Use and Types of Advance Care Planning Prior to Image-Guided Procedures

BackgroundAdvance care planning is a well-supported means of improving care for patients by clarifying goals and preferences prior to an intervention.PurposeThe purpose of this study was to assess the prevalence and types of advance care planning occurring prior to image-guided procedures.MethodsAll image-guided procedures performed at two healthcare systems over a 3-month period were reviewed, including 1384 procedures for 999 inpatients and 1255 procedures for 1217 outpatients.FindingsOf 2,639 total image-guided procedures, 36% of inpatient procedures and 18% of outpatient procedures had advance care planning documented within 3 months prior to the procedure. Use was more prevalent prior to procedures near the end of life (p < .01) and tended to be less structured forms such as goals of care discussions (p < .01). Use was more common in non-Hispanic and male patients (p = .04).DiscussionAdvance care planning prior to image-guided procedures may be underutilized with disparities in this care.     

医学生预立医疗照护计划知信行调查研究

目的调查医学生对预立医疗照护计划(ACP)的认知、态度、行为意向现状并进行相关影响因素分析。方法本研究为横断面研究。于2019年4—5月,采用便利抽样法选取在广东省3所医学院校及其附属医院实习的医学生作为研究对象。使用一般资料调查问卷、自行设计的医学生ACP知信行问卷对其进行调查。采用多重线性回归分析进行影响因素分析。本次调查共发放问卷276份,回收有效问卷274份,有效回收率为99.3%。结果医学生ACP认知调查问卷的平均正确率为48.75%;ACP态度调查问卷的条目均分为(4.00±0.53)分;医学生ACP行为意向调查问卷的条目均分为(3.94±0.59)分。多重线性回归分析结果显示,对所学专业的态度、有无社会兼职经历、是否听说过ACP以及是否接受过ACP的培训或课程是医学生ACP认知的影响因素(P<0.05);是否进入临床实习和是否有过患者死亡的救治经历是医学生ACP态度的影响因素(P<0.05);对所学专业态度、是否有过患者死亡的救治经历是医学生ACP行为意向的影响因素(P<0.05)。结论医学生对ACP有一定的接受度,但对ACP的知晓率普遍较低。应考虑完善相关教育方法和内容,为医学生在未来临床工作中做好角色适应,提升医学生的人文关怀素养以及ACP在临床中的推广做准备。     

Personal advance care planning uptake amongst Australian and New Zealand palliative care medical and nursing professionals

Background: Palliative care (PC) medical and nursing professionals are potentially the most death literate group in the community yet little is known about their personal uptake of advance care planning (ACP) or written advance care directives (ACDs).

Aim: To describe Australian and New Zealand PC medical and nursing professionals’ participation in personal ACP activities.

Method: Between 12 May 2014 and 6 June 2014 an anonymous cross sectional online survey about personal ACP activities was distributed to Australian and New Zealand PC medical and nursing professionals.

Results: The survey link was emailed to 946 medical and nursing PC health professionals with 329 (35%) recipients commencing the survey. Ninety-one percent of participating Australian and New Zealand PC medical and nursing health professionals have engaged in some form of ACP; 21% have a written ACD. Over 80% of those without a current ACD have engaged in an ACP conversation with family or significant others. Thirty percent of doctors did not feel an ACD was relevant for them, 29% considered them a low priority, 27% relied on conversations and 14% felt ACDs were poorly designed or ineffective. These proportions were 15%, 44%, 36%, and 2%, respectively for nurses.

Conclusion: This study supports the notion that familiarity with ACP increases overall participation however, it does not support the popular view that familiarity with ACDs ensures uptake. The favoured mode of ACP amongst this group of health professionals was a conversation outlining values and preferences with family or significant others.     

The safety and feasibility of high-force eccentric resistance exercise in persons with Parkinson's disease

OBJECTIVE: To examine the effect of high-force eccentric resistance exercise on measures of muscle damage and injury in persons with mild to moderate Parkinson's disease (PD). DESIGN: Before-after trial. SETTING: Tertiary care center clinical laboratory. PARTICIPANTS: Ten persons with PD (Hoehn and Yahr Staging Scale, stage 1-3). INTERVENTION: Participants trained 3 days a week for 12 weeks on an eccentric ergometer, performing high-force eccentric resistance exercise with bilateral lower extremities. MAIN OUTCOME MEASURES: Serum creatine kinase (CK) concentrations, muscle pain scores, and isometric force production were measured before, during, and after training. RESULTS: Mean CK levels did not differ and did not exceed the threshold of muscle damage at any time point (P=.17). Muscle visual analog scale scores were low and only differed at week 2 (P=.04). Participants were highly compliant, whereas total negative work and isometric force increased over time (P=.02, P=.006, respectively). CONCLUSIONS: Persons with mild to moderate PD can safely and feasibly participate in high-force eccentric resistance training. The data we present provide a basis for future investigations of the efficacy of this type of training on muscle size, strength, and mobility in persons with PD.     

The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson's disease

OBJECTIVE: To assess immediate and near-term effects of 2 exercise training programs for persons with idiopathic Parkinson's disease (IPD). DESIGN: Randomized control trial. SETTING: Public health facility and medical center. PARTICIPANTS: Fifteen persons with IPD. INTERVENTION: Combined group (balance and resistance training) and balance group (balance training only) underwent 10 weeks of high-intensity resistance training (knee extensors and flexors, ankle plantarflexion) and/or balance training under altered visual and somatosensory sensory conditions, 3 times a week on nonconsecutive days. Groups were assessed before, immediately after training, and 4 weeks later. MAIN OUTCOME MEASURES: Balance was assessed by computerized dynamic posturography, which determined the subject's response to reduced or altered visual and somatosensory orientation cues (Sensory Orientation Test [SOT]). Muscle strength was assessed by measuring the amount of weight a participant could lift, by using a standardized weight-and-pulley system, during a 4-repetition-maximum test of knee extension, knee flexion, and ankle plantarflexion. RESULTS: Both types of training improved SOT performance. This effect was larger in the combined group. Both groups could balance longer before falling, and this effect persisted for at least 4 weeks. Muscle strength increased marginally in the balance group and substantially in the combined group, and this effect persisted for at least 4 weeks. CONCLUSION: Muscle strength and balance can be improved in persons with IPD by high-intensity resistance training and balance training.     

Renal patients at end of life: A 5-year retrospective review

Context: Patients with end-stage renal disease (ESRD) have a life-limiting illness associated with significant morbidity. The ‘tipping point’ where increased medical and supportive care is needed urgently can be missed. It cannot be assumed that specialist palliative care (SPC) services which evolved to care for patients with cancer will also be right for patients with different diagnoses.

Objectives: To review retrospectively the end-of-life care of patients receiving renal replacement therapy (RRT) from our institution.

Methods: We conducted a single-centre retrospective cohort study. We reviewed medical charts and electronic records to record patient characteristics, mode of dialysis, place of death and the time spent in hospital.

Results: One hundred and sixty-one patients were included in our study. The mean age at death was 63 years and 68% were male. In their last year of life, patients spent a median of 53 days as inpatients with a median of three admissions. The haemodialysis cohort spent a median of 59 inpatient days in their last year of life, excluding day case attendances. One hundred and twenty-two (76%) patients died in hospital, 103 of those in our institution. Twenty-seven (17%) patients died at home while four (2%) died in an inpatient hospice unit. Preference for place of care was documented for 33 (20%) patients. Overall, 56 (35%) patients were referred to SPC.

Conclusion: End-of-life planning should be a more regular goal in all patients on RRT. Given the frequency of hospital attendance, opportunities should be grasped to make advance plans to facilitate patients’ wishes.     

Comparison of virtual reality versus physical reality on movement characteristics of persons with Parkinson's disease: effects of moving targets

Wang C-Y, Hwang W-J, Fang J-J, Sheu C-F, Leong I-F, Ma H-I. Comparison of virtual reality versus physical reality on movement characteristics of persons with Parkinson's disease: effects of moving targets.

Objective

To compare the performance of reaching for stationary and moving targets in virtual reality (VR) and physical reality in persons with Parkinson's disease (PD).

Design

A repeated-measures design in which all participants reached in physical reality and VR under 5 conditions: 1 stationary ball condition and 4 conditions with the ball moving at different speeds.

Setting

University research laboratory.

Participants

Persons with idiopathic PD (n=29) and age-matched controls (n=25).

Interventions

Not applicable.

Main Outcome Measures

Success rates and kinematics of arm movement (movement time, amplitude of peak velocity, and percentage of movement time for acceleration phase).

Results

In both VR and physical reality, the PD group had longer movement time (P<.001) and lower peak velocity (P<.001) than the controls when reaching for stationary balls. When moving targets were provided, the PD group improved more than the controls did in movement time (P<.001) and peak velocity (P<.001), and reached a performance level similar to that of the controls. Except for the fastest moving ball condition (0.5-s target viewing time), which elicited worse performance in VR than in physical reality, most cueing conditions in VR elicited performance generally similar to those in physical reality.

Conclusions

Although slower than the controls when reaching for stationary balls, persons with PD increased movement speed in response to fast moving balls in both VR and physical reality. This suggests that with an appropriate choice of cueing speed, VR is a promising tool for providing visual motion stimuli to improve movement speed in persons with PD. More research on the long-term effect of this type of VR training program is needed.     

Dysfunctional turning in Parkinson's disease

Purpose. People with Parkinson's disease (PD) frequently freeze or fall turning: They turn slowly taking numerous steps. We aimed to describe more fully the differences observed on turning between people with and without PD, in particular the extent of left-right asymmetry and the correlations between turning and age, balance and PD severity, using a simple clinical test.

Method. Twenty-eight people with PD (median age 71; median years since diagnosis eight) and 12 controls (median age 70) performed the video-based Standing Start 180° Turn Test. We counted turning steps (n), evaluated turn time (sec), type and quality (0 – 5, based on independence, ground clearance, stability, continuity and posture) and calculated the 95% limits of left-right agreement.

Results. The groups differed (p < 0.004) on step count (medians 4.5 vs. 3), time (2.3 sec vs. 1.7 sec) and quality (4 vs. 5). In the PD group, 75% turned ‘on-the-spot’ and differences turning left and right were marked (e.g., 95% upper limit for step count 6.6). Among controls, 42% turned ‘on-the-spot’ and turning was symmetrical (e.g., 95% upper limit for step count 1.7). Step count was most closely correlated with self-assessed disability in PD (r = 0.67; p = 0.001) and with age among controls (r = 0.87; p = 0.001).

Conclusions. People having difficulty turning are likely to have trouble with many everyday activities and thus may benefit from rehabilitation. Directional asymmetry in turning is easily identifiable and future studies should explore its diagnostic value.     

What contributes to driving ability in Parkinson's disease

Purpose.?To determine the most significant clinical predictors that influence driving ability in Parkinson disease (PD).

Methods.?National-multi-centre, cross-sectional study covering PD outpatients. Clinical assessment was based on the following questionnaires: cognition (SCOPA-Cog); motor impairment and disabilities (SCOPA motor); depression/anxiety; sleep (SCOPA-Sleep); psychosis and severity/global impairment (HY and CISI-PD). Driving status data was obtained using a standardized questionnaire. Comparisons between drivers and ex-drivers were calculated using χ² and Student t-tests as appropriate. Multi-variate logistic regression analysis was performed to identify independent driving ability clinical predictors.

Results.?Compared with the drivers, the ex-drivers were older (p?=?0.00005), had longer disease duration (p?=?0.03), had more overall cognitive dysfunction (p?=?0.004) and had greater motor impairment, as measured by the CISI (p?=?0.02), HY stage (p?=?0.034) and by the SCOPA-motor scale (p?=?0.002) and difficulty in activities of daily life (p?=?0.002). In the regression model analysis, aging and ADL impairment were the principal clinical predictors that differentiated drivers from ex-drivers.

Conclusions.?Although overall driving impairment in PD is associated with advancing disease severity, driving ability seems to be more strongly influenced by age and ADL impairment. Multi-disciplinary teams are required to assess driving ability in patients with PD and develop rehabilitation measures for safer driving.     

帕金森病患者认知功能损害的相关因素分析

目的观察帕金森病（PD）患者的认知功能,探讨PD患者认知损害的发生率和相关因素。方法分别采用简明精神状态量表（MMSE）、统一PD评定量表（UPDRS）、Hoehn—Yahr（H—Y）分期、汉密尔顿抑郁量表（HAMD）分别评价患者认知功能、PD疾病严重度以及情绪状态。结果60例PD患者中28例有认知损害．发生率为46．67％（28／60）,其中H—Y分期1～2期发生率为40％（8／20）;2．5—3期发生率为40％（8／20）;≥4期发生率为60％（12／20）。三组间发病率比较,差异无统计学差异（X^2=2．14,P〉0．05）。多元Logistic回归分析表明：认知损害与年龄、性别、UPDRSⅢ评分相关,差异均有统计学意义（β分别=0．11、1．64、0．07,P均〈0．05）,与病程、H—Y分期、文化程度、HAMD评分无关。结论认知损害在PD的不同阶段均可发生。年龄、性别、运动障碍严重程度为其相关因素。     

Five times sit-to-stand test performance in Parkinson's disease

Duncan RP, Leddy AL, Earhart GM. Five times sit-to-stand test performance in Parkinson's disease.

Objectives

To (1) determine intrarater and test-retest reliability of the Five times sit-to-stand test (FTSTS) in Parkinson's disease (PD), (2) characterize FTSTS performance in PD at different disease stages, (3) determine predictors of FTSTS performance in PD, and (4) determine the utility of the FTSTS for discriminating between fallers and nonfallers with PD, identifying an appropriate cutoff score to delineate between these groups.

Design

Measurement study of community-dwelling individuals with idiopathic PD.

Setting

A medical school laboratory.

Participants

Participants (N=82) were recruited via population-based sampling. The final sample included 80 participants. Two were excluded because of exclusion criteria and an unrelated illness, respectively.

Interventions

Not applicable.

Main Outcome Measures

FTSTS time (seconds) was the primary outcome measure. Secondary outcome measures included the Mini-Balance Evaluation Systems Test (Mini-BEST), Maximal Voluntary Isometric Contraction–Quadriceps, 9-Hole Peg Test (9HPT), 6-minute walk, Freezing of Gait Questionnaire, Activities-Specific Balance Confidence Scale, Physical Activity Scale for the Elderly, Parkinson's Disease Questionnaire-39, and Movement Disorders Society–Unified Parkinson's Disease Rating Scale.

Results

Interrater and test-retest reliability for the FTSTS were high (intraclass correlation coefficients: .99 and .76, respectively). Mean FTSTS performance was 20.25±14.12 seconds. All mobility measures were significantly correlated with FTSTS (P<.01). The Mini-BEST and 9HPT together explained 53% of the variance in FTSTS. Receiver operating characteristic analysis determined a cutoff of 16.0 seconds (sensitivity, .75; specificity, .68) for discriminating between fallers and nonfallers, with an area under the curve of .77.

Conclusions

The FTSTS is a quick, easily administered measure that is useful for gross determination of fall risk in individuals with PD.     

帕金森病静息态脑功能MRI研究

目的：应用血氧水平依赖的功能MRI（BOLD-fMRI）,探索帕金森病（PD）患者静息态脑功能可能存在的异常。材料与方法对68例PD患者和36例健康志愿者进行静息态BOLD-fMRI检查。分析PD组与正常对照组标准化脑功能低频振荡幅度（mALFF）的差异。结果与正常对照组比较,PD组在双侧辅助运动区、中后扣带回、楔前叶、海马、海马旁回、外侧苍白球、背侧丘脑、小脑前叶以及右侧局部初级运动皮层、岛叶、尾状核、壳核、小脑后叶等广泛区域mALFF值显著减低（P〈0.05,AlphaSim校正）,在双侧前额叶、顶叶及颞叶的广泛外侧皮层、左侧枕叶初级视觉皮层等区域mALFF值显著增高（P〈0.05,AlphaSim校正）。结论 PD患者静息态脑功能存在广泛异常,主要表现为PD患者在运动调节相关脑区、默认网络关键节点、边缘系统等部位神经元活动减弱,在前额叶、顶叶、颞叶的广泛外侧皮层以及初级视觉皮层等部位神经元活动增强。