Impaired Ambulation Research Articles

Making Every Step Count: Minute-by-Minute Characterization of Step Counts Augments Remote Activity Monitoring in People With Multiple Sclerosis.

BackgroundAmbulatory disability is common in people with multiple sclerosis (MS). Remote monitoring using average daily step count (STEPS) can assess physical activity (activity) and disability in MS. STEPS correlates with conventional metrics such as the expanded disability status scale (Expanded Disability Status Scale; EDSS), Timed-25 Foot walk (T25FW) and timed up and go (TUG). However, while STEPS as a summative measure characterizes the number of steps taken over a day, it does not reflect variability and intensity of activity.ObjectivesNovel analytical methods were developed to describe how individuals spends time in various activity levels (e.g., continuous low versus short bouts of high) and the proportion of time spent at each activity level.Methods94 people with MS spanning the range of ambulatory impairment (unaffected to requiring bilateral assistance) were recruited into FITriMS study and asked to wear a Fitbit continuously for 1-year. Parametric distributions were fit to minute-by-minute step data. Adjusted R2 values for regressions between distributional fit parameters and STEPS with EDSS, TUG, T25FW and the patient-reported 12-item MS Walking scale (MSWS-12) were calculated over the first 4-weeks, adjusting for sex, age and disease duration.ResultsDistributional fits determined that the best statistically-valid model across all subjects was a 3-compartment Gaussian Mixture Model (GMM) that characterizes the step behavior within 3 levels of activity: high, moderate and low. The correlation of GMM parameters for baseline step count measures with clinical assessments was improved when compared with STEPS (adjusted R2 values GMM vs. STEPS: TUG: 0.536 vs. 0.419, T25FW: 0.489 vs. 0.402, MSWS-12: 0.383 vs. 0.378, EDSS: 0.557 vs. 0.465). The GMM correlated more strongly (Kruskal-Wallis: p = 0.0001) than STEPS and gave further information not included in STEPS.ConclusionsIndividuals' step distributions follow a 3-compartment GMM that better correlates with clinic-based performance measures compared with STEPS. These data support the existence of high-moderate-low levels of activity. GMM provides an interpretable framework to better understand the association between different levels of activity and clinical metrics and allows further analysis of walking behavior that takes step distribution and proportion of time at three levels of intensity into account.

Successful treatment of carbon monoxide toxicity with high flow nasal oxygen compared to mechanical ventilation

AbstractTwo dogs were presented to the emergency room for suspected carbon monoxide toxicity associated with a furnace malfunction. Both dogs exhibited signs of impaired ambulation, abnormal mentation, and respiratory distress. Arterial co‐oximetry confirmed elevated carboxyhaemoglobin levels (27.6% and 23.6%). Initial treatment consisted of bilateral nasal oxygen administration. Due to progression of clinical signs, dog 1 was mechanically ventilated and dog 2 was administered high flow nasal oxygen (HFNO). After approximately 3 hours of treatment, both dogs had improved carboxyhaemoglobin levels of 4.9% and 5.2%, respectively, and had significant improvement of reported clinical signs. The calculated half‐life of carboxyhaemoglobin in dog 1 with mechanical ventilation was 150 minutes, and in dog 2 was 167 minutes with HFNO. Both dogs survived to discharge and no long‐term complications were reported. This is the first described case using HFNO as a treatment option for carbon monoxide toxicity in dogs.

Reliability of patient self-reports to clinician-assigned functional scores of inclusion body myositis

BackgroundSporadic inclusion body myositis (IBM) is a debilitating disease which leads to impaired ambulation and loss of hand function. Yale IBM Registry (IBMR) was launched in November 2016 to address the knowledge gap in IBM natural history data. The registry interface provides an IBM personalized index calculator (IBM-PIC) based on the IBM-functional rating scale (IBM-FRS). While the calculator is based on the IBM-FRS, it has not been directly compared to the IBM-FRS score. Therefore, in this study, we compared the patient-reported IBM-PIC score from this calculator with the physician-obtained IBM-FRS score. MethodIBM-FRS was administered over the phone within two weeks of their most recent IBM-PIC entry in the IBMR to 35 participants. To compare the agreement between IBM-FRS and IBM-PIC scores, Interrater Correlation Coefficient (ICC) analysis was performed. For individual questions, Fleiss Kappa statistics was used. ResultsThirty-five active IBM-PIC users participated. Eighty percent of the participants were men, and 91% were White Caucasians. The reported IBM-FRS score of this group was 23.5 ± 7.4 (range 1–38). The Interrater Correlation Coefficient (ICC) between the physician-administered IBM-FRS score and the IBM-PIC was 0.98 (0.96–0.99). There was moderate to substantial agreement on all the questions on IBM-FRS except for handwriting and fine motor skills. DiscussionIBM-PIC is a reliable indicator of the IBM-FRS score obtained by the physician. It is anticipated that this online platform will be a valuable tool for assessing IBM severity and monitoring disease progression remotely both in clinical practice and research studies.

Radical resection of lumbosacral lipomas in children: the Great Ormond Street Hospital experience.

In 2009, Pang described a radical resection technique for congenital lumbosacral lipomas, with lower long-term symptomatic re-tethering rates compared with partial resections and conservative management, and low surgical morbidity. We adopted this technique in 2011, and aim to describe our first results. In this monocentric retrospective audit, we included dorsal, transitional, chaotic, and caudal-type lumbosacral lipomas. Exclusion criteria were previously operated lipomas, pure filar lipomas, and concomitant major congenital anatomical urogenital/gastrointestinal abnormalities. Neuro-uro-orthopaedic status at presentation and at three months, one year and last postoperative follow-up, intraoperative electrophysiology, and extent of resection were collected. From January 2011 to September 2019, 91 patients were operated (median age 2y2m; 63 transitional; 14 caudal; 8 dorsal; 6 chaotic). Preoperatively, 67% were symptomatic. Preoperative and one-year postoperative rates of impaired ambulation (44% to 43%), hypoesthesia (8% to 5%), urodynamic/uroradiological abnormalities (49% to 37%), and foot/ankle deformities (8% to 5%) were comparable, whilst pain improved (25% to 5%) but catheterisation rates increased (21% to 36%). 23/92 (25%) suffered wound-related complications. 2/91 (2%) developed symptomatic re-tethering requiring second surgery. Mean cord/sac ratio was 0.47. 43% had > 20 mm3 residual fat, which improved with increasing surgical experience. Radical lipoma resection, guided by intraoperative neuromonitoring, with reconstruction of the neural placode and expansion duraplasty is technically feasible and results in low rates of late deterioration and re-tethering. Lipoma-type and pre-operative status are important outcome predictors. Operative risks are not insignificant. Future studies need to determine appropriate selection criteria for surgery.

Multiple Sclerosis Disease Activity and Disability Following Discontinuation of Natalizumab for Pregnancy

The magnitude of risk of pregnancy-related multiple sclerosis relapses, particularly severe relapses, following natalizumab cessation is unclear, as is whether this risk is reduced by pregnancy or other modifiable factors. To determine the association of early natalizumab withdrawal before or during pregnancy with risk of severe relapses and relapse-related disability. This prospective cohort study used data from the German Multiple Sclerosis and Pregnancy Registry, which enrolled participants between November 2006 and February 2018. Data were collected through structured telephone-administered questionnaires and review of neurologists' notes. Registry patients who stopped natalizumab treatment within the 2 years before or in the first trimester of pregnancy were included in this analysis. Data were analyzed between January and November 2021. Cessation of natalizumab before pregnancy or until the first trimester. Severe and significant relapse-related disability was defined as at least a 2.0-point increase on the expanded disability status scale or new or worsening relapse-related ambulatory impairment. Multivariable models accounting for measures of disease severity and repeated events were used. The cohort comprised 255 women with 274 pregnancies (mean [SD] age at pregnancy onset, 31.25 [4.27] years) who stopped natalizumab before pregnancy (n = 85; median time before last menstrual period, 14.29 weeks [IQR, 3.14-42.43 weeks]) or in the first trimester (n = 189). During pregnancy and the postpartum year, relapses were reported in 183 pregnancies (66.78%), severe relapses in 44 pregnancies (16.05%), and potentially life-threatening relapses in 3 pregnancies (1.10%). One year post partum, significant relapse-related disability was accrued in 29 pregnancies (10.58%). Relapses during pregnancy (n = 109; 39.78%) and in the postpartum period (n = 135; 49.27%) were common. Pregnancy (as a time-dependent covariate) was not associated with a reduced relapse risk (adjusted HR, 0.90; 95% CI, 0.64-1.27). Neither exclusive breastfeeding (adjusted HR, 1.34; 95% CI, 0.86-2.10) nor restarting natalizumab within 4 weeks post partum (adjusted HR, 1.06; 95% CI, 0.48-2.36) were associated with a reduced risk of early postpartum relapses 6 months after delivery. However, the relapse rate ratio during 12 months post partum was lower (0.49; 95% CI, 0.28-0.86) when natalizumab was restarted in the first 4 weeks after birth. This cohort study's finding suggest that 10% of women may retain clinically meaningful disability from pregnancy-related natalizumab cessation relapses 1 year post partum. This information should be shared with women on natalizumab who desire pregnancy to weigh the high risk of pregnancy-related relapses and disability to the partly uncertain risks of continuing natalizumab throughout pregnancy or switching to depleting agents before conception.

Internal fixation versus hip arthroplasty in patients with nondisplaced femoral neck fractures: short-term results from a geriatric trauma registry

PurposeTo determine whether internal fixation (IF) or hip arthroplasty (HA) is associated with superior outcomes in geriatric nondisplaced femoral neck fracture (FNF) patients.MethodsData from the Registry for Geriatric Trauma of the German Trauma Society (ATR-DGU) were analyzed (IF Group 449 and HA Group 1278 patients). In-hospital care and a 120-day postoperative follow-up were conducted. Primary outcomes, including mobility, residential status, reoperation rate, and a generic health status measure (EQ-5D score), and the secondary outcome of mortality were compared between groups. Multivariable analyses were performed to assess independent treatment group associations (odds ratios, ORs) with the primary and secondary end points.ResultsPatients in the HA group were older (83 vs. 81 years, p < 0.001) and scored higher on the Identification of Seniors at Risk screening (3 vs. 2, p < 0.001). We observed no differences in residential status, reoperation rate, EQ-5D score, or mortality between groups. After adjusting for key covariates, including prefracture ambulatory capacity, the mobility of patients in the HA group was more frequently impaired at the 120-day follow-up (OR 2.28, 95% confidence interval = 1.11–4.74).ConclusionTreatment with HA compared to treatment with IF led to a more than twofold increase in the adjusted odds of impaired ambulation at the short-term follow-up, while no significant associations with residential status, reoperation rate, EQ-5D index score, or mortality were observed. Thus, IF for geriatric nondisplaced FNFs was associated with superior mobility 120 days after surgery. However, before definitive treatment recommendations can be made, prospective, randomized, long-term studies must be performed to confirm our findings.

The association of selected multiple sclerosis symptoms with disability and quality of life: a large Danish self-report survey

BackgroundPeople with multiple sclerosis (MS) experience a wide range of unpredictable and variable symptoms. The symptomatology of MS has previously been reported in large sample registry studies; however, some symptoms may be underreported in registries based on clinician-reported outcomes and how the symptoms are associated with quality of life (QoL) are often not addressed.The aim of this study was to comprehensively evaluate the frequency of selected MS related symptoms and their associations with disability and QoL in a large self-report study.MethodsWe conducted a cross-sectional questionnaire survey among all patients at the Danish Multiple Sclerosis Center, Copenhagen University Hospital, Denmark. The questionnaire included information on clinical and sociodemographic characteristics, descriptors of QoL and disability, as well as prevalence and severity of the following MS symptoms: impaired ambulation, spasticity, chronic pain, fatigue, bowel and bladder dysfunction, and sleep disturbances.ResultsQuestionnaires were returned by 2244/3606 (62%). Participants without MS diagnosis or incomplete questionnaires were excluded, n = 235. A total of 2009 questionnaires were included for analysis (mean age 49.4 years; mean disease duration 11.7 years; and 69% were women).The most frequently reported symptoms were bowel and bladder dysfunction (74%), fatigue (66%), sleep disturbances (59%), spasticity (51%) and impaired ambulation (38%). With exception of fatigue and sleep disturbances, all other symptoms increased in severity with higher disability level. Invisible symptoms (also referred to as hidden symptoms) such as fatigue, pain and sleep disturbances had the strongest associations with the overall QoL.ConclusionWe found invisible symptoms highly prevalent, even at mild disability levels. Fatigue, pain and sleep disturbances had the strongest associations with the overall QoL and were more frequently reported in our study compared with previous registry-based studies. These symptoms may be underreported in registries based on clinician reported outcomes, which emphasizes the importance of including standardized patient reported outcomes in nationwide registries to better understand the impact of the symptom burden in MS.

Prevalence and predictors of bowel dysfunction in a large multiple sclerosis outpatient population: an Italian multicenter study

IntroductionBowel dysfunction (BD) is reported as a common and disabling symptom in multiple sclerosis (MS) patients. To date, no studies have explored the prevalence of these symptoms in a large multicenter outpatient setting. The aims of the present study are to assess: (i) the prevalence of BD in a large multicenter Italian MS population, and (ii) the correlation between clinico-demographic variables and the severity of BD.MethodsEach of the nine participating center screened MS patients prospectively: 1100 subjects were enrolled. All patients underwent the Expanded Disability Status Scale (EDSS) and completed the Neurogenic Bowel Dysfunction score (NBDs). Multivariable linear and logistic regression models were used to assess the association between NBDs and several clinico-demographic variables.ResultsFourteen percent of MS patients showed a moderate/severe BD (NBDs > 10); this percentage increased in patients with high disability, ranging from 26 to 32%. Moderate/severe BD was more frequent in MS patients with: progressive phenotypes, higher disability, older age, and longer disease duration. NBDs severity was predicted by female sex, ambulation impairment and bladder symptoms.ConclusionThis study confirms the relatively high prevalence of moderate/severe BD in a large, multicenter, unselected, outpatient MS population. BD appears to be mainly associated to female sex and MS-related disability.

Phenotypic characterisation of paroxysmal dyskinesia in Sphynx cats.

The aim of this study was to identify the phenotypic features of a paroxysmal dyskinesia observed in Sphynx cats. The owners of affected Sphynx cats were invited to provide video footage of abnormal episodes for review. Those that demonstrated episodes consistent with paroxysmal dyskinesia were then invited to complete an online questionnaire designed to allow further characterisation. Ten Sphynx cats were included in the study. All affected cats were <4 years of age at the onset of the episodes (range 0.5-4.0). The episodes had a duration of <5 mins in 9/10 cats (range 0.5-10), while episode frequency was variable between and within individual cats. The episodes were characterised by impaired ambulation due to muscle hypertonicity, most commonly affecting the hips and pelvic limbs (9/10) and shoulders and thoracic limbs (8/10). The head and neck (6/10), tail (5/10), and back and abdomen (3/10) were also involved in some cats. Sudden movement, excitement and stress were identified as possible triggers for the episodes in three cats. Therapeutic intervention was not attempted in 7/10 cases, although two cats were reported to become free of the episodes while receiving acetazolamide. The two cats that were followed beyond 2 years from onset entered spontaneous remission. None of the owners believed that the abnormal episodes had affected the quality of life of their cat. The phenotype of paroxysmal dyskinesia in Sphynx cats presented in this study appears to share similarities with paroxysmal kinesigenic dyskinesia described in human classification systems. Some cats appear to achieve episode freedom spontaneously. Subsequent research should focus on evaluating response to treatment and determining an underlying genetic cause.

Incidence, risk factors and management of venous thromboembolism in patients with primary CNS lymphoma.

Venous thromboembolism (VTE) is a known complication of malignancy. While brain tumors in general predispose to VTE, the incidence in primary central nervous system lymphoma (PCNSL) is poorly characterized. We sought to characterize incidence, risk factors, management, and outcome of VTE in PCNSL METHOD: Retrospective study of 78 PCNSL patients from 2/1/2002 to 4/1/2020 at the University of Virginia RESULTS: 31% (24/78) of patients developed VTE. 12.8% (10/78) had deep venous thrombosis (DVT) alone, 11.5% (9/78) isolated pulmonary embolism (PE) and 6.4% (5/78) both. The median time from PCNSL diagnosis to VTE was 3months. In a univariate competing risks analysis, previous VTE (p < 0.001), impaired ambulation (p = 0.035), baseline hemoglobin < 10g/dL (p = 0.025) and history of diabetes mellitus (type 1 or 2) (p = 0.007) were associated with increased VTE risk. 34.8% were anticoagulated acutely with heparin (8/23) or 65.2% LMWH (15/23), and 25.0% (6/24) received warfarin, 41.7% (10/24) LMWH, and 33.3% (8/24) DOACs long-term. One adverse event was attributable to anticoagulation (arm hematoma with hemoglobin decrease). Five patients received IVC filters with concomitant oral anticoagulation; one experienced IVC thrombosis after anticoagulation discontinuation. Six of the 24 patients experienced recurrent VTE, four while anticoagulated. Patients with PCNSL are at high risk of VTE, most of which accrues in the first few months. History of VTE, diabetes mellitus (type 1 or 2), impaired ambulatory status, or hemoglobin < 10g/dL may predispose patients to this complication. While optimal management is uncertain, anticoagulation prevented recurrent VTE in most patients without intracranial bleeding.

Functional Disabilities and Psychiatric Symptoms in Primary Progressive Aphasia

Introduction Frontotemporal dementia (FTD) compromises a group of clinically and pathologically heterogeneous neurodegenerative syndromes including two forms of primary progressive aphasia (PPA) – nonfluent aphasia and semantic dementia (SD). While language impairments are the most prominent and impairing initial symptom, over time additional disabilities accumulate as these illnesses progress, eroding quality of life and increasing the burden of care. Little is known about the chronology of acquiring non-language functional disabilities in PPA. The primary aim of this study is to describe the chronology of functional disabilities in PPA, and to examine temporal associations between psychiatric comorbidities and specific disabilities. Methods Data are from subjects enrolled in the National Alzheimer's Coordinating Center (NACC) database between June 2005 and May 2019. We included subjects whose recent diagnosis was PPA. Functional status was coded as a binary variable for the following functions: ambulation (gait and falls), transaction skills (shopping, taxes, and bills), verbal communication, meal preparation, and self-care. Descriptive statistics and cox proportional hazard analyses were used to characterize the emergence of disabilities and their association with medical and psychiatric comorbidities. Results We enrolled 1,944 subjects, comprising 91 with a CDR score of zero at baseline who were used in our analysis. Mean age of this population at baseline was 68.8 years and 43.5% were males. At the onset of the study, no individuals had impairments in self-care, while 7% had impairments in the transactions domain, 3% in ambulation, and 2% in meal preparation. Ninety-three percent had language impairments at the onset of the study, and all by 4 years. By 5 years, 41% of patients had impairments in ambulation and in self-care, 49% were impaired with respect to meal preparation and 70% had impairment in transactions. The presence of psychosis was associated with an increased risk for self-care impairment (HR 5.0, CI [2.4-10.6], p Conclusions We provide a preliminary estimation in a large sample of the year-by-year frequency of functional disability in PPA patients. Impairment in communication skills appear early, followed closely by impairment in transactions. Ambulation, self-care and meal preparation impairments occur later. A number of psychiatric symptoms were significantly associated with functional disability progression, suggesting the potential of forestalling disability progression by treating psychiatric symptoms. These findings, when fully developed, can be expected to provide clinicians with practical guidance for forecasting disabilities in their patients, providing a rational basis for targeted interventions, individualized programs of care, and care giver education and training. Funding The NACC database is funded by NIA/NIH Grant U01 AG016976. NACC data are contributed by the NIA-funded ADCs: P30 AG019610 (PI Eric Reiman, MD), P30 AG013846 (PI Neil Kowall, MD), P30 AG062428-01 (PI James Leverenz, MD) P50 AG008702 (PI Scott Small, MD), P50 AG025688 (PI Allan Levey, MD, PhD), P50 AG047266 (PI Todd Golde, MD, PhD), P30 AG010133 (PI Andrew Saykin, PsyD), P50 AG005146 (PI Marilyn Albert, PhD), P30 AG062421-01 (PI Bradley Hyman, MD, PhD), P30 AG062422-01 (PI Ronald Petersen, MD, PhD), P50 AG005138 (PI Mary Sano, PhD), P30 AG008051 (PI Thomas Wisniewski, MD), P30 AG013854 (PI Robert Vassar, PhD), P30 AG008017 (PI Jeffrey Kaye, MD), P30 AG010161 (PI David Bennett, MD), P50 AG047366 (PI Victor Henderson, MD, MS), P30 AG010129 (PI Charles DeCarli, MD), P50 AG016573 (PI Frank LaFerla, PhD), P30 AG062429-01(PI James Brewer, MD, PhD), P50 AG023501 (PI Bruce Miller, MD), P30 AG035982 (PI Russell Swerdlow, MD), P30 AG028383 (PI Linda Van Eldik, PhD), P30 AG053760 (PI Henry Paulson, MD, PhD), P30 AG010124 (PI John Trojanowski, MD, PhD), P50 AG005133 (PI Oscar Lopez, MD), P50 AG005142 (PI Helena Chui, MD), P30 AG012300 (PI Roger Rosenberg, MD), P30 AG049638 (PI Suzanne Craft, PhD), P50 AG005136 (PI Thomas Grabowski, MD), P30 AG062715-01 (PI Sanjay Asthana, MD, FRCP), P50 AG005681 (PI John Morris, MD), P50 AG047270 (PI Stephen Strittmatter, MD, PhD).

FUNCTIONAL NEUROMARKERS IN PARKINSON’S DISEASE (PD)

New neurotechnologies which help to study not only the structure but also brain work, especially in milliseconds, allow for a more accurate diagnosis of a given disease entity. The aim of our study was to characterize the functional neuromarkers, including a new neuromarker, that is high rolandic beta, in Parkinson’s disease (PD). A 76-year-old male patient, a university professor, a widower, in an intimate relationship with a beloved partner, was tested in the Reintegration and Training Center of the Polish Society of Neuropsychology. Five years earlier (when he was 71 years old), following long-term stress, he had had a transient ischemic attack (TIA). In the following years he experienced two neurological episodes, and was diagnosed, on the basis of MRI findings and clinical symptoms, with vascular (multi-infarct) Parkinsonism. A sudden deterioration in his functioning, including hand tremors at rest, bradykinesia (motor slowdown), asymmetrical gait difficulties, postural instability, and falls typical for PD, as well as MRI finding (the appearance of ‘a swallow tail ’ on the left side, and the lack on the right of the substantia nigra within the midbrain) was the cause of further differential diagnosis. He was assessed using the HBI methodology (Kropotov 2016; Pąchalska, Kaczmarek, Kropotov 2014). EEG was recorded from 19 scalp sites, in resting state conditions, with eyes open and eyes closed, and during the cued GO/NOGO tasks with animal/plants as GO/NOGO stimuli. The electrodes were applied according to the International 10-20 system. The EEG was recorded referentially to linked ears, allowing for a computational re-referencing of the data (remontaging). Event related potentials (ERPs) were used to assess the functional changes manifested by the patient. To compare our patient with healthy controls we used the normative Human Brain Index (HBI), a database obtained through joint research by Swiss, Norwegian, Polish and Russian neuroscientists (Kropotov 2018). This database included behavioral parameters and ERP measures in 6 different neuropsychological tasks for 1000 healthy subjects. What is striking, no signs of cognitive dysfunction was found; however observed were an asymmetrical frontal lobe alpha (a neuromarker of depression) and excessive Rolandic beta (a neuromarker of Parkinson’s disease). We will discuss the results on the basis of recent subject literature findings, including the personal factors that might influenced the process of the diagnosis and treatment of this patient, ones which should be also taken into account in any differential diagnosis. The obtained results show the importance of using HBI methodology in clinical practice. Physicians involved in the diagnosis and treatment of those with progressive ambulatory impairment and an abnormal white matter (WM) signal on neuroimaging, should when formulating any differential diagnosis consider the use of this approach. ------------------------------------------------------------------------------------------------------------------------------------

Decentralised convenience: Digitised clinical assessment for impaired ambulation

Decentralised convenience: Digitised clinical assessment for impaired ambulation

High mortality rate following periprosthetic femoral fractures after total hip arthroplasty. A multicenter retrospective study

The main objective of this study was to evaluate the morbidity and mortality following periprosthetic femoral fractures (PFFs) after total hip arthroplasty. The secondary objectives were to explore risk factors for mortality and compare outcomes by method of treatment. A multicenter retrospective study was conducted (2016-2017) of all PFFs after total hip arthroplasty. We collected data on: ASA score, Charlson comorbidity index, type of fracture, method of treatment, timing of surgery, length of stay, systemic and local complications and mortality. Functional outcome was assessed in terms of preoperative and postoperative ambulatory status. Univariate and multivariate analysis were performed in the sample to identify risk factors for mortality. A total of 107 patients were evaluated and their mean age was 81 years old. The most common type of fracture according to the Vancouver classification was B1 (52.4% of patients), followed by B2 fractures (31.8%). The mortality rate during the first month was 9.3% and was associated with patients with ASA >3. Mortality rate in the first year was 22.3% and was associated with poorer walking ability before surgery and Charlson index ≥3. In the multivariable analysis, Charlson index ≥3 (odds ratio=6.85) and age ≥80 years old (odds ratio=7.446) were associated with 1-year mortality. Neither complications nor mortality rate were associated with either time to surgery or method of treatment. More than half of the patients (57.9%) did not regain their prefracture walking status. Major systemic complications developed in 23.4% of the patients and major local complications in 12.1%. Despite modern surgical techniques and multidisciplinary management, this study highlights the ambulatory status impairment and high rate of complications and mortality after PFF. Although the mortality rate during the first year was similar to that observed in other studies on PFFs, we found a higher mortality rate within the first month.

The correlation between motor and cognitive dysfunction in multiple sclerosis

The correlation between motor and cognitive dysfunction in multiple sclerosis Konstantin K. Mineev, Andrey M. Petrov, Marina V. Votintseva, Igor' D. Stolyarov N.P. Beсhtereva Institute of Human Brain of the Russian Academy of Sciences, St. Petersburg, Russia Introduction. Impaired ambulation is one of the most common and disabling symptoms in multiple sclerosis (MS). Cognitive impairment occurs in the early stages of MS and worsens as the disease progresses. The aim of the study was to investigate the correlation between walking speed and distance and the severity of neurological and cognitive impairment in MS. Materials and methods. We examined 59 patients with relapsing-remitting MS in clinical remission. Motor function was evaluated using the timed 25-foot walk (mobility and leg function performance test based on a timed 25-walk), the nine-hole peg test was used to assess upper limb motor function, the Ashworth Scale was used to evaluate lower limb spasticity, the EDSS scale (pyramidal function) was used to evaluate gait spasticity, and tests for sustained attention, counting skills, short-term and delayed memory, mathematical logic, speech fluency, and sensorimotor reaction speed were used to assess cognitive function. Results. In MS, an increased score on the disability scale was accompanied by increased motor disturbances, reduced distance covered when walking, decreased walking speed, and slower hand movements. Increased spasticity was accompanied by a deterioration in cognitive test performance. The study showed a high correlation between spasticity and reduced computational abilities, mathematical logic, and the ability to remember shapes. Walking distance correlated with attention span and short-term and delayed memory while walking speed characteristics correlated with the movement speed of the non-dominant hand. Slower hand activity correlated with the conducted cognitive tests, with the most significant differences recorded in the non-dominant hand. Conclusion. The study results indicate significant and varied motor and cognitive dysfunction in MS patients, caused by damage to both the conduction pathways in the brain and spinal cord and the cortical grey matter. The obtained data on the close correlation between motor and cognitive impairments allow us to better understand the mechanisms of MS development and to apply this knowledge in clinical practice.

U-turn speed is a valid and reliable smartphone-based measure of multiple sclerosis-related gait and balance impairment

BackgroundPeople living with multiple sclerosis (MS) experience impairments in gait and mobility, that are not fully captured with manually timed walking tests or rating scales administered during periodic clinical visits. We have developed a smartphone-based assessment of ambulation performance, the 5 U-Turn Test (5UTT), a quantitative self-administered test of U-turn ability while walking, for people with MS (PwMS). Research questionWhat is the test-retest reliability and concurrent validity of U-turn speed, an unsupervised self-assessment of gait and balance impairment, measured using a body-worn smartphone during the 5UTT? Methods76 PwMS and 25 healthy controls (HCs) participated in a cross-sectional non-randomised interventional feasibility study. The 5UTT was self-administered daily and the median U-turn speed, measured during a 14-day session, was compared against existing validated in-clinic measures of MS-related disability. ResultsU-turn speed, measured during a 14-day session from the 5UTT, demonstrated good-to-excellent test-retest reliability in PwMS alone and combined with HCs (intraclass correlation coefficient [ICC] = 0.87 [95 % CI: 0.80–0.92]) and moderate-to-excellent reliability in HCs alone (ICC = 0.88 [95 % CI: 0.69–0.96]). U-turn speed was significantly correlated with in-clinic measures of walking speed, physical fatigue, ambulation impairment, overall MS-related disability and patients’ self-perception of quality of life, at baseline, Week 12 and Week 24. The minimal detectable change of the U-turn speed from the 5UTT was low (19.42 %) in PwMS and indicates a good precision of this measurement tool when compared with conventional in-clinic measures of walking performance. SignificanceThe frequent self-assessment of turn speed, as an outcome measure from a smartphone-based U-turn test, may represent an ecologically valid digital solution to remotely and reliably monitor gait and balance impairment in a home environment during MS clinical trials and practice.

The impairment of the functional system and fatigue at the onset of the disease predict reaching disability milestones in relapsing-remitting multiple sclerosis differently in female and male patients.

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system with variable types of disability progression (DP). Previous studies, defining different disability milestones (DMs), have reported symptoms at MS onset to be the predictors of DP and sex as a risk factor. Meanwhile, accounting for sex differences in MS, predictors in female and male patients might differ. To investigate whether the symptoms at MS onset predict reaching DMs in patients with relapsing-remitting (RR) MS and whether the predictors vary between different DMs and female and male patients. Data from 128 RR MS patients (84 females, 44 males) was retrospectively studied. EDSS scores 4 and 6 (associated with impaired ambulation) were taken as DMs. Association between symptoms at MS onset and time to reach DMs was assessed with Cox multiple regression model. Pyramidal symptoms and fatigue at MS onset predicted the progression to EDSS 4 in the whole study population (HR 1.84, 95% CI 1.07-3.2, p = 0.028 and HR 2.01, 95% CI 1.12-3.4, p = 0.011, correspondingly). The same symptoms predicted reaching DM in female, but not male patients. Bowel/bladder symptoms predicted reaching EDSS 6 in the whole study population (HR 4.31, 95% CI 1.47-12.6, p = 0.008) and female patients only (HR 3.93, 95% CI 1.04-14.8, p = 0.043). In female patients, fatigue was also the predictor of reaching EDSS 6 (HR 3.54, 95% CI 1.16-10.8, p = 0.026). Impairment of functional symptoms at MS onset can predict reaching DMs in patients with RR-MS, but the predictors for EDSS 4 and EDSS 6 differ in female and male patients.

Smartphone Accelerometry: A Smart and Reliable Measurement of Real-Life Physical Activity in Multiple Sclerosis and Healthy Individuals.

Background: Mobility impairment is common in persons with multiple sclerosis (pwMS) and can be assessed with clinical tests and surveys that have restricted ecological validity. Commercial research-based accelerometers are considered to be more valuable as they measure real-life mobility. Smartphone accelerometry might be an easily accessible alternative.Objective: To explore smartphone accelerometry in comparison to clinical tests, surveys, and a wrist-worn ActiGraph in pwMS and controls.Methods: Sixty-seven pwMS and 70 matched controls underwent mobility tests and surveys. Real-life data were collected with a smartphone and an ActiGraph over 7 days. We explored different smartphone metrics in a technical validation course and computed afterward correlation between ActiGraph (steps per minute), smartphone accelerometry (variance of vector magnitude), clinical tests, and surveys. We also determined the ability to separate between patients and controls as well as between different disability groups.Results: Based on the technical validation, we found the variance of the vector magnitude as a reliable estimate to discriminate wear time and no wear-time of the smartphone. Due to a further association with different activity levels, it was selected for real-life analyses. In the cross-sectional study, ActiGraph correlated moderately (r = 0.43, p < 0.05) with the smartphone but less with clinical tests (rho between |0.211| and |0.337|). Smartphone data showed stronger correlations with age (rho = −0.487) and clinical tests (rho between |0.565| and |0.605|). ActiGraph only differed between pwMS and controls (p < 0.001) but not between disability groups. At the same time, the smartphone showed differences between pwMS and controls, between RRMS and PP-/SPMS, and between participants with/without ambulatory impairment (all p < 0.001).Conclusions: Smartphone accelerometry provides better estimates of mobility and disability than a wrist-worn standard accelerometer in a free-living context for both controls and pwMS. Given the fact that no additional device is needed, smartphone accelerometry might be a convenient outcome of real-life ambulation in healthy individuals and chronic diseases such as MS.

Tibial bypass in patients with intermittent claudication is associated with poor outcomes

ObjectiveGiven that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC. MethodsThe Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries. ResultsOf 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival. ConclusionsIn patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.

Octogenarians and Nonoctogenarians Have Similar Outcomes after Upper Extremity Hemodialysis Access Creation

Routine arteriovenous (AV) access creation in octogenarians is controversial. Our goal was to assess perioperative and long-term outcomes in octogenarians after undergoing upper extremity AV access to determine whether advanced age should influence AV access decision-making. All AV access creations performed at a single institution from 2014-2018 were retrospectively reviewed. Patients were categorized as octogenarians and nonoctogenarians. Perioperative short-term outcomes were compared. Among 620 patients who underwent AV access creation, there were 40 octogenarians and 580 nonoctogenarians. Octogenarians were more likely to have private insurance, coronary artery disease, dementia, previous stroke, impaired ambulation, and less likely to be current smokers. There were no differences in outpatient status or tunneled dialysis catheter presence at creation. Access types were similar radiocephalic (12.5% vs. 14.3%), brachiocephalic (50% vs. 42.6%), brachiobasilic (12.5% vs. 26.2%), and grafts (25% vs. 13.8%). Univariable analysis demonstrated no differences in perioperative return to the operating room, hematoma, and patency loss. There were no differences in 90-day mortality (OR 0.46, 95% CI 0-2.5, P=0.25), readmission (OR 1.36, 95% CI 0.67-2.76, P=0.39), maturation (OR 0.97, 95% CI 0.46-2.01, P=0.93), or reintervention (HR 0.9, 95% CI 0.64-1.25, P=0.53). Octogenarians had lower two-year survival (82.5% vs. 91.9%, P<0.001), but there was no difference in reintervention-free survival (55% vs. 47%, P=0.47) or occlusion-free survival (25% vs. 24%, P=0.62). Octogenarians and nonoctogenarians have similar outcomes after upper extremity dialysis access creation. Advanced age alone should not influence dialysis access creation.