Abstract Stegemöller EL, Buckley TA, Pitsikoulis C, Barthelemy E, Roemmich R, Hass CJ. Postural instability and gait impairment during obstacle crossing in Parkinson's disease. Objective To examine ...whether Parkinson's disease (PD) affects gait behavior and stability while walking over an obstacle. Design Parallel group comparisons were completed in which participants completed 5 trials of normal walking and 5 trials of obstacle crossing while gait kinematics and kinetics were collected. Setting University biomechanics laboratory. Participants Individuals with PD (n=10) and age- and sex-matched healthy older adults (n=10). Interventions Not applicable. Main Outcome Measures Gait parameters, obstacle clearance parameters, and center of mass motion were calculated during normal walking and obstacle crossing. Results Results revealed that decrements in gait performance in individuals with PD were amplified during obstacle crossing, suggesting that due to disease-related degradation, individuals with PD chose a more conservative strategy for obstacle crossing. Moreover, an increased duration of single limb support (18% increase), a decrease in anteroposterior range of motion (20% decrease), and an increase in mediolateral range of motion (36% increase, though not significant) coupled with the reduction in the distance between the center of pressure and center of mass (mean of 21% decrease across toe-off and heel strike) and increase in margin of stability (31% increase at toe-off and 71% increase at heel strike) may suggest that deficits in muscle strength and balance may contribute to this impairment. Conclusions Persons with PD alter their behavior to reduce the mechanical demands and increase dynamic stability during obstacle avoidance tasks.
The present uncertainty of which live viral or bacterial vaccines can be given to immunodeficient patients and the growing neglect of societal adherence to routine immunizations has prompted the ...Medical Advisory Committee of the Immune Deficiency Foundation to issue recommendations based on published literature and the collective experience of the committee members. These recommendations address the concern for immunodeficient patients acquiring infections from healthy subjects who have not been immunized or who are shedding live vaccine–derived viral or bacterial organisms. Such transmission of infectious agents can occur within the hospital, clinic, or home or at any public gathering. Collectively, we define this type of transmission as close-contact spread of infectious disease that is particularly relevant in patients with impaired immunity who might have an infection when exposed to subjects carrying vaccine-preventable infectious diseases or who have recently received a live vaccine. Immunodeficient patients who have received therapeutic hematopoietic stem transplantation are also at risk during the time when immune reconstitution is incomplete or while they are receiving immunosuppressive agents to prevent or treat graft-versus-host disease. This review recommends the general education of what is known about vaccine-preventable or vaccine-derived diseases being spread to immunodeficient patients at risk for close-contact spread of infection and describes the relative risks for a child with severe immunodeficiency. The review also recommends a balance between the need to protect vulnerable subjects and their social needs to integrate into society, attend school, and benefit from peer education.
Highlights • Summarizes current literature on enteric virus survival and inactivation on soft surfaces. • New quality assessment tool for evaluating laboratory-based microbiological studies. • ...Enteric viruses capable of surviving extended periods on soft surfaces. • Enteric viruses resistant commonly used sanitizers on soft surfaces.
Objective The early postoperative period following neonatal cardiac surgery is a time of increased risk for brain injury, yet the mechanisms underlying this risk are unknown. To understand these ...risks more completely, we quantified changes in postoperative cerebral metabolic rate of oxygen (CMRO2 ), oxygen extraction fraction (OEF), and cerebral blood flow (CBF) compared with preoperative levels by using noninvasive optical modalities. Methods Diffuse optical spectroscopy and diffuse correlation spectroscopy were used concurrently to derive cerebral blood flow and oxygen utilization postoperatively for 12 hours. Relative changes in CMRO2 , OEF, and CBF were quantified with reference to preoperative data. A mixed-effect model was used to investigate the influence of total support time and deep hypothermic circulatory arrest duration on relative changes in CMRO2 , OEF, and CBF. Results Relative changes in CMRO2 , OEF, and CBF were assessed in 36 patients, 21 with single-ventricle defects and 15 with 2-ventricle defects. Among patients with single-ventricle lesions, deep hypothermic circulatory arrest duration did not affect relative changes in CMRO2 , CBF, or OEF ( P > . 05). Among 2-ventricle patients, total support time was not a significant predictor of relative changes in CMRO2 or CBF ( P > . 05), although longer total support time was associated significantly with greater increases in relative change of postoperative OEF ( P = .008). Conclusions Noninvasive diffuse optical techniques were used to quantify postoperative relative changes in CMRO2 , CBF, and OEF for the first time in this observational pilot study. Pilot data suggest that surgical duration does not account for observed variability in the relative change in CMRO2 , and that more comprehensive clinical studies using the new technology are feasible and warranted to elucidate these issues further.
More than 20 North American academic centers account for the majority of hematopoietic stem cell transplantation (HCT) procedures for primary immunodeficiency diseases (PIDs), with smaller numbers ...performed at additional sites. Given the importance of a timely diagnosis of these rare diseases and the diversity of practice sites, there is a need for guidance as to best practices in management of patients with PIDs before, during, and in follow-up for definitive treatment. In this conference report of immune deficiency experts and HCT physicians who care for patients with PIDs, we present expert guidance for (1) PID diagnoses that are indications for HCT, including severe combined immunodeficiency disease (SCID), combined immunodeficiency disease, and other non-SCID diseases; (2) the critical importance of a high degree of suspicion of the primary care physician and timeliness of diagnosis for PIDs; (3) the need for rapid referral to an immune deficiency expert, center with experience in HCT, or both for patients with PIDs; (4) medical management of a child with suspicion of SCID/combined immunodeficiency disease while confirming the diagnosis, including infectious disease management and workup; (5) the posttransplantation follow-up visit schedule; (6) antimicrobial prophylaxis after transplantation, including gamma globulin administration; and (7) important indications for return to the transplantation center after discharge. Finally, we discuss the role of high-quality databases in treatment of PIDs and HCT as an element of the infrastructure that will be needed for productive multicenter clinical trials in these rare diseases.
Allogeneic hematopoietic cell transplantation (HCT) has been used for 40 years to ameliorate or cure primary immune deficiency (PID) diseases, including severe combined immunodeficiency (SCID) and ...non-SCID PID. There is a critical need for evaluation of the North American experience of different HCT approaches for these diseases to identify best practices and plan future investigative clinical trials. Our survey of incidence and prevalence of PID in North American practice sites indicates that such studies are feasible. A conference of experts in HCT treatment of PID has recommended (1) a comprehensive cross-sectional and retrospective analysis of HCT survivors with SCID; (2) a prospective study of patients with SCID receiving HCT, with comparable baseline and follow-up testing across participating centers; (3) a pilot study of newborn screening for SCID to identify affected infants before compromise by infection; and (4) studies of the natural history of disease in patients who do or do not receive HCT for the non-SCID diseases of Wiskott-Aldrich syndrome and chronic granulomatous disease. To accomplish these goals, collaboration by a consortium of institutions in North America is proposed. Participation of immunologists and HCT physicians having interest in PID and experts in laboratory methods, clinical outcomes assessment, databases, and analysis will be required for the success of these studies.
Abstract Nocera JR, Buckley T, Waddell D, Okun MS, Hass CJ. Knee extensor strength, dynamic stability, and functional ambulation: are they related in Parkinson's disease? Objective To evaluate the ...relationship between knee extensor strength, postural stability, functional ambulation, and disease severity in Parkinson's disease (PD). Design A cohort study. Setting University research laboratory. Participants Patients (N=44) with idiopathic PD. Intervention Not applicable. Main Outcome Measures Participants were evaluated on their isokinetic knee extensor strength. Additionally, participants completed an assessment of their postural stability (Functional Reach Test for static stability and a dynamic postural stability assessment as measured by the center of pressure–center of mass moment arm during gait initiation). Participants also underwent an evaluation of their functional ambulation as measured by a 6-minute walk test. Lastly, participants were evaluated by a neurologist specially trained in movement disorders to assess neurologic status and disease severity using the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr disability score. Results Knee extensor strength positively correlated with dynamic postural stability and negatively correlated with disease severity. Further, dynamic postural stability was negatively correlated to disease severity and positively correlated with functional ambulation in this cohort of patients with PD ( P <.05). The results also suggest that the Functional Reach Test may be a valuable assessment tool to examine postural stability in PD. Conclusions These findings suggest a malleable relationship between knee extensor strength, dynamic stability, and disease severity in PD. Although strength is only one piece of the puzzle in the functional outcome of PD, these findings may assist clinicians in designing appropriate interventions aimed at increasing function and decreasing fall risk in PD.
The Alliance for Academic Internal Medicine (AAIM) supports the need for a uniform subspecialty fellowship training and advanced residency training start date. At present, training programs and their ...sponsoring institutions vary widely in the timing of institutional orientation and fellowship/advanced residency training start dates. Some institutions conduct orientation programs before the scheduled completion of the initial training program, which leads to conflicts for the resident between current and future obligations. AAIM believes that requiring residents to report for fellowship before completion of residency training is disruptive to medical education, creates unnecessary stress for the residents, and risks, violating federal labor laws and Center for Medicare and Medicaid Services graduate medical education funding rules. Adoption of Jul 1, 2015 as the earliest start date for all training and orientation activities can be endorsed internally by AAIM institutions and would resolve these conflicts. Here, Barrett et al examine AAIM adoption of a uniform subspecialty fellowship and other advanced training.
Hypothesis Posterolateral rotatory instability (PLRI) of the elbow results from injury to the lateral collateral ligament complex from trauma or iatrogenic injury. The lateral pivot-shift test (PST) ...is standard for diagnosing PLRI, but its subjectivity affects diagnosis and makes it difficult to train young surgeons. A well-controlled investigation has not been done to quantify interclinician and intraclinician variability in PST mechanics in the intact and unstable elbow. The authors predict that there exist differences in PST mechanics between clinicians. Materials and methods Five unpaired elbow specimens underwent PST intact and after sequential sectioning of lateral stabilizing ligaments. Multiple PST trials were performed on each specimen by 3 clinicians (1 expert, 2 in-training) while 3-dimensional motion and loads were recorded. Intraclinician and interclinician variability were analyzed. Results Mean supination torque, valgus torque, and axial force were 3.6 ± 1.9 Nm, 5.6 ± 3.1 Nm, and –8.3 ± 15.7 N, respectively. Mean radial head displacement was 13.7 ± 4.6 mm. There were no significant differences in these measures after sequential ligament sectioning. One surgeon (in-training 2) applied significantly greater axial compressive forces across the elbow joint (5-9 N difference). Variability of axial force (380% ± 473%) was greater than that of supination torque (20% ± 11%), valgus torque (14% ± 4%), and radial head displacement (8% ± 6%; P < .05 for analysis of variance). Discussion The clinicians performed the PST consistently and with comparable loads, with the exception of axial compressive force across the radiohumeral joint, which varied across clinicians by 1 to 2 pounds (5-9 N). Conclusion This study suggests that the PST is a mechanically reproducible clinical examination, despite differing levels of training in performing the maneuver. With the exception of axial force, PST mechanics are highly repeatable for a given surgeon applying the test on a single specimen.
Background Heavy physical exertion, emotional stress, heavy meals and respiratory infection transiently increase the risk of myocardial infarction, sudden death and stroke, however it remains ...uncertain how to use this information for disease prevention. Aims We determined the feasibility of taking targeted medication for the hazard duration of a triggering activity to reduce risk. Methods After a run-in training period over 1 month, 17 healthy subjects recorded for 1 month all episodes of physical and emotional stress, heavy meal and respiratory infection. For each episode, they were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal) and record adherence with taking medication. Subjects performed exertion while wearing a heart rate monitor, once during the run-in period, and once 30 min after taking propranolol and aspirin. Results Based on study diary subjects reliably documented triggers with 94% adherence. Designated medication was also reliably taken, with 88% adherence. Propranolol taken prior to exertion resulted in a lower peak heart rate (128 ± 38 versus 149 ± 21, p < 0.01) compared to similar exercise during the run-in period. Over two-thirds (71%) of subjects considered that it was feasible to continue taking medication in this manner. Conclusions The study indicates that potential triggers of acute cardiovascular disease can be reliably identified, and it is feasible and acceptable to take targeted medication at the time of these triggers. These findings encourage further investigation of the potential role of this therapeutic strategy.
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