes and matched one-to-one to patients without PD based on principal diagnosis (exact matching), age, gender, race and ethnicity, and Elixhauser comorbidity index (coarsened exact matching). We identified potentially preventable complications based on the absence of present on admission indicators among secondary diagnoses. In the matched cohort, we compared inpatient complications, early Do-Not-Resuscitate (DNR) orders (placed within 24 h of admission), use of life-sustaining therapies, new nursing facility requirement on discharge, and death or hospice discharge for patients with and without PD. Results: We identified 35,457 patients with PD among the ten leading indications for hospitalization in older adults who were matched one-to-one to patients without PD (n = 70,914 in total). Comorbid PD was associated with an increased odds of developing aspiration pneumonia (OR 1.17 95% CI 1.02-1.35) and delirium (OR 1.11 95% CI 1.02-1.22) during admission. Patients with PD had greater odds of early DNR orders [placed within 24 h of admission] (OR 1.34 95% CI 1.29-1.39). While there was no difference in the odds of mechanical ventilation (OR 1.04 95% CI 0.98-1.11), patients with PD demonstrated greater odds of tracheostomy (OR 1.41 95% CI 1.12-1.77) and gastrostomy placement (OR 2.00 95% CI 1.82-2.20). PD was associated with greater odds of new nursing facility requirement upon discharge (OR 1.58 95% CI 1.53-1.64). Patients with PD were more likely to die as a result of their hospitalization (OR 1.11 95% CI 1.06-1.16). Conclusion: Patients with PD are at greater risk of developing aspiration pneumonia and delirium as a complication of their hospitalization. While patients with PD more often have early DNR orders, they have greater utilization of life-sustaining therapies and experience worse outcomes of their hospitalization including new nursing facility requirement upon discharge and greater mortality.

Virtual Adaptation of an International Exchange Program in Medical Education.

Medical education has drastically transformed during the COVID-19 pandemic. Measures such as adopting telemedicine visits, minimizing the number of trainees on service, discontinuing external rotations, and converting in-person to online didactics have been broadly and swiftly implemented. While these innovations have promoted greater interconnectivity amongst institutions and made continuing medical education possible, international exchange programs in medical education are still largely disrupted. In response to the changing guidelines and restrictions necessitated by the COVID-19 pandemic, the authors used Kern's six-step approach to design and implement a virtual curriculum to replace the in-person activities of the 2020-2021 Neurology Peru-Rochester exchange program (NeuroPro). Twenty-seven trainees participated in this virtual adaptation. The average daily attendance was ≥85% and the program was rated 9/10 on average in a feedback survey (63% response rate). The median percentage of correct answers during the pre-test was 64% and it increased to 79% during the post-test (P = 0.003). Virtual adaptation of international exchange programs in medical education is feasible to safely continue international collaborative efforts to promote symbiotic building of local expertise and cross-cultural exchange during the ongoing COVID-19 pandemic and beyond.

Improving Access to Care: Telemedicine Across Medical Domains.

Over the past 20 years, the use of telemedicine has increased exponentially. Its fundamental aim is to improve access to care. In this review, we assess the extent to which telemedicine has fulfilled this promise across medical domains. Additionally, we assess whether telemedicine has improved related health outcomes. Finally, we determine who has benefited from this novel form of health care delivery. A review of the literature indicates that (a) telemedicine has improved access to care for a wide range of clinical conditions ranging from stroke to pregnancy; (b) telemedicine in select circumstances has demonstrated improved health outcomes; and (c) telemedicine has addressed geographical, but less so social, barriers to care. For telemedicine to fulfill its promise, additional evidence needs to be gathered on health outcomes and cost savings, the digital divide needs to be bridged, and policy changes that support telemedicine reimbursement need to be enacted.

Sex-related differences in homebound advanced Parkinson's disease patients.

BACKGROUND: Women with Parkinson's disease (PD) are more likely to be older, have greater disease severity and comorbidities, and yet are less likely to receive care from a neurologist, as compared with men with PD. Within the PD population, homebound individuals are a particularly vulnerable group facing significant barriers to care, yet within this understudied population, sex-related differences have not been reported. PURPOSE: To identify and describe differences in homebound men and women with advanced PD and related disorders, participating in an interdisciplinary home visit program. PATIENTS AND METHODS: This was an exploratory analysis of homebound patients seen between February 2014 and July 2016 using data collected via in-person interviews and chart review. RESULTS: We enrolled 85 patients, of whom 52% were women. PD was the most common diagnosis (79%), followed by dementia with Lewy bodies (5%), and other atypical parkinsonism (16%). Men were more likely to have a PD dementia diagnosis than women (17.1% vs 2.3%, p=0.03). Women were more likely to live alone (18.1% of women had no caregiver vs 2.4% of men, p=0.05). CONCLUSION: The role of the caregiver in facilitating safe aging-in-place is crucial. Among homebound individuals with advanced PD, women were far more likely to live alone. The absence of a spouse or care partner may be due in part to variable sex-based life expectancies. Our findings suggest that homebound women with advanced PD may face greater barriers to accessing support.

Evaluation of friction on self-ligating and conventional brackets associated with different types of archwires submitted to sliding mechanics

Aim: The aim of this study was to verify the frictional force during sliding mechanics in orthodontic tooth movement, using conventional metal brackets of the active and passive self-ligating types with stainless steel and copper nickel titanium archwires. Methods: This experimental in vitro study was conducted with conventional metal (Morelli, Sorocaba, SP, Brazil) brackets, active self-ligated (SLI Morelli, Sorocaba, SP, Brazil) and passive self-ligated (SLP Morelli, Sorocaba, SP, Brazil), with slot 0.022 x 0.028 inches and Roth prescription. The brackets were tested with rectangular section 0.019 x 0.025 inch copper nickel titanium and stainless steel archwires. For each type of bracket, 10 sets of plate/bracket/archwire segment (n=10) were fabricated. Non-parametric Kruskal Wallis and Dunn tests were used for comparison between types of brackets and Wilcoxon tests for comparison between types of archwires. Results: The results showed that the frictional force values were higher with copper nickel titanium than with stainless steel archwires (p<0.05). When copper nickel titanium archwires were used, the active self-ligating brackets showed higher frictional force values than the other types, followed by the conventional brackets. Lower frictional force values were observed with passive self-ligating brackets. For stainless steel archwires, no difference was observed between conventional and active self-ligating brackets, the passive self-ligating type presented lower frictional force values than the others. Conclusion: It was concluded that the higher frictional force was observed when active self-ligating brackets were associated with copper nickel titanium archwires. Lower frictional force was verified between passive self-ligating brackets combined with stainless steel archwires

Interdisciplinary Home Visits for Individuals with Advanced Parkinson's Disease and Related Disorders.

Parkinson's disease (PD) is a complex, multisymptom, neurodegenerative disease affecting primarily older adults. With progression, many individuals become homebound and removed from coordinated, expert care, resulting in excess morbidity, mortality, and healthcare expenditures in acute care settings and institutions. Home visit care models have achieved the triple aim of improving individual and population health while reducing costs in many frail, community-dwelling geriatric cohorts. This study details a novel, interdisciplinary home visit program specifically designed for individuals with PD and related disorders and their family caregivers built upon best practice principles in the care of multimorbid older adults. At each quarterly home visit, a movement disorders-trained neurologist, social worker, and nurse work in parallel with the individual and caregiver to complete a history, physical, detailed medication reconciliation, psychosocial needs assessment, and home safety assessment. A comprehensive, person-centered plan is agreed upon, referrals to community resources are made, standardized documentation is shared, and follow-up communication is instituted. In the first 2 years, 272 visits were conducted with 85 individuals who represent one of the oldest, most disabled PD populations reported. Satisfaction with and retention in the program were high. This study represents the first translation of the success of interdisciplinary and home-based geriatric care models to a population with a specific neurological disease. Preliminary evidence supports the need for such programs in vulnerable populations. Future studies will prospectively assess person-centered outcomes, the effect of using telemedicine on sustainability, and cost effectiveness.

mTOR and HDAC Inhibitors Converge on the TXNIP/Thioredoxin Pathway to Cause Catastrophic Oxidative Stress and Regression of RAS-Driven Tumors.

Although agents that inhibit specific oncogenic kinases have been successful in a subset of cancers, there are currently few treatment options for malignancies that lack a targetable oncogenic driver. Nevertheless, during tumor evolution cancers engage a variety of protective pathways, which may provide alternative actionable dependencies. Here, we identify a promising combination therapy that kills NF1-mutant tumors by triggering catastrophic oxidative stress. Specifically, we show that mTOR and HDAC inhibitors kill aggressive nervous system malignancies and shrink tumors in vivo by converging on the TXNIP/thioredoxin antioxidant pathway, through cooperative effects on chromatin and transcription. Accordingly, TXNIP triggers cell death by inhibiting thioredoxin and activating apoptosis signal-regulating kinase 1 (ASK1). Moreover, this drug combination also kills NF1-mutant and KRAS-mutant non-small cell lung cancers. Together, these studies identify a promising therapeutic combination for several currently untreatable malignancies and reveal a protective nodal point of convergence between these important epigenetic and oncogenic enzymes.Significance: There are no effective therapies for NF1- or RAS-mutant cancers. We show that combined mTOR/HDAC inhibitors kill these RAS-driven tumors by causing catastrophic oxidative stress. This study identifies a promising therapeutic combination and demonstrates that selective enhancement of oxidative stress may be more broadly exploited for developing cancer therapies. Cancer Discov; 7(12); 1450-63. ©2017 AACR.This article is highlighted in the In This Issue feature, p. 1355.

Time-scaling based sliding mode control for Neuromuscular Electrical Stimulation under uncertain relative degrees.

This paper addresses the application of the sliding mode approach to control the arm movements by artificial recruitment of muscles using Neuromuscular Electrical Stimulation (NMES). Such a technique allows the activation of motor nerves using surface electrodes. The goal of the proposed control system is to move the upper limbs of subjects through electrical stimulation to achieve a desired elbow angular displacement. Since the human neuro-motor system has individual characteristics, being time-varying, nonlinear and subject to uncertainties, the use of advanced robust control schemes may represent a better solution than classical Proportional-Integral (PI) controllers and model-based approaches, being simpler than more sophisticated strategies using fuzzy logic or neural networks usually applied in this control problem. The objective is the introduction of a new time-scaling base sliding mode control (SMC) strategy for NMES and its experimental evaluation. The main qualitative advantages of the proposed controller via time-scaling procedure are its independence of the knowledge of the plant relative degree and the design/tuning simplicity. The developed sliding mode strategy allows for chattering alleviation due to the impact of the integrator in smoothing the control signal. In addition, no differentiator is applied to construct the sliding surface. The stability analysis of the closed-loop system is also carried out by using singular perturbation methods. Experimental results are conducted with healthy volunteers as well as stroke patients. Quantitative results show a reduction of 45% in terms of root mean square (RMS) error (from 5.9° to [Formula: see text] ) in comparison with PI control scheme, which is similar to that obtained in the literature.

Interpretation of urine drug testing results in patients using transdermal buprenorphine preparations for the treatment of chronic noncancer pain.

OBJECTIVE: To determine whether the prevailing liquid chromatography and tandem mass spectroscopy assay (LC-MS/MS) assay designed to monitor buprenorphine compliance of the sublingual formulation used in the substance abuse treatment setting can be extrapolated to the transdermal formulation used in the chronic pain treatment setting, which is 1000-fold less concentrated. DESIGN: Retrospective chart review. SUBJECTS: Self-reported compliant patients using the transdermal or sublingual formulations of buprenorhphine. Transdermal patch application was also visually confirmed during clinic visits. METHODS: Urine drug test results from a LC-MS/MS were compared between samples from transdermal and sublingual patients. RESULTS: While all sublingual patients tested positive for at least one metabolite of buprenorphine, only 69% of the transdermal patients did so. In addition, the most abundant metabolite in the transdermal patients was buprenorphine-glucuronide, as compared with norbuprenorphine-glucuronide in sublingual patients. CONCLUSIONS: These data suggest that currently available urine drug tests for buprenorphine, including the more expensive LC-MS/MS based assays, may not be sufficiently sensitive to detect the metabolites from transdermal buprenorphine patients. This study highlights the need to evaluate the value and sensitivity of urine drug tests given the wide range of buprenorphine dosing in clinical practice. These results underscore the need for additional cost benefit analyses comparing different confirmatory drug testing techniques including many commercially available drug testing options. © 2014 Wiley Periodicals, Inc.

Lectinas leguminosas no auxílio para caracterizaçäo de Leishmania / Characterizations of Leishmania by lectin plants

A superfície polissacarídica das espécies de Leishmanias pertecentes aos grupos mexicano, brasiliensis e estoques isolados no laboratório Gaspar Viana, foram estudadas através do teste de aglutinaçäo direta mediada por lectinas. Foram preparadas dez lectinas de sementes de leguminosas ( Lens culinaris, Ricinus communis, Artocarpus integrifolia, Persea americana, Arachis hypogaea, Magífera índica, Pisum sativum, Glycine max, Tamarino e Tritium vulgaris) e duas foram adquiridas no comércio (Canavalia ensiformis e Phytohemagglutinin P). No teste de aglutinaçäo direta com essas lectinas, foram observados variados agrupamentos quanto ao número e variedade de sítios receptores na superfície das leshmania, tendo as cepas do complexo brasiliensis apresentado maior número de sítios ligantes para as lectinas do que as do complexo mexicano e aquelas isoladas de pacientes no laboratório Gaspar Viana BARBOSA, W. et al, 1976, 1982,1984). Confirmamos através da reaçäo de imunofluorescência direta que as Lens culinaris e Canavalia ensiformis marcadas para nós com isotiocianato de fluoresceína (CLARK & SHEPARD), apresentaram resultados similares aos verificados com o teste de aglutinaçäo direta. Paralelamente testamos a capacidade das 12 lectinas aglutinarem Tripanossoma cruzi. Constatamos que a superfície do Tripanossoma apresenta mais epitopos ligantes para as lectinas do que a superfície de leishmanias. Acreditamos que a interaçäo lectinas com epítopos situados na superfície da membrana plasmática possibilita a caracterizaçäo de constituintes da superfície celular, o que tem contribuído para a caracterizaçäo de espécie celular

Nota sobre a variaçäo do comportamento da patogenicidade de imunogecidade de cepas de T. cruzi variedade hastatus E y mutante após longo período de manutençäo em cultura / Note about variation of the patogenicity and immunogenicity of strains of T. cruzi, hastatus and Y, maintained in cultures for longer periods

Neste trabalho nos reportamos a falta absoluta de proteçäo de camundongos isogênicos Balc-C, desafiados com cepa Y de T. cruzi patogênica, que se deu tanto com formas de cultivo epimastigotas e tripomastigotas induzidas em cultivo e delas associadas, quanto com as glicoproteínas de superfície do T.hastatus mais adjuvantes. A cepa do T. hastatus foi a mesma que há anos atrás havia protegido camundongos näo isogênicos desafiados com a mesma cepa Y patogênica. Estes dados sugeriram a perda da imunogenicidade da cepa de T. hastatus, já näo infectante, ao longo de sua manutençäo em cultura. Na mesma ocasiäo, foi constatada a perda da infectividade da cepa Y mutante de T. cruzi mantida por 15 anos em cultura. Consideraçöes de natureza teórica foram feitas admitindo-se que as variaçöes biológicas e de natureza bioquímica ocorrentes com T. cruzi se desenvolvem permanente e evolutivamente, provavelmente em funçäo de mutaçöes na dependência da interaçäo entre o parasita e os componentes do meio em que ele vive

Notas parasitológicas sobre Lagochilascaríase humana em Goiás / Parasitological notes about human lagochilascariasis from Goiás

Temos , até o presente momento, 10 casos de lagochilascaríase humana diagnosticados em Goiás. Os autores chamam atençäo para a freqüência e distribuiçäo geográfica do parasito na área compreendida entr o norte do Estado e a regiäo sul do Pará (Amazônia Legal). Foram realizadas tentativas de reproduçäo experimental do ciclo evolutivo do verme com resultados infrutíferos

Leishmania M. (misteriosa) provável nova espécie ocorrente em Goiás, isolada do sangue periférico de chagásico crônico / M. Leishmania (mmisterious) a probabel new-specie occurred in Goiás, isolated of the bloodstream of Chagasic Chronic patient

Descrevemos o isolamento ocasional de uma Leishmania do sangue periférico de um paciente chagásico crônico em Goiás, durante a tentativa de isolamento do T. cruzi em meio LIT. O estudo taxonômico dela sugere tratar-se de uma nova espécie, ou no mínimo uma sub-espécie do grupo da Leishmania Gasparvianai

Doença de Chagas Congênita em Goiânia-Go, Brasil / Congenit Chagas'disease

Trata-se de relato de caso de Doença de Chagas congênita constatado em criança de 4 meses de idade, sexo masculino, procedente de Goiânia-Go, nascimento - parto prematuro que evoluiu para o óbito, tendo sido esclarecido o diagnóstico através de dados de necrópsia

Novo meio líquido autoclavável, isento de sangue, para isolamento primário de Leishmanias de lesöes tegumentares: I-sua potencialidade no estudo da biologia dos tripanosomatídeos / A new autoclavable culture medium, devoid of blood for isolation of Leishmania from skin lesions: I - its potentiality in the study of the biology of Trypanosomidae

Novo meio, inicialmente denominado, BHYMI (Brain-heart-yeast-meat infusion) logo Rq., constante basicamente de extrato de cérebro, extrado de coraçäo, estrato de carne, extrato de levedura, mais glicose, cloreto de sódio e água, é meio monofásico de baixo custo, disponível no comércio ou facilmente preparado com matérias primas locais, no laboratório, de fácil esterilizaçäo, claro, facilitando a coleta e contagem dos organismos cultivados; foi usado, inicialmente, como a fase líquida dos meios difásicos NNN ou Ducrey, logo como meio de cultura único (exclusivo) para cultivo de leishmanias. É capaz de isolar primariamente leishmania de lesöes, em proporçäo bastante razoáveis, manter cepas isoladas e de funcionar mesmo após ser guardado por 12 meses à temperatura ambiente, como líquido ou por mais tempo quando liofilizado. Seu pH ótimo é de 7.4 a 7.6. Quando enriquecido com soro fetal bovino (S.F.B) na proporçäo de 5, 10, 20 e/ou 30 pôr cento potencia o crescimento das cepas de leishmanias e permite o cultivo de Trypanossomas sp; usado em temperatura mais elevada condiciona o aparecimento de formas amastigotas dos tripanosomatídeos. Quando associado a soro de pato e/ou na presença de cloridrato de tetraciclina estimula a metaciclogenese do Trypanosoma cruzi. Associado ao sangue (Plasma e/ou soro) de galinha estimula a transformaçäo de promastigota de leishmania sp para amastigota em temperatura adequada (35º C). Enriquecido com carväo de sangue de feto bovino, de bovino adulto e de pato ("Charcoal" - sangue dissecado pelo calor lento e permanente, desidratado ou näo, previamente, a vácuo, e moído finamente, para se transformar em pó) - permite o crescimento exuberante de Trypanosomatídeos e mantém os atributos que soros e plasmas frescos ou conservados conferem ao meio, sendo muito bom para manutençäo e crescimento de Trypanosoma cruzi. Este meio pode ser usado como difásico sendo incorporado à peptona ou ágar, como base, tendo como meio líquido o próprio meio, soros consevados de boi, SFB ou soro de pato, meio 199, meio de Grace ou suplemento líquido de Hanks, dependendo da finalidade do cultivo. A associaçäo de extrato de flebotomíneos ou de triatomíneos ao meio permitiu também crescimento aumentado das leishmanias