Quantitative lateralized measures of bradykinesia at different stages of Parkinson's disease: The role of the less affected side

The onset of motor abnormalities in Parkinson's disease (PD) is usually unilateral. However, current therapeutic trials do not analyze separately the performance of the more affected (MA) and less affected (LA) limbs. From a cohort of 85 subjects at different stages of PD, we asked whether the relationship between bradykinesia and disease severity was similar on both limbs and if the MA side remained more bradykinetic than the LA side in advanced PD. MA and LA limb determination was made from the history of the side first affected. Twenty‐one age‐matched subjects were used as controls. The velocities of finger and arm movements on both sides were inversely correlated with disease severity (P < 0.03). The slope of the decline in wrist movement velocity was steeper on the LA side (P = 0.029). When the regression lines were extrapolated to the y‐axis (UPDRS III = 0) the performance of the LA side was not different from that of controls (P = 0.954 and P = 0.829 for finger and arm movements, respectively), whereas that of the MA side was slower (P = 0.019 and P = 0.016), suggesting that at the theoretical state of no disease the LA side would reflect less or no contralateral nigral pathology. With increasing disease severity, there was less difference between MA and LA sides in both finger and arm bradykinesia (P < 0.004). These findings highlight the value of analyzing separately the MA and LA sides in subjects with PD, especially for clinical trials of potential disease modifying agents in early stages of disease. © 2009 Movement Disorder Society     

Development of a brief ataxia rating scale (BARS) based on a modified form of the ICARS

To develop a brief ataxia rating scale (BARS) for use by movement disorder specialists and general neurologists. Current ataxia rating scales are cumbersome and not designed for clinical practice. We first modified the International Cooperative Ataxia Rating Scale (ICARS) by adding seven ataxia tests (modified ICARS, or MICARS), and observed only minimally increased scores. We then used the statistics package R to find a five‐test subset in MICARS that would correlate best with the total MICARS score. This was accomplished first without constraints and then with the clinical constraint requiring one test each of Gait, Kinetic Function‐Arm, Kinetic Function‐Leg, Speech, and Eye Movements. We validated these clinical constraints by factor analysis. We then validated the results in a second cohort of patients; evaluated inter‐rater reliability in a third cohort; and used the same data set to compare BARS with the Scale for the Assessment and Rating of Ataxia (SARA). Correlation of ICARS with the seven additional tests that when added to ICARS form MICARS was 0.88. There were 31,481 five‐test subtests (48% of possible combinations) that had a correlation with total MICARS score of ≥0.90. The strongest correlation of an unconstrained five‐test subset was 0.963. The clinically constrained subtest validated by factor analysis, BARS, had a correlation with MICARS‐minus‐BARS of 0.952. Cronbach alpha for BARS and SARA was 0.90 and 0.92 respectively; and inter‐rater reliability (intraclass correlation coefficient) was 0.91 and 0.93 respectively. BARS is valid, reliable, and sufficiently fast and accurate for clinical purposes. © 2009 Movement Disorder Society     

维吾尔族先天性髋关节脱位调查研究

了解维吾尔族活产儿小儿先天性髋关节脱位情况,提供维吾尔族先天性髋关节脱位患病率.[方法]对喀什市具有确诊及治疗小儿先天性髋关节脱位水平的5所医院住院分娩6 015例维吾尔族活产儿进行前瞻性研究.[结果]确诊小儿先天性髋关节脱位患儿18例,总患病率为0.30%,男生患病率为0.16%,女生患病率为0.44%,男女患病率差异均无统计学意义(x2=3.781,P＞0.05).早产儿先天性髋关节脱位者12例,早产儿患病率为3.01%.剖宫产患病率为1.01%.有家族遗传史5例.左侧先天性髋关节脱位10例,右侧8例,无双侧同时脱位患儿,左右侧患儿比例为1∶0.8.第1胎14例,第2胎4例.[结论]维吾尔族先天性髋关节脱位发病率比较低,女性先天性髋关节脱位患儿多于男性患儿.左侧先天性髋关节脱位略高于右侧.     

Scoliosis repair in a teenager with Duchenne’s muscular dystrophy: who calls the shots?

In this exchange, a clinician (the first author) presents a case scenario for comment by an ethicist (the second author). The case concerns a 15-year-old boy with Duchenne's muscular dystrophy requested palliative surgical correction of a 60 degree thoraco-lumbar scoliosis. The surgical team were initially reluctant to offer surgery given their assessment of the perioperative and postoperative risks (anesthetic review suggested an 80% chance of surviving the surgery and 50% likelihood of returning home), but the operation proceeded. The case raises issues of the rights of patients to insist on nonfutile but high risk surgery, risk perception, resource allocation, autonomy, and the integrity of clinicians.     

Quality of recovery from two types of general anesthesia for ambulatory dental surgery in children: a double-blind, randomized trial

Background:  Pediatric dental procedures are increasingly performed under general anesthesia because of the inability to cooperate, situational anxiety, or other behavioral problems. Volatile anesthetics have been associated with emergence delirium in children, whereas the use of propofol for anesthetic maintenance has been shown to reduce the incidence of emergence delirium after other types of surgeries. The aim of this study is to compare a sevoflurane-based anesthetic with a propofol-based technique as it relates to the incidence of emergence delirium and the quality of recovery after pediatric dental surgery, in patients who present with risk factors for perioperative behavioral issues.
Methods:  We prospectively collected data of 179 pediatric patients scheduled for ambulatory dental surgery using a double-blind and randomized trial design. Subjects were anesthetized following standardized protocols for either a sevoflurane- or a propofol-based technique. The incidence of emergency delirium, as measured by the Pediatric Anesthesia Emergence Delirium score, was the primary outcome. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), number of nursing interventions in the recovery room, time to discharge readiness, and parental satisfaction.
Results:  We found no difference in the incidence of emergence delirium after both types of anesthesia. However, use of sevoflurane significantly increased both the risk of PONV and the number of postoperative nursing interventions. Discharge criteria were met about 10 min earlier in patients anesthetized with sevoflurane. Parental satisfaction was equally high with both anesthesia regimens.
Conclusions:  A propofol-based anesthetic technique did not lead to a lower incidence of emergence delirium after dental surgery in children but did result in significantly less PONV and fewer postoperative nursing interventions.     

Comfortably numb? Exploring satisfaction with chronic back pain visits

Background contextChronic back pain is a condition characterized by high rates of disability, health-care service use, and costs.PurposeThe purpose of this study was to identify factors associated with patients' satisfaction with their last health-care provider visit for chronic low back pain (LBP).Study design/settingA cross-sectional, state-level, telephone survey was administered to patients with chronic LBP.Patient sampleThe sample consisted of 624 individuals with chronic LBP who reported seeing a health-care provider in the previous year.Outcome measuresDependent variables included satisfaction with last visit for LBP and intent to seek care from additional providers. Independent variables included the Roland-Morris Disability Questionnaire, 3-month pain ratings using a 0 to 10 Likert scale, the Medical Outcomes Survey Short Form 12, and self-reported health service utilization (provider type, number of visits to health-care providers, medication use during the previous month, and treatments and diagnostic tests during the previous year).MethodsBivariate and multivariate analyses were used to explore how demographic, insurance-related, and health-related characteristics were associated with patient satisfaction.ResultsParticipants who were not satisfied with one or more aspects of their last clinic visit were younger (51.0 vs. 54.21 years), reported higher 3-month pain ratings (7.23 vs. 6.53), and were more commonly Hispanic (53.2% vs. 46.8% for other ethnicities) and uninsured (43.1% vs. 29.3% for other insurance groups). Those who intended to seek care from additional providers were younger (50.05 vs. 55.49 years), had higher 3-month pain ratings (7.20 vs. 6.46), had lower Short Form 12 mental health component scores (44.75 vs. 49.55) and physical component scores (30.07 vs. 31.55), and were more commonly black (54.6% vs. 45.4% for other racial groups) and uninsured (56.9% vs. 43.1% for other insurance groups). Narcotic use was associated with satisfaction (odds ratio=2.12, p=.01), whereas lack of insurance was associated with respondents' intent to seek care from additional providers (odds ratio=2.97, p<.01).ConclusionsFactors other than disability were associated with satisfaction with chronic LBP visits. Understanding the role of medication in satisfaction and its implications for the health behaviors of this highly disabled population may be particularly important.     

Health-related quality of life in hospital inpatients with pressure ulceration: Assessment using generic health-related quality of life measures

The objective of this study was to determine the impact of pressure ulceration on health-related quality of life (HRQoL) and to undertake a pilot study for a future larger study. The study comprised two parts. First, data from a large UK prospective cohort study were analyzed and the HRQoL of 218 people with pressure ulcers was compared with that of 2,289 people without ulcers using the Short Form-36 (SF-36) questionnaire. After adjusting for age, sex, and comorbidities, patients with pressure ulceration had significantly lower scores for both the physical (coefficient=−3.12, p <0.001) and mental (coefficient=−1.50, p =0.04) component summary scores of the SF-36. Second, a small pilot study was conducted to explore use of other tools. HRQoL was assessed in six patients with and 16 patients without pressure ulcers using the SF-36, the EQ-5D and a pain visual analog scale. SF-36 scores indicated that patients with pressure ulcers had significantly poorer physical functioning ( d =22.3, p =0.001), role limitations due to physical problems ( d =12.9, p =0.02), and vitality ( d =20.6, p =0.04) than those without. EQ-5D scores were also poorer for patients with pressure ulceration, for both the visual analog scale ( d =19.2, p =0.02) and the index ( d =0.29, p =0.08). Patients with pressure ulceration had more perceived pain than those without; however, this difference was of borderline significance ( d =−23.9, p =0.06). Pressure ulceration therefore has an impact on HRQoL that is measurable and persists after adjusting for potential confounding.