Drug Treatment,Postural Control,and Falls: An Observational Cohort Study of 504 Patients With Acute Stroke,the Fall Study of Gothenburg

ObjectiveTo identify whether, and to what extent, treatment with cardiovascular drugs and neurotropic drugs are associated with postural control and falls in patients with acute stroke.DesignObservational cohort study.SettingA stroke unit at a university hospital.ParticipantsA consecutive sample of patients (N=504) with acute stroke.InterventionsNot applicable.Main Outcome MeasuresPostural control was assessed using the modified version of the Postural Assessment Scale for Stroke Patients. Data including baseline characteristics, all drug treatments, and falls were derived from medical records. Univariable and multivariable logistic regression and Cox proportional hazards models were used to analyze the association of drug treatment and baseline characteristics with postural control and with falls.ResultsIn the multivariable logistic regression analysis, factors significantly associated with impaired postural control were treatment with neurotropic drugs (eg, opioids, sedatives, hypnotics, antidepressants) with an odds ratio (OR) of 1.73 (95% confidence interval [CI], 1.01-2.97, P=.046); treatment with opioids (OR 9.23, 95% CI, 1.58-54.00, P=0.014); age (OR 1.09, 95% CI, 1.07-1.12, P<.0001), stroke severity, which had a high National Institutes of Health Stroke Scale-score (OR 1.29, 95% CI, 1.15-1.45, P<.0001), and sedentary life style (OR 4.32, 95% CI, 1.32-14.17, P=.016). No association was found between neurotropic drugs or cardiovascular drugs and falls.ConclusionsTreatment with neurotropic drugs, particularly opioids, in the acute phase after stroke, is associated with impaired postural control. Since impaired postural control is the major cause of falls in patients with acute stroke, these results suggest opioids should be used with caution in these patients.     

Swallowing and Voice Outcomes in Patients Hospitalized With COVID-19: An Observational Cohort Study

ObjectiveTo evaluate the presentations and outcomes of inpatients with coronavirus disease 2019 (COVID-19) presenting with dysphonia and dysphagia to investigate trends and inform potential pathways for ongoing care.DesignObservational cohort study.SettingAn inner-city National Health Service Hospital Trust in London, United Kingdom.ParticipantsAll adult inpatients hospitalized with COVID-19 (N=164) who were referred to Speech and Language Therapy (SLT) for voice and/or swallowing assessment for 2 months starting in April 2020.InterventionsSLT assessment, advice, and therapy for dysphonia and dysphagia.Main Outcome MeasuresEvidence of delirium, neurologic presentation, intubation, tracheostomy, and proning history were collected, along with type of SLT provided and discharge outcomes. Therapy outcome measures were recorded for swallowing and tracheostomy pre- and post-SLT intervention and Grade Roughness Breathiness Asthenia Strain Scale for voice.ResultsPatients (N=164; 104 men) aged 56.8±16.7 years were included. Half (52.4%) had a tracheostomy, 78.7% had been intubated (mean, 15±6.6d), 13.4% had new neurologic impairment, and 69.5% were delirious. Individualized compensatory strategies were trialed in all and direct exercises with 11%. Baseline assessments showed marked impairments in dysphagia and voice, but there was significant improvement in all during the study (P<.0001). On average, patients started some oral intake 2 days after initial SLT assessment (interquartile range [IQR], 0-8) and were eating and drinking normally on discharge, but 29.3% (n=29) of those with dysphagia and 56.1% (n=37) of those with dysphonia remained impaired at hospital discharge. A total of 70.9% tracheostomized patients were decannulated, and the median time to decannulation was 19 days (IQR, 16-27). Among the 164 patients, 37.3% completed SLT input while inpatients, 23.5% were transferred to another hospital, 17.1% had voice, and 7.8% required community follow-up for dysphagia.ConclusionsInpatients with COVID-19 present with significant impairments of voice and swallowing, justifying responsive SLT. Prolonged intubations and tracheostomies were the norm, and a minority had new neurologic presentations. Patients typically improved with assessment that enabled treatment with individualized compensatory strategies. Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways.     

Gender Differences in Pain Risk in Old Age: Magnitude and Contributors

ObjectivesTo identify the factors associated with the excess risk of pain observed among older women compared with men.Patients and MethodsWe used information from a cohort of 851 women and men age 63 years and older who were free of pain during 2012 and were followed up to December 31, 2015. Sociodemographic variables, health behaviors, psychosocial factors, morbidity, and functional limitations were assessed in 2012 during home visits. Incident pain in 2015 was classified according to its frequency, intensity, and number of localizations into lowest, middle, and highest categories.ResultsDuring a mean follow-up of 2.8 years, the incidence of middle and highest pain was 12.5% and 22.6% in women and 12.4% and 12.6% in men, respectively. The age-adjusted relative risk ratios and 95% CIs of middle and highest pain in women versus men were 1.20 (0.79-1.83) and 2.03 (1.40-2.94), respectively. In a mediation analysis, a higher frequency in women than men of osteomuscular disease, impaired mobility, and impaired agility accounted, respectively, for 31.1%, 46.6%, and 32.0% of the excess risk of highest pain in women compared with men. Other relevant mediators were psychological distress (25.2%), depression (8.7%), poor sleep quality (10.7%), and lower recreational physical activity (12.6%).ConclusionA greater frequency of some chronic diseases, worse functional status, psychological distress, and lower physical activity can mediate the excess risk of pain in older women compared with men.Trial Registrationclinicaltrials.gov Identifier: NCT02804672     

Human Immunodeficiency Virus Infection and Variation in Heart Failure Risk by Age,Sex, and Ethnicity: The HIV HEART Study

ObjectivesTo evaluate the risk of heart failure (HF) linked to human immunodeficiency virus (HIV) infection, how risk varies by demographic characteristics, and whether it is explained by atherosclerotic disease or risk factor treatment.Patients and MethodsWe performed a retrospective cohort study of persons with HIV (PWHs) from January 1, 2000, through December 31, 2016, frequency-matched 1:10 to persons without HIV on year of entry, age, sex, race/ethnicity, and treating facility. We evaluated the risk of incident HF associated with HIV infection, overall and by left ventricular systolic function, and whether HF risk varied by demographic characteristics.ResultsAmong 38,868 PWHs and 386,586 matched persons without HIV, mean ± SD age was 41.4±10.8 years, with 12.3% female, 21.1% Black, 20.5% Hispanic, and 3.9% Asian/Pacific Islander. During median follow-up of 3.8 years (interquartile range, 1.4-9.0 years), the rate (per 100 person-years) of incident HF was 0.23 in PWHs vs 0.15 in those without HIV (P<.001). The PWHs had a higher adjusted HF rate (adjusted hazard ratio [aHR], 1.73; 95% confidence interval [CI], 1.57 to 1.91), which was only modestly attenuated after accounting for interim acute coronary syndrome events. Results were similar by systolic function category. The adjusted risk of HF in PWHs was more prominent for those 40 years and younger (aHR, 2.45; 95% CI, 1.92 to 3.03), women (aHR, 2.48; 95% CI, 1.90 to 3.26), and Asian/Pacific Islanders (aHR, 2.46; 95% CI, 1.27 to 4.74).ConclusionHIV infection increases the risk of HF, which varied by demographic characteristics and was not primarily mediated through atherosclerotic disease pathways or differential use of cardiopreventive medications.     

Pain Manifestations of COVID-19 and Their Association With Mortality: A Multicenter Prospective Observational Study

ObjectivesTo determine the prevalence and breakdown of pain symptoms among patients with coronavirus disease 2019 (COVID-19) infection admitted for nonpain symptoms and the association between the presence of pain and intensive care unit (ICU) admission and death.Patients and MethodsIn this multicenter prospective study, data on the intensity and type of pain were collected on 169 patients with active severe acute respiratory syndrome coronavirus 2 infection at 2 teaching hospitals in the United States and Korea and on 8 patients with acute pain at another large teaching hospital between February 1, 2020, and June 15, 2020.ResultsSixty-five of 169 patients (38.5%) reported an active pain condition. Among the 73 patients with pain, the most common pain symptoms were headache (n=22; 30.1%), chest pain (n=17; 23.3%), spinal pain (n=18; 24.7%), myalgia (n=13; 17.8%), abdominal or pelvic pain (n=13; 17.8%), arthralgia (n=11; 15.1%), and generalized pain (n=9; 12.3%). Those reporting headache as their main symptom were less likely to require ICU admission (P=.003). Acetaminophen or nonsteroidal anti-inflammatory drugs were prescribed to 80.8% (n=59), opioids to 17.8% (n=13), adjuvants to 8.2% (n=6), and ketamine to 5.5% (n=4) of patients with pain. When age 65 years and older and sex were controlled for in multivariable analysis, the absence of pain was associated with ICU admission (odds ratio, 2.92; 95% CI, 1.42 to 6.28; P=.004) and death (odds ratio, 3.49; 95% CI, 1.40 to 9.76; P=.01).ConclusionAcute pain is common during active COVID-19 infection with the most common manifestations being headache, chest pain and spine pain. Individuals without pain were more likely to require intensive care and expire than those with pain. Reasons why pain may be associated with reduced mortality include that an intense systemic stimulus (eg, respiratory distress) might distract pain perception or that the catecholamine surge associated with severe respiratory distress might attenuate nociceptive signaling.     

Efficacy of Vestibular Rehabilitation in Patients With Neurologic Disorders: A Systematic Review

ObjectiveThe aim of this systematic review is to critically assess the effectiveness of vestibular rehabilitation (VR) administered either alone or in combination with other neurorehabilitation strategies in patients with neurologic disorders.Data SourcesAn electronic search was conducted by 2 independent reviewers in the following databases: MEDLINE (PubMed), the Physiotherapy Evidence Database, and the Cochrane Database of Systematic Reviews.Study SelectionAll clinical studies carried out on adult patients with a diagnosis of neurologic disorders who performed VR provided alone or in combination with other therapies were included.Data ExtractionScreening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa Scale.Data SynthesisThe summary of results was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Twelve studies were included in the review. All the included studies, with 1 exception, report that improvements provided by customized VR in subject affected by a central nervous system diseases are greater than traditional rehabilitation programs alone.ConclusionsBecause of the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VR cannot be made. Results show that VR programs are safe and could easily be implemented with standard neurorehabilitation protocols in patients affected by neurologic disorders. Hence, more high-quality randomized controlled trials of VR in patients with neurologic disorders are needed.     

Ballistic Resistance Training: Feasibility,Safety, and Effectiveness for Improving Mobility in Adults With Neurologic Conditions: A Systematic Review

ObjectivesTo determine whether ballistic resistance training is feasible, safe, and effective in improving muscle strength, power generation, and mobility in adults with neurologic conditions.Data SourcesNine electronic databases were searched from inception to March 2019 in addition to the reference lists of included articles.Study SelectionArticles were independently screened by 2 authors and were included if they were full-text; English-language articles published in a peer-reviewed journal; investigated ballistic resistance training for adults with a neurologic condition; and reported on feasibility, safety, strength, power, or mobility.Data ExtractionTwo authors independently extracted data. Study quality was assessed using the McMaster critical review form and the Physiotherapy Evidence Database scale.Data SynthesisThe search identified 1540 articles, with 13 articles describing 9 studies meeting the criteria for inclusion. Five studies were randomized controlled trials and 4 were cohort studies. Ballistic resistance training was feasible and safe with only 1 intervention-related adverse event reported. Findings indicated improvements in strength for hip abduction, leg press, knee flexion, and ankle dorsiflexion, but not for hip flexion, hip extension, knee extension, or ankle plantarflexion. Muscle power generation improved for hip flexion, hip abduction, leg press, knee extension, and knee flexion, but not for ankle plantarflexion. Treatment effect was positive for self-selected walking speed, with a standardized mean difference (SMD) of 0.69 (95% confidence interval [CI], 0.01-1.38) from 3 studies. However, fastest comfortable walking speed results were inconclusive with a SMD from 4 studies of 0.45 (95% CI, –0.01 to 0.91).ConclusionsBallistic training is safe and feasible for people with a neurologic condition. The effects on muscle strength, power generation, and mobility were found to be positive but not conclusive.     

Comparative Relevance of Physical Fitness and Adiposity on Life Expectancy: A UK Biobank Observational Study

ObjectiveTo investigate the extent to which 2 measures of physical fitness—walking pace and handgrip strength—are associated with life expectancy across different levels of adiposity, as the relative importance of physical fitness and adiposity on health outcomes is still debated.Patients and MethodsUsual walking pace (self-defined as slow, steady/average, brisk), dynamometer-assessed handgrip strength, body mass index (BMI), waist circumference, and body-fat percentage determined at baseline in the UK Biobank prospective cohort study (March 13, 2006, to January 31, 2016). Life expectancy was estimated at 45 years of age.ResultsThe median age and BMI of the 474,919 participants included in this analysis were 58.2 years and 26.7 kg/m², respectively; over a median follow-up of 6.97 years, 12,823 deaths occurred. Participants reporting brisk walking pace had longer life expectancies across all levels of BMIs, ranging from 86.7 to 87.8 years in women and 85.2 to 86.8 years in men. Conversely, subjects reporting slow walking pace had shorter life expectancies, being the lowest observed in slow walkers with a BMI less than 20 kg/m² (women: 72.4 years; men: 64.8 years). Smaller, less consistent differences in life expectancy were observed between participants with high and low handgrip strength, particularly in women. The same pattern of results was observed for waist circumference or body-fat percentage.ConclusionBrisk walkers were found to have longer life expectancies, which was constant across different levels and indices of adiposity. These findings could help clarify the relative importance of physical fitness and adiposity on mortality.     

Association Between Performance on an Interdisciplinary Stroke Assessment Battery and Falls in Patients With Acute Stroke in an Inpatient Rehabilitation Facility: A Retrospective Cohort Study

ObjectiveTo explore the association between demographic factors and functional performance measures of patients with acute stroke in an inpatient rehabilitation facility (IRF) and falls during the IRF stay and to quantify the diagnostic accuracy of functional outcome measures in identifying fallers.DesignRetrospective cohort study.SettingInpatient rehabilitation facility.ParticipantsIndividuals with acute stroke admitted to hospital-based IRF (N=139).InterventionsNot applicable.Main Outcome MeasuresOdds ratios were used to examine the relationship between fall frequency and functional outcome measures (National Institute of Stroke Scale, neglect [Item #11], Berg Balance Scale, Stroke Rehabilitation Assessment of Movement mobility and Stroke Rehabilitation Assessment of Movement lower extremity subscales [STREAM-LE], Montreal Cognitive Assessment, Dynamic Gait Index, and Stroke Impact Scale). Receiver operator characteristic analysis with area under the curve, sensitivity, specificity, and diagnostic odds ratio were used to assess the diagnostic accuracy of each functional outcome measure to distinguish patients who fell vs those who did not fall in the IRF.ResultsA total of 23 patients (16.2%) fell during the IRF hospitalization. Patients who did and did not fall did not differ in terms of age, sex, stroke type, or stroke location. Only the STREAM-LE was associated with falls (odds ratio, 0.93; 95% CI, 0.86-0.99). Area under the curve was 0.67 (95% CI, 0.51-0.82). With a positivity cutoff point of 12, sensitivity and specificity were 73.3% (95% CI, 54.6%-92.2%) and 50.0% (95% CI, 39.9%-59.2%), respectively. The diagnostic odds ratio was 3.4.ConclusionsThe STREAM-LE score at admission to IRF may identify patients with acute stroke who are more likely to fall during their stay. However, the search for measures with greater diagnostic accuracy should continue.     

Comparison of the Short Test of Mental Status and the Montreal Cognitive Assessment Across the Cognitive Spectrum

ObjectiveTo compare the Short Test of Mental Status (STMS) with the Montreal Cognitive Assessment (MoCA) for predicting and detecting mild cognitive impairment (MCI).Participants and MethodsParticipants from the community-based Mayo Clinic Study of Aging (MCSA) (November 24, 2010, through May 19, 2012) and an academic referral Alzheimer’s Disease Research Center (ADRC) (March 16, 2015, through September 5, 2018) were analyzed. All participants were evaluated using a standardized neuropsychological battery, and a multidisciplinary consensus diagnosis was assigned. The MCSA and ADRC samples included 313 and 106 stable cognitively normal (CN) participants, 72 and 8 CN participants at baseline who developed incident MCI or dementia, 114 and 96 participants with prevalent MCI, and 25 and 132 participants with dementia, respectively.ResultsThere were no statistically significant differences between the 2 tests in 6 of 7 diagnostic comparisons across academic referral and community populations. The STMS had a better area under the curve (0.90; 95% CI, 0.87-0.93) for differentiating prevalent MCI from CN participants in the MCSA cohort compared with the MoCA cohort (0.85; 95% CI, 0.81-0.89; P=.01). In addition, 53% of the stable CN participants (222 of 419) scored less than 26 on the MoCA, with specificity of 47% for diagnosing prevalent MCI.ConclusionWe provide evidence that the STMS performs similarly to the MoCA in a variety of settings and neurodegenerative syndromes. These results suggest that the current recommended MoCA cutoff score may be overly sensitive, consistent with previous studies. We also provide a conversion table for comparing the 2 cognitive tests.     

Sex- and Gender-Related Differences in Common Functional Gastroenterologic Disorders

Functional gastrointestinal (GI) disorders (FGIDs) result from central and peripheral mechanisms, cause chronic remitting-relapsing symptoms, and are associated with comorbid conditions and impaired quality of life. This article reviews sex- and gender-based differences in the prevalence, pathophysiologic factors, clinical characteristics, and management of functional dyspepsia (FD) and irritable bowel syndrome (IBS) that together affect approximately 1 in 4 people in the United States. These conditions are more common in women. Among patients with IBS, women are more likely to have severe symptoms and coexistent anxiety or depression; constipation or bloating and diarrhea are more common in women and men, respectively, perhaps partly because defecatory disorders, which cause constipation, are more common in women. Current concepts suggest that biological disturbances (eg, persistent mucosal inflammation after acute gastroenteritis) interact with other environmental factors (eg, abuse) and psychological stressors, which influence the brain and gut to alter GI tract motility or sensation, thereby causing symptoms. By comparison to a considerable understanding of sex-based differences in the pathogenesis of visceral hypersensitivity in animal models, we know less about the contribution of these differences to FGID in humans. Slow gastric emptying and colon transit are more common in healthy women than in men, but effects of gonadal hormones on colon transit are less important than in rodents. Although increased visceral sensation partly explains symptoms, the effects of sex on visceral sensation, colonic permeability, and the gut microbiome are less prominent in humans than rodents. Whether sex or gender affects response to medications or behavioral therapy in FD or IBS is unclear because most patients in these studies are women.     

An International,Mixed-Methods Study of the Perceived Intrusiveness of Remote Digital Diabetes Monitoring

ObjectiveTo assess the relationship between remote digital monitoring (RDM) modalities for diabetes and intrusiveness in patients’ lives.Patients and MethodsOnline vignette-based survey (February 1 through July 1, 2019). Adults with diabetes (type 1, 2, or subtypes such as latent autoimmune diabetes of adulthood) assessed three randomly selected vignettes among 36 that combined different modalities for monitoring tools (three options: glucose- and physical activity [PA]–monitoring only, or glucose- and PA-monitoring with occasional or regular food monitoring), duration/feedback loops (six options: monitoring for a week before all vs before specific consultations with feedback given in consultation, vs monitoring permanently, with real-time feedback by one's physician vs by anoter caregiver, vs monitoring permanently, with real-time, artificial intelligence-generated treatment feedback vs treatment and lifestyle feedback), and data handling (two options: by the public vs private sector). We compared intrusiveness (assessed on a 5-point scale) across vignettes and used linear mixed models to identify intrusiveness determinants. We collected qualitative data to identify aspects that drove participants’ perception of intrusiveness.ResultsOverall, 1010 participants from 30 countries provided 2860 vignette-assessments (52% were type 1 diabetes). The monitoring modalities associated with increased intrusiveness were food monitoring compared with glucose- and PA-monitoring alone (β=0.34; 95% CI, 0.26 to 0.42; P<.001) and permanent monitoring with real-time physician-generated feedback compared with monitoring for a week with feedback in consultation (β=0.25; 95% CI, 0.16 to 0.34, P<.001). Public-sector data handling was associated with decreased intrusiveness as compared with private-sector (β=?0.15; 95% CI, ?0.22 to ?0.09; P<.001). Four drivers of intrusiveness emerged from the qualitative analysis: practical/psychosocial burden (eg, RDM attracting attention in public), control, data safety/misuse, and dehumanization of care.ConclusionRDM is intrusive when it includes food monitoring, real-time human feedback, and private-sector data handling.     

Detection of Plasma Cell Disorders by Mass Spectrometry: A Comprehensive Review of 19,523 Cases

ObjectivesTo verify the analytical performance of a new mass spectrometry–based method, termed MASS-FIX, when screening for plasma cell disorders in a routine clinical laboratory.Patients and MethodsResults from 19,523 unique patients tested for an M-protein between July 24, 2018, and March 6, 2020, by a combination serum protein electrophoresis (SPEP) and MASS-FIX were examined for consistency with pretest implementation performance. MASS-FIX’s ability to verify abnormal results from SPEP and free light chain measurements was then compared with that of immunofixation electrophoresis (IFE) using a separate cohort of 52,586 patients tested by SPEP/IFE during the same period.ResultsOverall, 62.4% of our cohort was negative for an M-protein. Importantly, 7.3% of all specimens had an M spike on SPEP (0.1 to 8.5 g/dL) and MASS-FIX detected an M-protein in all these samples. Of all samples, 30.3% had M-proteins that were detected by MASS-FIX but the SPEP finding was too small for quantification. Of the positive samples, 5.7% contained a therapeutic monoclonal antibody. Of the positive samples, 4.1% had an N-glycosylated light chain (biomarker of high-risk plasma cell disorders). MASS-FIX confirmed a higher percentage of SPEP abnormalities than IFE. MASS-FIX was slightly more sensitive than IFE when confirming an M-protein in samples with an abnormal free light chain ratio. MASS-FIX had a very low sample repeat rate (1.5%). MASS-FIX was highly automatable resulting in a higher number of samples/technologist/day than IFE (～30% more).ConclusionOverall, MASS-FIX was successful in maintaining validation characteristics. MASS-FIX was more sensitive in confirming SPEP abnormalities when compared with IFE. Ability to detect therapeutic monoclonal antibodies and glycosylated light chains was distinctly advantageous.