Neurodegeneration and the Cerebellum.

BACKGROUND: The cerebellum modulates diverse neuronal networks, regulating motor, cognitive, behavioral, and limbic circuits. Structural and functional changes to the cerebellum that occur with neurodegenerative conditions have not been systematically reviewed. OBJECTIVE: We synthesize the current understanding of cerebellar somatotopy and function with previously described cerebellar changes in neurodegenerative diseases not associated with primary cerebellar pathology. METHODS: A thorough literature review defines the role of the cerebellum in normal function and neurodegeneration, and we additionally provide exemplar cases of cerebellar dysfunction in neurodegenerative disorders. RESULTS: Comparisons between normal function and neurodegenerative disease states emphasize how normal organization of the cerebellum is altered in neurodegenerative disease states. We illustrate key anatomic structures using novel cerebellar segmentation tools and images. CONCLUSIONS: Altered cerebellum in neurodegeneration can provide important diagnostic and pathologic insights into both predicting disease progression and network dysfunction.

Bedside Fluorescence Microangiography for Frostbite Diagnosis in the Emergency Department.

INTRODUCTION: Frostbite leads to progressive ischemia eventually causing tissue necrosis if not quickly reversed. Patients with frostbite tend to present to the emergency department (ED) for assessment and treatment. Acute management includes rewarming, pain management, and (when indicated) thrombolytic therapy. Thrombolytic therapy in severe frostbite injury may decrease rates of amputation and improve patient outcomes. Fluorescence microangiography (FMA) has been used to distinguish between perfused and non-perfused tissue. The purpose of this study was to evaluate the potential role of FMA in the acute care of patients with frostbite, specifically its role as a tool to identify perfusion deficit following severe frostbite injury, and to explore its role in time to tissue plasminogen activator (tPA). METHODS: This retrospective analysis included all patients from December 2020-March 2021 who received FMA in a single ED as part of their initial frostbite evaluation. In total, 42 patients presented to the ED with concern for frostbite and were evaluated using FMA. RESULTS: Mean time from arrival in the ED to FMA was 46.3 minutes. Of the 42 patients, 14 had clinically significant perfusion deficits noted on FMA and received tPA. Mean time to tPA (measured from ED arrival to administration of tPA) for these patients was 117.4 minutes. This is significantly faster than average historical times at our institution of 240-300 minutes. CONCLUSION: Bedside FMA provides objective information regarding perfusion deficits and allows for faster decision-making and improved times to tPA. Fluorescence microangiography shows promise for quick and efficient evaluation of perfusion deficits in frostbite-injured patients. This could lead to faster tPA administration and potentially greater rates of tissue salvage after severe frostbite injury.

Stand Up and Fight Falls: Can a Video Intervention Help Reduce Falls in the Geriatric Population?

INTRODUCTION: Falls are a major source of morbidity and mortality in the geriatric population. However, efforts to reduce falls have had limited success. This study examines if a video intervention presented in the ED to patients who have fallen could improve fall education and reduce future falls. METHODS: Patients 65 years and older who presented to a large academic ED for a fall between June and December 2017 were identified via triage note for an intercept study. Patients who did not speak English, who were cognitively impaired, or whose condition was too acute (determined by providing physician) were excluded. Sixty-two eligible and consenting patients were shown a six-minute video intervention with recommendations to prevent future falls. Primary objectives include (1) whether patients found the recommendations reasonable to implement and (2) rate of implementation. Secondary aims were (3) perceived health status between patients who followed the recommendations versus those who did not and (4) rates of recurrent falls and ED revisits between the two groups. Data were analyzed using the Newcombe-Wilson Score Method and Fisher's exact two-tailed t-tests. RESULTS: Of 62 patients enrolled, 38 were retained at a six-month follow-up. Ninety-two percent of patients found the video intervention to be a reasonable education tool. At six months, 44.7% of patients implemented behavioral changes discussed in the video, and 21.1% had at least one new fall, with no significant difference between people who implemented video interventions and those who did not (23.5% and 19.0%, difference 0.045, 95% CI [-0.24 to 0.34], p=1.0). The rate of return to the ED at six months for all patients was 31.6%, with no significant difference between the two groups (23.5% versus 38.1%, difference 0.146, 95% CI [-0.18 to 0.43], p=0.49). Difference in the proportion of people feeling the same or better between the two groups was not significant at either the one-month (66.7% versus 75.0%, difference 0.083, 95% CI [-0.21 to 0.34], p=0.75) or six-month follow up (64.7% versus 47.6%, difference 0.171, 95% CI [-0.17 to 0.46], p=0.34). CONCLUSION: This study found that while most patients find behavioral interventions feasible and reasonable to implement, only half actually make changes to their lives to reduce the risk of falling. This suggests that identifying and limiting barriers to implementation should be a priority in future studies, along with exploring the relationship between interventions and health status, ED revisits, and recurrent falls.

Fall Prevention Knowledge, Attitudes, and Behaviors: A Survey of Emergency Providers.

INTRODUCTION: Falls are a frequent reason geriatric patients visit the emergency department (ED). To help providers, the Geriatric Emergency Department Guidelines were created to establish a standard of care for geriatric patients in the ED. We conducted a survey of emergency providers to assess 1) their knowledge of fall epidemiology and the geriatric ED guidelines; 2) their current ED practice for geriatric fall patients; and 3) their willingness to conduct fall-prevention interventions. METHODS: We conducted an anonymous survey of emergency providers including attending physicians, residents, and physician assistants at a single, urban, Level 1 trauma, tertiary referral hospital in the northeast United States. RESULTS: We had a response rate of 75% (102/136). The majority of providers felt that all geriatric patients should undergo screening for fall risk factors (84%, 86/102), and most (76%, 77/102) answered that all geriatric patients screened and at risk for falls should have an intervention performed. While most (80%, 82/102) answered that geriatric falls prevention was very important, providers were not willing to spend much time on screening or interventions. Less than half (44%, 45/102) were willing to spend 2-5 minutes on a fall risk assessment and prevention, while 46% (47/102) were willing to spend less than 2 minutes. CONCLUSION: Emergency providers understand the importance of geriatric fall prevention but lack knowledge of which patients to screen and are not willing to spend more than a few minutes on screening for fall interventions. Future studies must take into account provider knowledge and willingness to intervene.

Treatments for Primary Immune Thrombocytopenia: A Review.

Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of "chronic refractory ITP" is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic refractory ITP.