Toronto Clinical Research Articles

Assessment of small fiber neuropathy and distal sensory neuropathy in female patients with fibromyalgia.

We investigated sudomotor dysfunction, small fiber neuropathy (SFN), and their clinical significance in female fibromyalgia patients. Fibromyalgia patients and healthy controls (HCs) were recruited. Clinical and laboratory data were measured. Electrochemical skin conductance (ESC) values of hands and feet were assessed by SUDOSCAN. Additionally, several other methods were employed, including nerve conduction study (NCS), electromyography (EMG), and questionnaires. Spearman correlation coefficient was calculated to identify factors associated with ESC values of SUDOSCAN. Twenty-two female fibromyalgia patients and 22 female HCs were recruited. The fibromyalgia group had lower EQ5D and higher Toronto Clinical Neuropathy scores than the HC group. Most of the EMG/NCS findings of motor and proximal sensory nerves were comparable between the fibromyalgia and HC groups, whereas sensory nerve action potential amplitudes of distal sensory nerves were significantly lower in the fibromyalgia group. Mean ESC values of hands and feet were significantly lower in the fibromyalgia group than in the HC group (57.6 ± 16.2 vs. 68.8 ± 10.3 μS, p = 0.010 for hands, 64.9 ± 11.5 vs. 72.0 ± 8.2 μS, p = 0.025 for feet, respectively). Moderate to severe SFN was more common in the fibromyalgia group (68.2%) than in the HC group (68.2 vs. 50%, p = 0.019). Fibromyalgia disease duration was significantly correlated with the ESC values of hands/feet, and tricyclic antidepressant (TCA) responders had higher ESC values than non-responders. SFN was commonly detected in fibromyalgia patients who had normal EMG/NCS findings and was more severe in fibromyalgia patients with longer disease duration. SUDOSCAN may predict response to TCA therapy.

Analysis of MDA, SOD, TAOC, MNCV, SNCV, and TSS scores in patients with diabetes peripheral neuropathy.

To explore the impact of score in patients with diabetes peripheral neuropathy (DPN) treated with traditional Chinese medicine package (TCMP) plus red light therapy and lipoic acid on malondialdehyde (MDA), erythrocyte superoxide dismutase (SOD), total antioxidant capacity (TAOC), motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), and Toronto Clinical Scoring System (TSS). A total of 108 patients with DPN hospitalized in the hospital were chosen and divided into groups with the random number table. In the control group (CG) 54 patients were treated with conventional lipoic acid, and 54 patients in the experimental group (EG) accepted TCMP plus red light on the basis of the CG. The MDA, SOD, TAOC, MNCV, SNCV, and TSS scores before treatment and after treatment were compared between the two groups. Before treatment, there was no statistically significant difference in the levels of oxidation indicators, nerve conduction velocity, and symptom scores between the two groups (P > 0.05). After treatment, the MDA in the EG was lower than that in the CG, with a statistical significance difference (P < 0.05). The SOD and TAOC in the EG were higher than those in the CG, and the difference was statistically significant (P < 0.05). The MNCV and SNCV of median nerve, common peroneal nerve, and tibial nerve in the EG were significantly higher than those in the CG (P < 0.05). The TSS score of the EG was lower than that of the CG, and the difference was statistically significant (P < 0.05). The treatment of patients with DPN with lipoic acid plus TCMP and red light therapy can improve the symptoms and signs of disease, promote the recovery of motor and sensory conduction velocity, and optimize the body oxidation indicators.

23 Probing bias: Understanding the experiences of Black, Indigenous and People of Colour (BIPOC) caregivers for children with developmental disabilities and their involvement with child protection

Abstract Background In Canada and abroad, a disproportionate number of Black Indigenous and Persons of Colour (BIPOC) experience referral to child protective services (CPS). Children with developmental disabilities, including Autism Spectrum Disorders (ASD) and intellectual disabilities (IDD), are also disproportionately CPS-involved. Recent Canadian research has suggested that almost a quarter of children from a complex care paediatric program are CPS-involved, however there is no known research for ASD/IDD populations seen in a general paediatric clinic. Further, intersections of race/ethnicity and ASD/IDD and CPS involvement have not been examined. Objectives We are conducting a mixed methods study to explore the intersections of race, developmental disabilities and involvement with CPS for our paediatric population. Design/Methods Phase 1: We completed a retrospective cohort study of 349 patients (0-18 years of age) who were seen by a paediatrician and social worker at a large, hospital-based paediatric clinic in Toronto, Canada in 2019. Electronic medical record data was reviewed and the following binary variables (yes/no) coded CPS-involved or referral made, 1+ caregiver identify as BIPOC, and primary language of caregiver(s) not English. Results Preliminary analyses indicate that 11.7% of our sample is CPS-involved. Contrary to over-representation of BIPOC families in the general CPS population, we found that the proportion of families involved with CPS was lower for BIPOC than non-BIPOC families. A similar pattern was observed for primary language, with a trend towards caregivers who reported English as a second language being less likely to be CPS-involved. In our presentation, we will present analyses regarding the type and intensity of CPS involvement and include other demographic characteristics of the family. These findings will be interpreted with findings from Phase 2 (currently underway), which explores lived experiences of 40 caregivers involved with CPS drawn from Phase 1. Conclusion Within an ASD/IDD patient sample, BIPOC families were less likely to be involved with CPS than non-BIPOC families. This finding is in stark contrast to provincial rates that suggest a 2.2 times greater likelihood of CPS-involvement for Black youth. While these results on the surface suggest equity, they may still reflect bias. It is possible that the concerns of BIPOC families are being downplayed in comparison to non-BIPOC families, reducing their access to supportive services.

The Detection of Peripheral Neuropathy by Clinical Scales in Patients Diagnosed With Alcohol Use Disorder.

Introduction Peripheral neuropathy is a well-known manifestation of alcohol overconsumption, but neurophysiological confirmation of peripheral nerve damage is costly and sometimes involves invasive procedures. The aim of this study was to investigate the ability of commonly used clinical scales to detect the presence of neuropathy in patients with alcohol use disorder (AUD). Methods Data were collected retrospectively on 116 patients diagnosed with AUD and treated voluntarily in a detoxification special unit. Ninety-eight age and gender-matched healthy subjects without a diagnosis of AUD were used as the control group. The five tested clinical neuropathy scales were the Neuropathy Symptoms Score (NSS), the Neuropathy Disability Score, the Neuropathy Impairment Score (NIS), the Neuropathy Impairment Score of the Lower Limbs, and the modified Toronto Clinical Neuropathy Scale. Results The mean values of all tested clinical scales of the patients with AUD were significantly higher than the control group. All examined clinical scales were determined to be useful in discriminating between patients with neuropathy from patients without neuropathy. The strongest discrimination was seen with the NIS, including the best sensitivity and specificity for the range of scores obtained. All scales, except NSS, showed a stronger correlation with measures of large (LFN) than small fiber neuropathy (SFN). Conclusion Our study suggests that clinical scales could be used to detect peripheral neuropathy in patients with AUDwhen neurophysiological testing is not available. Moreover, we suggest that the NIS and the NSS scales would be most helpful in assessing LFN and SFN, respectively, in patients with AUD.

Single simple question in axonal polyneuropathy.

The single simple question (SSQ), "What percentage of normal (0%-100%) do you feel regarding your disease?" has proven feasible and valid in assessing myasthenia gravis and a heterogeneous spectrum of neuropathies. This study explores the utility of the SSQ in axonal polyneuropathies (PNPs), encompassing diabetic neuropathy, and evaluates its responsiveness to scale changes. A retrospective chart review of 150 patients with axonal PNP responding to the SSQ was performed. Patients underwent clinical and electrophysiological evaluations, and were evaluated by clinical and disability scales, including the Medical Research Council sum score, modified Toronto Clinical Neuropathy score (mTCNS), Overall Neuropathy Limitation Scale, and Rasch-built Overall Disability Scale (RODS). The SSQ total scores correlated moderately with both the RODS score (r = .59, p < .001) and the mTCNS symptom score (r = -.43, p < .001), maintaining significance after adjustment for multiple comparisons. Longitudinally, after adjusting for multiple comparisons, the change in mTCNS symptom score retained statistical significance (adjusted p = .048). The SSQ did not show any association with electrophysiological parameters or sensory symptoms, other than a lower score in those with pain (100% with SSQ <40%, 85% with SSQ 40%-70%, and 34% with SSQ >70%). The SSQ is a feasible, valid scale that may be utilized to assess and follow patients with length-dependent axonal PNPs. Given that the SSQ is not strongly associated with clinical and disability scales or electrophysiological findings, additional investigations are required for a comprehensive assessment of PNP.

53838 Real-world drug survival of risankizumab at a tertiary care psoriasis clinic in Toronto, Canada

53838 Real-world drug survival of risankizumab at a tertiary care psoriasis clinic in Toronto, Canada

The Association between the Severity of Distal Sensorimotor Polyneuropathy and Increased Carotid Atherosclerosis in Individuals with Type 2 Diabetes.

Diabetes contributes to a spectrum of complications encompassing microvascular and macrovascular disorders. This study aimed to explore the correlation between distal sensorimotor polyneuropathy (DSPN) severity and heightened carotid atherosclerosis among individuals with type 2 diabetes mellitus (T2DM). Method: Participants underwent comprehensive assessments including nerve conduction studies (NCS), Toronto Clinical Neuropathy Score (TCNS) evaluations, assessment of cardiometabolic risk factors, and carotid sonography studies covering dynamic and morphological parameters. The resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) in both the common carotid artery (CCA) and internal carotid artery (ICA), carotid intima-media thickness (IMT), and carotid plaque score (CPS) were also measured. Peripheral nerve function severity was assessed using composite amplitude scores (CAS) derived from NCS. Individuals with DSPN exhibited lower EDV in the CCA and ICA (p < 0.0001 and p = 0.002), higher PI and RI in both CCA and ICA (all p < 0.0001), and higher CPS (p = 0.002). They also demonstrated a higher prevalence of retinopathy as an underlying condition, higher index HbA1c, and reduced estimated glomerular filtration rate (eGFR) (all p < 0.0001). Multiple linear regression analysis revealed significant associations where eGFR, ICA-PI, index HbA1c, waist circumference, and age were correlated with CAS. Meanwhile, diabetes duration, waist circumference, age, and index HbA1c showed significant associations with TCNS. Our study suggests that individuals with T2DM who exhibit more severe carotid atherosclerosis may not only be at increased risk of developing DSPN but also may experience greater severity of DSPN. PI in both the CCA and ICA, along with the CPS, serve as surrogate biomarkers for DSPN severity.

A Case Report on the Ayurvedic Management of Diabetic Peripheral Neuropathy

Diabetic neuropathy is one of the most common microvascular complications of diabetes mellitus. It has a significant impact in lowering quality of life (QOL) of diabetic patients. Currently, there is no effective management rather than tight blood sugar control. Hence an effective management for diabetic peripheral neuropathy (DPN) has to be deduced. A 41‑year‑old female patient, who was a known case of diabetes mellitus presenting with the symptoms of diabetic peripheral neuropathy was treated with a combination of Ayurvedic internal as well as external therapies, considering the treatment protocol of Prameha upadrava and Vatarakta chikitsa. The symptoms were assessed before and after treatment using the Toronto Clinical Scoring System. Significant improvement was seen in all the scores after the treatment. This case elicited that DPN can be successfully managed by Ayurvedic treatment.

Eleven neurology-related proteins measured in serum are positively correlated to the severity of diabetic neuropathy

About 20% of patients with diabetes suffer from chronic pain with neuropathic characteristics. We investigated the multivariate associations between 92 neurology-related proteins measured in serum from 190 patients with painful and painless diabetic neuropathy. Participants were recruited from the Pain in Neuropathy Study, an observational cross-sectional multicentre study in which participants underwent deep phenotyping. In the exploration cohort, two groups were defined by hierarchical cluster analyses of protein data. The proportion of painless vs painful neuropathy did not differ between the two groups, but one group had a significantly higher grade of neuropathy as measured by the Toronto Clinical Scoring System (TCSS). This finding was replicated in the replication cohort. Analyzing both groups together, we found that a group of 11 inter-correlated proteins (TNFRSF12A, SCARB2, N2DL-2, SKR3, EFNA4, LAYN, CLM-1, CD38, UNC5C, GFR-alpha-1, and JAM-B) were positively associated with TCSS values. Notably, EFNA4 and UNC5C are known to be part of axon guidance pathways. To conclude, although cluster analysis of 92 neurology-related proteins did not distinguish painful from painless diabetic neuropathy, we identified 11 proteins which positively correlated to neuropathy severity and warrant further investigation as potential biomarkers.

Prevalence and Risk Factors of Distal Symmetric Polyneuropathy Among Predominantly Non-Hispanic Black, Low-Income Patients.

Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Evaluation of Effectiveness and Safety of Firstline Drugs Used in the Treatment of Peripheral Neuropathy Among Elderly Population-A Randomised, Open-label, Active Comparator Study.

Peripheral neuropathy is four times more common in geriatric age group patients compared to younger ones. Most of the trials have targeted adult population, and there is scarcity of data in the geriatric age group. A real-world study was planned on geriatric patients suffering from peripheral neuropathy to analyse the effectiveness and safety of first-line drugs used in the management of peripheral neuropathy. It was a randomised, open-label, active comparator clinical trial in which first-line drugs for peripheral neuropathy were compared [amitriptyline (10 mg), duloxetine (30 mg), gabapentin (300 mg), pregabalin (75 mg)] for their effectiveness and safety. The trial duration was eight weeks. The modified Toronto Clinical Neuropathy Score (mTCNS), Verbal Rating Scale (VRS) and Geriatric Depression Scale (GDS) were used for effectiveness. Safety was assessed by monitoring adverse events. Multiple groups were compared with Kruskal-Wallis test, and post hoc analysis was performed with Dunn's test. A p value <.05 was considered significant. A total of 80 patients were recruited (20 patients in each arm) with a mean age of 65.4 years, and 56.3% were male. Pregabalin was superior to amitriptyline (p = .04) and duloxetine (p = .02) in reducing mTCNS. Similarly, pregabalin was superior to amitriptyline (p = .041 and duloxetine (p = .009) in reducing GDS score. All drugs were comparable in reducing VRS (p = .17). A total of 14 adverse events were observed, out of which constipation, sedation and dizziness were common. Maximum adverse events were observed in the duloxetine arm (6/14). Pregabalin was superior to amitriptyline and duloxetine, whereas it was comparable to gabapentin in effectiveness. Constipation was the most common adverse event, but the central nervous system was the most involved in adverse events.

P.019 A shared decision-model toolkit for pregnancy related care in neurology

Background: Shared decision-making (SDM) is a dynamic, patient-engaged approach to collaborative medical care. Limited SDM tools exist in pregnancy. We aimed to examine the need and usability of a novel SDM tool for pharmaco-therapeutic treatment of neurological conditions in pregnancy. Methods: This is an exploratory mixed-methods study. Non-pregnant women of any age were recruited using convenience, purposive sampling from an academic neurology clinic in Toronto. Participants reported the user friendliness of the SDM by completing the systems usability (SUS) questionnaire and participated in a focus group to further elaborate on their experience. Results: Eleven participants completed the survey 45% each between age 31-40, and 51-60. Median time spent on the tool was 17.2 minutes, and median SUS score 70 (&lt;68 being not usable). Thematic data analysis from 2 focus groups, identified technical and content improvements: use of inclusive language, simplified design, and importance of patient engagement in SDM. Conclusions: Based on our preliminary results, a SDM web-tool for medication-related concerns of pregnant patients with neurological conditions is needed and usable. With integration of patients’ lived experiences, this novel tool may serve as an anchor point for future work in this field.

Evaluation of peripheral and autonomic nervous systems dysfunctions in patients with Parkinson’s disease

BackgroundPeripheral neuropathy (PN) is increasingly recognized in Parkinson’s disease (PD). This study aimed to evaluate peripheral nerve and autonomic nervous system dysfunction in PD. Forty patients with PD (20 drug-naïve, 20 on treatment) and 20 controls underwent neurological examination, Toronto Clinical Neuropathy Score (TCNS), nerve conduction studies, autonomic function tests including (heart rate variability, Blood pressure changes with standing and sustained handgrip, and sudomotor pathways. The Ewing classification system scored each test to quantify autonomic failure severity). Laboratory tests (B12, homocysteine, methylmalonic acid).ResultsTreated patients with PD had higher MDS-UPDRS scores than drug-naïve (p = 0.001). TCNS indicated mild PN in some drug-naïve patients, and mild–moderate PN in treated patients. Nerve conduction studies showed significant sensory and motor neuropathy in treated versus drug-naïve PD and controls. Treated patients had lower B12, higher homocysteine/methylmalonic acid than other groups. Across autonomic tests, controls had the most normal results, followed by drug-naïve patients, with treated patients being most abnormal. Autonomic dysfunction correlated with disease duration, severity, L-dopa dose. Lower B12, higher homocysteine/methylmalonic acid levels were associated with greater neuropathy and disease severity.ConclusionPatients with PD show evidence of PN and autonomic dysfunction, which is milder in drug-naïve patients but worsens with disease progression and treatment. Peripheral nervous system assessments may help diagnose and monitor PD neuropathy and effects of interventions.

Long-term efficacy and safety of Huangqi ()-based Traditional Chinese Medicine in diabetic peripheral neuropathy: a Meta-analysis of randomized controlled trials.

To assess the long-term effectiveness of Huangqi (Radix Astragali Mongolici, HQ)-based Traditional Chinese Medicine (TCM) in the treatment of diabetic peripheral neuropathy (DPN). Nine databases were searched to retrieve available randomized controlled trials that compared HQ-based TCM and Western Medicines in the treatment of DPN. The methodological quality of the included studies was assessed using the Cochrane bias risk tool, and RevMan 5.4 was used for data analysis. The effect estimates of interest were risk ratio (RR), mean difference (MD) or standardized mean difference (SMD) with 95% confidence interval (CI). The results from 48 available studies assessing 3759 patients demonstrated that cases administered HQ-based TCM [RR = 1.30, 95% CI (1.21, 1.40), P < 0.000 01] or HQ-based TCM combined with Western Medicines [RR = 1.25, 95% CI (1.19, 1.31), P < 0.000 01] exhibited higher total efficacy rates than individuals who received Western Medicine alone. The results showed that the HQ-based TCM group had decreased Toronto Clinical Scoring System scores [MD =－1.50, 95% CI (－1.83, －1.17), P < 0.000 01], and reduced serum interleukin 6 [SMD = －0.57, 95% CI (－0.87, －0.27), P = 0.0002] and tumor necrosis factors-α levels [SMD = －0.60, 95% CI (－0.95, －0.25), P = 0.0009]. In addition, both HQ-based TCM and HQ-based TCM combined with Western Medicine increased nerve conduction velocity and decreased glycaemia compared with Western Medicine alone. In terms of blood lipids, oxidative stress and adverse drug reactions, there were no significant differences between the HQ-based TCM groups and the Western Medicine control group. The current Meta-analysis revealed that HQ-based TCM yields higher efficacy and safety than Western Medicine alone for the treatment of DPN, although further well-designed RCTs are required to validate these findings.

The Safety and Efficacy of a “No Touch” Abortion Program Implemented in the Greater Toronto Area During the COVID-19 Pandemic

ObjectivesTo evaluate the safety and efficacy of first-trimester “No Touch” medication abortion programs at 2 clinics in Toronto, Ontario during their early implementation in response to the COVID-19 pandemic. MethodsThis retrospective study included all patients who underwent virtual consultation for mifepristone-misoprostol medication abortion between April 2020–August 2022 at 2 reproductive health clinics. In response to the pandemic, “No Touch” abortion protocols have been developed that align with the Canadian Protocol for the Provision of Medical Abortion via Telemedicine. Records were reviewed for demographic information, clinical course, investigations required, confirmation of complete abortion and adverse events. The primary outcome was complete medication abortion, defined as expulsion of the pregnancy without requiring uterine aspiration. ResultsA total of 277 patients had abortions initiated in the “No Touch” or “Low Touch” care pathways and had sufficient follow-up to determine outcomes. Of these patients, 92.8% (95% CI 89.7%–95.8%) had a complete medication abortion (n = 257) and 76.1% (n = 159) remained “No Touch” throughout their care. Investigations were performed for 102 participants before or after their abortion, classifying them as “Low Touch”. Nineteen patients (6.9%) underwent uterine aspiration. The rate of adverse events was low, with 1 case of a missed ectopic pregnancy and 1 patient requiring hospitalization for endometritis. Conclusions“No Touch” provision of mifepristone-misoprostol medication abortion care was safe and effective with outcomes comparable to previous studies. These results provide evidence for the efficacy and safety of a “No Touch” approach in the Canadian context, which has the potential to reduce barriers to accessing abortion care.

Cross-Sectional Study of the Relationship Between Medial Plantar Nerve Conduction Studies and Severity of Diabetic Neuropathy.

Diabetic peripheral neuropathy (DPN), a complication of diabetes, is detected only in later stages. Medial plantar nerve (MPL) can identify earlier stages of neuropathy. We evaluated the correlation of MPL sensory nerve action potentials (SNAPs) and severity of DPN measured using the Toronto Clinical Neuropathy Score (TCNS). In this hospital-based, cross-sectional study, we recruited diabetic subjects referred for suspected DPN. Neuropathy was graded with TCNS. Sural nerve conduction studies were performed using standard techniques. MPL studies were conducted using the modified Ponsford technique. All evaluations were performed on Nihon Kohden (model MEB 9200K). Averaged MPL SNAP was correlated with TCNS using Pearson's correlation coefficient. To estimate a correlation of 0.4 with 80% power (P = 0.05), we needed 46 subjects. Linear regression was conducted to adjust for age, duration, and diabetic control. Receiver operating characteristic (ROC) curve analysis was performed to obtain the cutoff for MPL SNAP values using the Youden index. Fifty-one subjects with a mean age of 53.5 years (8.7) and mean duration of diabetes of 10.2 years (7.2) were included. MPL SNAPs were recordable in 12 patients, and the mean amplitude was 5.15 (2.9) µV. There was correlation between MPL SNAP and TCNS (r = -0.43, P = 0.02). No confounding was seen. Use of MPL SNAP resulted in diagnosis of DPN in an additional six (11.8%) patients. The ROC curve suggested that MPL SNAP cutoff of 1.05 µV had an accuracy of 67% in identifying neuropathy as defined by TCNS. MPL SNAP has a moderate correlation with clinical score and identifies more diabetic neuropathy than sural nerve.

Patient Perceived Barriers and Enablers to Medication Adherence in the Treatment of Depression: A Qualitative Study.

Depression affects approximately 280 million individuals globally and it is a leading cause of disability. Despite effective medication options, 50% of patients prematurely discontinue antidepressants within 6 months. We sought to understand patients' perspectives regarding their needs and expectations related to antidepressants. To identify and describe enablers and barriers that influence adult patients' medication adherence in depression treatment and to explore patients' educational needs on initiating or continuing antidepressant therapy. Qualitative descriptive study was conducted using individual, semi-structured interviews of adult patients with depression who were prescribed an antidepressant within 3 months of study recruitment at an urban primary care clinic in Toronto, Canada. Thirteen participants were interviewed. Interviews were recorded and transcribed verbatim for inductive thematic analysis. Six themes emerged: safety and effectiveness of antidepressant, understanding of depression and its management, medication administration, healthcare experiences in the treatment of depression, and social influences and relationships. Barriers to adherence included adverse effects of antidepressants, preference for non-pharmacological therapies, uncertainty about therapeutic effects, and social stigma. In contrast, enablers were positive responses from antidepressants, fear of relapse, reminder aids, established routine, and a trusting patient-provider relationship. Participants desired access to reliable, evidence-based, and personalized educational information delivered through verbal, written, and digital formats to support antidepressant adherence. To overcome the identified barriers, educational strategies should involve both patients and their prescribers to identify patient-specific needs and treatment goals, engage in shared decision-making, and maintain consistent follow-up to support antidepressant adherence.

Increasing rates of screening and treatment of iron deficiency in ambulatory patients with heart failure with reduced ejection fraction: a quality improvement cohort study

IntroductionIron deficiency anaemia (IDA) is common in patients with heart failure (HF) and is associated with advanced HF and increased mortality. Intravenous iron supplementation increases exercise tolerance, improves quality of...

Early detection of peripheral neuropathy in patients with diabetes mellitus type 2

BackgroundEarly diagnosis of diabetic polyneuropathy (DPN) can significantly improve the prognosis and help prevent severe complications. The aim of this work was to study clinical, radiological, laboratory and neurophysiological findings for early detection of peripheral neuropathy in T2DM.MethodsA total of 60 diabetic patients were classified according to Toronto Clinical Neuropathy Score (TCNS) into: Group 1: 20 diabetic patients with no evident neuropathy. Group 2: 20 diabetic patients with mild neuropathy. Group 3: 20 diabetic patients with moderate and severe neuropathy. All patients underwent a neurological examination, nerve conduction studies and optical coherence tomography (OCT) to assess retinal nerve fiber layer (RNFL) thickness. Additionally, ELISA technique to measure serum interleukin-6 (IL-6).ResultsThe analysis of gender and age distributions among the groups revealed no significant differences. There were statistically significant differences regarding disease duration, HBA1c, body mass index Systolic and diastolic blood pressure. Group 3 had such significant impairment that resulted in an inability to record the measurements of sural nerves. The study's statistical analysis results for OCT variables, and post hoc comparisons revealed significant differences between all three groups. The results demonstrated significant variations in Serum IL6 levels among the groups, with Group 3 having the highest IL6 levels. In groups 1, 2, and 3 the area under the curve for IL-6 and RNFL showed a good differentiation ability between groups.ConclusionWe conclude that the total thickness RNFL and serum IL-6 levels are a potential biomarker in prediction the severity of DPN.

Electrophysiological grading scale for polyneuropathy severity.

To establish a simple electrophysiological scale for patients with distal symmetric axonal polyneuropathy, in order to promote standardized and informative electrodiagnostic reporting, and understand the complex relationship between electrophysiological and clinical polyneuropathy severity. We included 76 patients with distal symmetric axonal polyneuropathy, from a cohort of 151 patients with polyneuropathy prospectively recruited from November 2016 to May 2017. Patients underwent nerve conduction studies (NCS), were evaluated by the Toronto Clinical Neuropathy Score (TCNS), and additional tests. The number of abnormal NCS parameters was determined, within the range of 0-4, considering low amplitude or conduction velocity in the sural and peroneal nerve. Higher number of NCS abnormalities was associated with higher TCNS, indicating more severe polyneuropathy. Polyneuropathy severity per the TCNS was most frequently (63%-70%) mild in patients with a low (0-1) number of NCS abnormalities, and most frequently (57%-67%) severe in patients with a high number (3-4) of NCS abnormalities, while patients with an intermediate (2) number of NCS abnormalities showed mainly mild and moderate severity with equal distribution (40%). A simple NCS classification system can objectively grade polyneuropathy severity, although significant overlap exists especially at the intermediate range, underscoring the importance of clinical based scoring.