Does Rehabilitation Matter in Patients With Femoral Neck Fracture and Cognitive Impairment? A Prospective Study of 246 Patients

Al-Ani AN, Flodin L, Söderqvist A, Ackermann P, Samnegård E, Dalén N, Sääf M, Cederholm T, Hedström M. Does rehabilitation matter in patients with femoral neck fracture and cognitive impairment? A prospective study of 246 patients.

Objective

To identify factors associated with preserved walking ability and Katz activities of daily living (ADLs) index at 4-month and 12-month follow-up in cognitively impaired patients with femoral neck fracture.

Design

Population-based cohort study.

Setting

A multicenter study of the Stockholm Hip Fracture Group including 4 university hospitals.

Participants

Consecutive patients (N=246) with femoral neck fracture, older than 65 years (mean, 84y; 72% women) with cognitive impairment (known dementia or low [0-2 points] score) in Short Portable Mental Status Questionnaire [0-10 points]) and able to walk before the fracture.

Interventions

Not applicable.

Main Outcome Measure

Walking ability and ADLs index at 4-month and 12-month follow-up.

Results

Significant predictors of preserved walking ability at 12-month follow-up were discharge to rehabilitation unit (odds ratio [OR]=2.83; confidence interval [CI], 1.1-7.26; P=.03) and walking ability before the fracture (OR=8.98; CI, 3.52-22.93; P<.001), while type of surgery was not (P=.197). Analyses were adjusted for age, sex, American Society of Anesthesiologists score, fracture type, and surgical method. Corresponding predictors of preserved Katz ADLs index at 12-month follow-up, after adjustment for age and sex, were discharge to rehabilitation unit (OR=5.33; CI, 1.44-19.65; P=.012) and ADLs index before fracture (OR=2.51; CI, 1.8-3.5; P<.001), while type of surgery was not (P=.376).

Conclusions

Discharge to rehabilitation unit, a factor we can influence, was associated with preserved walking ability and ADLs index in cognitively impaired patients with hip fracture.     

Is Spastic Muscle Echo Intensity Related to the Response to Botulinum Toxin Type A in Patients With Stroke? A Cohort Study

Picelli A, Bonetti P, Fontana C, Barausse M, Dambruoso F, Gajofatto F, Girardi P, Manca M, Gimigliano R, Smania N. Is spastic muscle echo intensity related to the response to botulinum toxin type A in patients with stroke? A cohort study.ObjectiveTo investigate the relationship between gastrocnemius muscle echo intensity and response to botulinum toxin type A (BoNT-A) in patients with spastic equinus foot resulting from stroke.DesignCohort study.SettingUniversity hospital.ParticipantsAdult patients (N=56) with spastic equinus foot resulting from stroke scheduled to receive BoNT-A injection into the gastrocnemius muscle.InterventionsAll patients were injected with BoNT-A (abobotulinumtoxinA) into the gastrocnemius muscle with an ultrasonography-guided, multisite injection technique. The toxin dose was 250U for the gastrocnemius medialis and 250U for the gastrocnemius lateralis (dilution 500U/2mL) in each patient. All patients were evaluated before and 4 weeks after BoNT-A injection.Main Outcome MeasuresSpastic gastrocnemius muscle echo intensity visually graded with the Heckmatt scale. Clinical assessment of the spastic gastrocnemius with the Modified Ashworth Scale, Tardieu Scale, and ankle passive range of motion.ResultsPostintervention testing at 4 weeks showed overall significant improvements in the clinical assessment of the spastic gastrocnemius muscle. No significant change was observed in the echo muscle intensity of the spastic gastrocnemius after BoNT-A injection. Post hoc comparisons showed that all clinical outcomes were significantly better in those patients with echo muscle intensity of the spastic gastrocnemius graded II on the Heckmatt scale than those with grades III (P<.001) and IV (P<.001) after botulinum toxin injection.ConclusionsThese findings support the hypothesis that patients with higher spastic muscle echo intensity have a reduced response to BoNT-A.     

Is Mindfulness Associated With Lower Pain Reactivity and Connectivity of the Default Mode Network? A Replication and Extension Study in Healthy and Episodic Migraine Participants

Formal training in mindfulness-based practices promotes reduced experimental and clinical pain, which may be driven by reduced emotional pain reactivity and undergirded by alterations in the default mode network, implicated in mind-wandering and self-referential processing. Recent results published in this journal suggest that mindfulness, defined here as the day-to-day tendency to maintain a non-reactive mental state in the absence of training, associates with lower pain reactivity, greater heat-pain thresholds, and resting-state default mode network functional connectivity in healthy adults in a similar manner to trained mindfulness. The extent to which these findings extend to chronic pain samples and replicate in healthy samples is unknown. Using data from healthy adults (n = 36) and episodic migraine patients (n = 98) and replicating previously published methods, we observed no significant association between mindfulness and heat-pain threshold, pain intensity or unpleasantness, or pain catastrophizing in healthy controls, or between mindfulness and headache frequency, severity, impactor pain catastrophizing in patients. There was no association between default mode network connectivity and mindfulness in either sample when probed via seed-based functional connectivity analyses. In post-hoc whole brain exploratory analyses, a meta-analytically derived default mode network node (ie, posterior cingulate cortex) showed connectivity with regions unassociated with pain processing as a function of mindfulness, such that healthy adults higher in mindfulness showed greater functional connectivity between the posterior cingulate cortex-and cerebellum. Collectively, these findings suggest that the relationship between mindfulness and default mode network functional connectivity may be nuanced or non-robust, and encourage further investigation of how mindfulness relates to pain.PerspectiveThis study found few significant associations between dispositional mindfulness and pain, pain reactivity and default mode connectivity in healthy adults and migraine patients. The relationship between mindfulness and default mode network connectivity may be nuanced or non-robust.     

Oxytocin and Misoprostol With Diclofenac in the Preparation for Magnetic Resonance–Guided High-Intensity Ultrasound Treatment of Symptomatic Uterine Fibroids: A Prospective Cohort Study

Uterine fibroids (UFs) are very common benign tumors of the female reproductive tract. According to recent reports, magnetic resonance–guided high-intensity ultrasound (MR-HIFU) appears to be a well-tolerated and efficient treatment option for UFs. However, MR-HIFU still presents several limitations. The treatment is rarely associated with achieving complete non-perfused volume (NPV). Not all patients are qualified for a final procedure, and selected women obtain very good results in such treatment. The primary objective of this experimental study was to assess the effect of transvaginal misoprostol and intravenous oxytocin preparation on UF volume change, sonication time and NPV after MR-HIFU procedure in women of reproductive age with symptomatic UFs. Secondary outcomes included the effect on the peri-procedural effectiveness of misoprostol and oxytocin. This study enrolled 247 women with symptomatic UFs; based on gynecologic examinations and magnetic resonance imaging (MRI) scans, 128 women qualified for MR-HIFU without pharmacologic treatment, 57 women qualified for the misoprostol/diclofenac group and 62 women qualified for the oxytocin group. Pharmacologic pre-treatment improved NPV compared with non-pharmacologic treatment (average NPV: controls 61.9% ± 25.8%; oxytocin 76.8% ± 20.7%; misoprostol/diclofenac 85.2% ± 15.1%; average sonication time: controls 120 min ± 56.4%; oxytocin 111 min ± 45.4%; misoprostol/diclofenac 80 min ± 47.7%). Statistical analysis did not reveal significant intergroup differences in UF volume changes after 6 mo (controls: n = 40, 37.4% ± 27.5%; oxytocin n = 25, 45.8% ± 31%; misoprostol/diclofenac n = 19, 33.4% ± 23.2%). The misoprostol/diclofenac group, which achieved the highest NPV immediately after the MR-HIFU procedure, was characterized by the lowest UF volume change percentages 6 mo later. The administration of vasoconstrictor drugs (oxytocin and misoprostol/diclofenac) to support MR-HIFU in UF treatment is a new issue that may improve the total effectiveness of this method. Randomized controlled trials are necessary to estimate the real effect of vasoconstrictors on MR-HIFU.     

Impact of Targeted Therapy on the Quality of End-of-Life Care for Patients With Non–Small-Cell Lung Cancer: A Population-Based Study in Taiwan

Context

Targeted therapies with epidermal growth factor receptor tyrosine kinase inhibitors have been widely used in the treatment of advanced non–small-cell lung cancer (NSCLC). However, little research has focused on the use of targeted therapies at the end of life (EOL).

Screening for Distress and Depression in Cancer Patients: Is Ultrashort Depression Screening a Valid Measure in the UK? A Prospective Validation Study

This study sought to validate the two-question (2Q) depression screen as a screening tool for psychological distress and depression against four criterion measures (Hospital Anxiety and Depression Scale [HADS], General Health Questionnaire-12, Brief Symptom Inventory-18 [BSI-18], and the distress thermometer) for a UK cancer population. We used a prospective cross-sectional study design. A consecutive sample of 399 outpatients from four outpatient oncology clinics and a palliative care day center in North London were initially identified. Of these, 249 were eligible, of whom 171 consented to take part. Data were analyzed using receiver operating characteristic analysis to examine the sensitivity and specificity of the 2Q depression instrument against the cutoff scores already shown to demonstrate clinically significant symptoms (“caseness”) in the criterion measures. Sensitivity and specificity, with 95% confidence intervals, were calculated in addition to positive and negative predictive values. The 2Q depression screen showed sensitivity of 68%–89% and specificity of 70%–84% when compared with our four criterion measures in screening for psychological distress; its best performance was against the HADS (89% sensitivity and 79% specificity). In screening for depression, the 2Q depression screen showed sensitivity of 84%–94% and specificity of 72%–73% when compared with our two criterion measures, its best performance being against the BSI depression subscale (94% sensitivity and 72% specificity). Our study demonstrated that the 2Q depression screen showed good psychometric properties, which further supports its usefulness as a simple instrument in screening for psychological distress in cancer patients in the UK.     

Is Aerobic or Resistance Training the Most Effective Exercise Modality for Improving Lower Extremity Physical Function and Perceived Fatigue in People With Multiple Sclerosis? A Systematic Review and Meta-analysis

ObjectiveThe purpose of this systematic review was to investigate whether aerobic training (AT) or resistance training (RT) is most effective in terms of improving lower limb physical function and perceived fatigue in persons with multiple sclerosis (PwMS).Data SourcesNine databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health, Allied and Complementary Medicine Database, Physiotherapy Evidence Database, SPORTDiscus, PsycINFO, Web of Science, and Scopus) were electronically searched in April 2020.Study SelectionIncluded studies were randomized controlled trials (RCTs) involving PwMS attending 1 of 2 exercise interventions: AT or RT. Studies had to include at least 1 objective or self-reported outcome of lower extremity physical function and/or perceived fatigue.Data ExtractionData were extracted using a customized spreadsheet, which included detailed information on patient characteristics, interventions, and outcomes. The methodological quality of the included studies was independently assessed by 2 reviewers using the Tool for Assessment of Study Quality for Reporting on Exercise rating scale.Data SynthesisTwenty-seven articles reporting data from 22 RCTS (AT=14, RT=8) including 966 PwMS. The 2 modalities were found to be equally effective in terms of improving short walk test (AT: effect size [ES]=0.33 [95% confidence interval (CI), −1.49 to 2.06]; RT: ES=0.27 [95% CI, 0.07-0.47]) and long walk test performance (AT: ES=0.37 [95% CI, −0.04 to 0.78]; RT: ES=0.36 [95% CI, −0.35 to 1.08]), as well as in reducing perceived fatigue (AT: ES=−0.61 [95% CI, −1.10 to −0.11]; RT: ES=−0.41 [95% CI, −0.80 to −0.02]). Findings on other functional mobility tests along with self-reported walking performance were sparse and inconclusive.ConclusionsAT and RT appear equally highly effective in terms of improving lower extremity physical function and perceived fatigue in PwMS. Clinicians can thus use either modality to target impairments in these outcomes. In a future perspective, head-to-head exercise modality studies are warranted. Future MS exercise studies are further encouraged to adapt a consensus “core battery” of physical function tests to facilitate a detailed comparison of results across modalities.     

“It Makes You Feel That Somebody Is Out There Caring”: A Qualitative Study of Intervention and Control Participants' Perceptions of the Benefits of Taking Part in an Evaluation of Dignity Therapy for People With Advanced Cancer

ContextParticipants in a Phase II randomized controlled trial of Dignity Therapy felt that the intervention had helped them; however, the processes underlying this are not known.ObjectivesTo explore intervention and control participants' perceptions of the benefits of taking part in an evaluation of Dignity Therapy within the frame of the underlying model of the intervention.MethodsWe interviewed 29 patients at one-week follow-up and 20 at four-week follow-up. We also interviewed nine family members of patients in the intervention group. We used the Framework approach to qualitative analysis. This comprised five stages: familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation. The analysis was both deductive (a priori themes from the model informing the content and therapeutic tone of the intervention) and inductive (from participants' views).ResultsThere was support for five of the seven themes from the model underlying Dignity Therapy: “generativity,” “continuity of self,” “maintenance of pride,” “hopefulness,” and “care tenor.” With the exception of generativity, all were evident in both groups. Prevalent emergent themes for the intervention group were “reminiscence” and “pseudo life review.” “Making a contribution” was prevalent in the control group.ConclusionPatients with advanced cancer and their families found that Dignity Therapy had helped them in many ways; however, patients in the control group sometimes perceived similar benefits from taking part in the study, highlighting elements of Dignity Therapy that are common to dignity conserving care.