Clinical Scale Scores Research Articles

Clinical impact of combined assessment of the CHADS2 score and geriatric nutritional risk index on clinical outcomes in patients with lower extremity artery disease without atrial fibrillation

Abstract Background The CHADS2 score is a well-known risk score for ischemic stroke in atrial fibrillation (AF) patients. Recently, it has been reported that the CHADS2 score was associated with an increased risk of new-onset lower extremity artery disease (LEAD) in patients without AF, the association between the CHADS2 score and clinical outcomes in patients with LEAD undergoing endovascular treatment (EVT) without AF remains unclear. Furthermore, malnutrition assessed by the geriatric nutritional risk index (GNRI) has been reported to be predictive of clinical outcomes in patients with LEAD. However, there are limited studies regarding the association of combined assessment of the GNRI and CHADS2 score and clinical outcomes in patients with LEAD without AF. Purpose The purpose of this study was to investigate the association between the combined assessment of GNRI and CHADS2 score, and mortality of LEAD patients undergoing EVT without AF. Methods This retrospective study investigated 236 consecutive LEAD patients who underwent EVT without AF. CHADS2 scores were calculated by assigning one point for heart failure, hypertension, age ≥75 years, and diabetes; and assigning 2 points for a prior history of stroke or transient ischemic attack. The GNRI on admission was calculated as follows: [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight)], and the CHADS2 score and GNRI were calculated for each patient. We scored GNRI by assigning 2 points to low GNRI (GNRI <82) and 1 point to intermediate GNRI (GNRI =82 to <92). We then calculated the CHADS2 plus GNRI score for each patient and then patients were divided into the high CHADS2 plus GNRI scoregroup (CHADS2 plus GNRI score> 2, n = 123) and the low CHADS2plus GNRI score group (CHADS2 plus GNRI score≤ 2, n = 113) according to the median CHADS2 plus GNRI score. We investigated the associations between all-cause mortality in patients with LEAD who underwent EVT and the CHADS2 plus GNRI score. Results The mean age was 71.9±10.4 years, and 66.9% were men. During the median follow-up of 752 (283–1472) days, 50 patients died. Kaplan-Meier curves revealed that the cumulative incidence of all-cause death was significantly higher in the high CHADS2 plus GNRI score group than in the low CHADS2 plus GNRI score group (log-rank p = 0.003). Furthermore, even in the multivariate analysis,after adjusting for other risk factors including hemodialysis and clinical frailty scale, CHADS2 plus GNRI score was independently associated with all-cause death (per one score increase, hazard ratio: 1.26, 95% confidence interval (CI) 1.01-1.56, P=0.038). Conclusions In LEAD patients who underwent EVT without AF, a higher CHADS2 plus GNRI score was associated with an increased risk of all-cause death. A Combined CHADS2 plus GNRI score assessment may be a useful prognostic marker in patients with LEAD without AF.

Effects of Family Audio Recordings on Depression, Cognitive Function, and Sleep Quality of Individuals With Alzheimer's Disease: A Randomized Controlled Trial.

To explore the effects of family audio recordings on depression, cognitive function, and sleep quality among individuals with Alzheimer's disease in nursing homes. A randomized controlled study design was used, and 107 participants with Alzheimer's disease were stratified and randomly assigned to groups based on Clinical Dementia Rating Scale scores. The control group received usual care and health education, and the experimental group received usual care, health education, and a family audio recording intervention. The experimental group showed significantly lower depression scores compared to the control group post-intervention. A within-group comparison of sleep quality scores in the experimental group was significantly different. At post-intervention, cognitive function scores in the control group significantly decreased compared to before the intervention. Family audio recording interventions helped alleviate depression symptoms in individuals with Alzheimer's disease, improved their sleep quality, and delayed the progression of cognitive decline to some extent. [Journal of Gerontological Nursing, xx(x), xx-xx.].

Clinical Frailty Scale score is a predictor of short-, mid- and long-term mortality in critically ill older adults (≥ 70years) admitted to the emergency department: an observational study.

The estimated prognos of a patient might influence the expected benefit/risk ratio of different interventions. The main purpose of this study was to investigate the Clinical Frailty Scale (CFS) score as an independent predictor of short-, mid- and long-term mortality in critically ill older adults (aged ≥ 70) admitted to the emergency department (ED). This is a retrospective, single-center, observational study, involving critically ill older adults, recruited consecutively in an ED. All patients were followed for 6.5-7.5years. The effect of CFS score on mortality was adjusted for the following confounders: age, sex, Charlson's Comorbidity Index, individual comorbidities and vital parameters. All patients (n = 402) were included in the short- and mid-term analyses, while patients discharged alive (n = 302) were included in the long-term analysis. Short-term mortality was analysed with logistic regression, mid- and long-term mortality with log rank test and Cox proportional hazard models. The CFS was treated as a continuous variable in the primary analyses, and as a categorical variable in completing analyses. There was a significant association between mortality at 30days after ED admission and CFS score, adjusted OR (95% CI) 2.07 (1.64-2.62), p < 0.0001. There was a significant association between mortality at one year after ED admission and CFS score, adjusted HR (95% CI) 1.75 (1.53-2.01), p < 0.0001. There was a significant association between mortality 6.5-7.5years after discharge and CFS score, adjusted HR (95% CI) 1.66 (1.46-1.89), p < 0.0001. Adjusted HRs are also reported for long-term mortality, when the CFS was treated as a categorical variable: CFS-score 5 versus 1-4: HR (95% CI) 1.98 (1.27-3.08); 6 versus 1-4: HR (95% CI) 3.60 (2.39-5.44); 7 versus 1-4: HR (95% CI) 3.95 (2.38-6.55); 8-9 versus 1-4: HR (95% CI) 20.08 (9.30-43.38). The completing analyses for short- and mid-term mortality indicated a similar risk-predictive value of the CFS. Clinical frailty scale score was independently associated with all-cause short-, mid- and long-term mortality. A nearly doubled risk of death was observed in frail patients. This information is clinically relevant, since individualised treatment and care planning for older adults should consider risk of death in different time perspectives.

Decisions about the limitations of life-sustaining treatment for acutely admitted older patients: a retrospective study of a Danish patient cohort.

Life-sustaining therapy, including heart and lung resuscitation and transfer to the intensive care department, is demanding for patients and relatives and utilizes large amounts of healthcare resources. For older patients acutely admitted to the hospital, very sparse data exist on decision making about life-sustaining therapy. Retrospective data were extracted from patients ≥ 70 years old who were acutely admitted to the hospital. Age, sex, clinical frailty scale score and Charlson comorbidity index were manually extracted from patients' files. Furthermore, data about life-sustaining treatment decisions were extracted. This was further divided into decisions documented within 24h from admission or during the hospital stay. Data were extracted for 200 patients with a median age of 80 years. Patients had a Charlson Comorbidity Index of 6 (5-8 IQR) and a Clinical Frailty Scale (CFS) score of 5 (3-6 IQR). During the first 24h, 61 patients (30.5%) had a written decision about heart and cardiopulmonary resuscitation (CPR), and 52 patients (26%) had written information about intensive care therapy. A total of 93 patients (46.5%) had a written decision about cardiopulmonary resuscitation (CPR), intensive care therapy or both during their hospital stay. With increasing Charlson Comorbidity Index and Clinical Frailty Scale scores, more patients had decisions about limitations in therapy documented in their files. Within the first 24h, 30.5% of the patients had a written decision about cardiopulmonary resuscitation (CPR), and 26% had written information about intensive care therapy. These numbers increased to 46.5% of patients who had a decision made during their hospital stay whether they were candidates for either cardiopulmonary resuscitation (CPR), intensive care therapy or both. These data suggest that further work should be done to determine the limitations of therapy early on the admission for all older frail acutely admitted patients.

Effects of cooperative learning and situational simulation on nursing competence in clinical practice among nursing students: A quasi-experimental study

BackgroundAppropriate cooperative learning and situational simulation designs can enhance mental health and nursing competence in clinical practice. This approach is crucial for cultivating the clinical nursing competence of nursing students. AimTo determine the effect of combining cooperative learning and situational simulation on nursing competence in clinical practice. DesignA quasi-experimental study. Setting and participantsThis study was conducted with 142 s-year students in the nursing department of a university in Taiwan. MethodsThe experimental group received cooperative learning combined with situational simulation methods, while the control group used only cooperative learning methods. Data were collected using the Clinical Practice Stress Scale and the Fundamental Nursing Competence Scale. Percentiles and frequency distributions were used to analyze the data, and independent t-tests were conducted to compare differences between the groups. ResultsThere were no significant differences in descriptive characteristics between the groups (p > .05). Post-test measurements of nursing technical performance, total score on the fundamental nursing competence scale and six sub-dimensional scores of the students in the experimental group were significantly improved compared to the control group (p < .001). However, there were no significant differences in total clinical practice stress scale scores between the groups (p > .05). Interestingly, the knowledge score of the control group was significantly higher than that of the experimental group (p < .05). ConclusionThe combined methods of cooperative learning and situational simulation have been shown to positively impact students' academic and nursing technical performance. The results indicate improvements in nursing competence in clinical practice, with signs of a reduction in clinical practice-related stress. Nurse educators can apply these strategies in clinical nursing education to achieve better outcomes.

Time to Sustained Recovery Among Outpatients With COVID-19 Receiving Montelukast vs Placebo

The effect of montelukast in reducing symptom duration among outpatients with mild to moderate COVID-19 is uncertain. To assess the effectiveness of montelukast compared with placebo in treating outpatients with mild to moderate COVID-19. This randomized clinical trial (Accelerating COVID-19 Therapeutic Interventions and Vaccines [ACTIV]-6) was conducted from January 27 through June 23, 2023, during the circulation of Omicron subvariants. Participants aged 30 years or older with confirmed SARS-CoV-2 infection and 2 or more acute COVID-19 symptoms for less than 7 days were included across 104 US sites. Participants were randomized 1:1 to receive montelukast, 10 mg once daily, or matched placebo for 14 days. The primary outcome was time to sustained recovery (defined as ≥3 consecutive days without symptoms). Secondary outcomes included time to death; time to hospitalization or death; a composite of health care utilization events (hospitalization, urgent care clinic visit, emergency department visit, or death); COVID-19 clinical progression scale score; and difference in mean time unwell. A modified intention-to-treat approach was used for the analysis. Among 1250 participants who were randomized and received the study drug or placebo, the median age was 53 years (IQR, 42-62 years), 753 (60.2%) were female, and 704 (56.3%) reported receiving 2 or more doses of a SARS-CoV-2 vaccine. Among 628 participants who received montelukast and 622 who received placebo, differences in time to sustained recovery were not observed (adjusted hazard ratio [AHR], 1.02; 95% credible interval [CrI], 0.92-1.12; P = .63 for efficacy). Unadjusted median time to sustained recovery was 10 days (95% CI, 10-11 days) in both groups. No deaths occurred, and hospitalizations were reported for 2 participants (0.3%) in each group; the composite of health care utilization events was reported for 18 participants (2.9%) in the montelukast group and 18 (2.9%) in the placebo group (AHR, 1.01; 95% CrI, 0.45-1.84; P = .48 for efficacy). Five participants (0.4%) experienced serious adverse events (3 [0.5%] in the montelukast group and 2 [0.3%] in the placebo group). In this randomized clinical trial of outpatients with mild to moderate COVID-19, treatment with montelukast did not reduce duration of COVID-19 symptoms. These findings do not support the use of montelukast for the treatment of mild to moderate COVID-19. ClinicalTrials.gov Identifier: NCT04885530.

Discharge Destination, Mortality Outcomes and Rehabilitation Utilization, a One Year Follow Up of Frail Older Medical Inpatients

Abstract Background Patients with increasing frailty constitute a large proportion of acute hospital admissions. Deconditioning is a known complication of acute medical admission. This study reviews the outcomes for a population identified as frail during their admission, including utilisation of formal rehabilitation and discharge destination. Mortality rates at 6 and 12 months are also reviewed to assess if frailty could be used as a prognostication tool. Methods The patients selected were included in a hospital wide point prevalence study in 2023. Patients included were over 70 years of age and admitted under a medical team. Clinical frailty scale (CFS) score was recorded on all patients. The hospital electronic record provided information on transfer for formal rehabilitation, discharge home with home care package or discharge to long term care. The cohort were coded based on discharge destination. Mortality outcome at 6 and 12 months were also obtained via electronic record and RIP.ie. Results 233 patients were included, 177 (75.9%) were identified as frail. Only 8 (3.43%) of the group were discharged to formal rehabilitation. 52 (22.3%) were transferred directly to Long term care from hospital without a trial of formal rehabilitation. 8 of this group had specific rehab needs documents, all 8 were alive at 6 and 12 months. Approximately 40% of the total group had died within 12 months. Conclusion Rehabilitation benefits the individual patient and the health service as a whole, by impacting care needs and facilitating discharge home (Van Craen et al., 2010). This study has shown that approximately 1 in 4 patients over 70 were discharged directly to long term care without appropriate rehabilitation. Just over 3.4% of the group received formal rehabilitation outside of the acute hospital. This has highlighted the need to radically act on egress pathways to provide appropriate rehabilitation and care for our patients.

Incidence of buprenorphine-precipitated opioid withdrawal in adults with opioid use disorder: A systematic review.

Buprenorphine is an evidence-based treatment for opioid use disorder, and the risk of precipitated withdrawal contributes to its underuse. The goal of this systematic review was to determine the incidence of buprenorphine-precipitated withdrawal in adults with opioid use disorder. This systematic review was registered on PROSPERO (CRD42023437634). We searched Medline, Embase Classic + Embase, and Cochrane CENTRAL from inception to 10 November 2023, and included original research that reported the incidence of sublingual buprenorphine-precipitated withdrawal in adults with opioid use disorder. Primary screening was completed by four independent reviewers. Full text review, data extraction and risk of bias assessments using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2 tool were completed by two independent reviewers. The primary outcome was precipitated withdrawal. Secondary outcomes were baseline opioids used, induction dose, initial Clinical Opiate Withdrawal Scale (COWS) score, location of induction, definition and severity of precipitated withdrawal and adverse events. The range of incidence of precipitated withdrawal across studies was described. Our search yielded 10 197 unique citations. Twenty-one cohort and five randomized trials met inclusion criteria (n = 4497, range 20-1293). The overall incidence of precipitated withdrawal ranged from 0 to 13.2%. Nine studies defined precipitated withdrawal; definitions were inconsistent. Most patients used heroin at baseline. The most common initial dose of buprenorphine was between 2mg and 8mg (range: 0.075 mg-24 mg). Initial minimum COWS score ranged from 5 to 13. Induction locations included home, inpatient, emergency department, pre-hospital, outpatient and residential units. Of the fifteen studies with cases of precipitated withdrawal, nine studies did not report the severity of withdrawal experienced. Other induction-related adverse events varied. The overall quality of included studies was poor. The best available evidence suggests the incidence of buprenorphine-precipitated withdrawal in adults with opioid use disorder is low and should not be a barrier to use.

The inertial-based gait normalcy index of dual task cost during turning quantifies gait automaticity improvement in early-stage Parkinson’s rehabilitation

BackgroundThe loss of gait automaticity is a key cause of motor deficits in Parkinson’s disease (PD) patients, even at the early stage of the disease. Action observation training (AOT) shows promise in enhancing gait automaticity. However, effective assessment methods are lacking. We aimed to propose a novel gait normalcy index based on dual task cost (NIDTC) and evaluate its validity and responsiveness for early-stage PD rehabilitation.MethodsThirty early-stage PD patients were recruited and randomly assigned to the AOT or active control (CON) group. The proposed NIDTC during straight walking and turning tasks and clinical scale scores were measured before and after 12 weeks of rehabilitation. The correlations between the NIDTCs and clinical scores were analyzed with Pearson correlation coefficient analysis to evaluate the construct validity. The rehabilitative changes were assessed using repeated-measures ANOVA, while the responsiveness of NIDTC was further compared by t tests.ResultsThe turning-based NIDTC was significantly correlated with multiple clinical scales. Significant group-time interactions were observed for the turning-based NIDTC (F = 4.669, p = 0.042), BBS (F = 6.050, p = 0.022) and PDQ-39 (F = 7.772, p = 0.011) tests. The turning-based NIDTC reflected different rehabilitation effects between the AOT and CON groups, with the largest effect size (p = 0.020, Cohen’s d = 0.933).ConclusionThe turning-based NIDTC exhibited the highest responsiveness for identifying gait automaticity improvement by providing a comprehensive representation of motor ability during dual tasks. It has great potential as a valid measure for early-stage PD diagnosis and rehabilitation assessment.Trial registration Chinese Clinical Trial Registry: ChiCTR2300067657

Clinical profiles of older adults in French Caribbean nursing homes: a descriptive cross-sectional study.

Nursing homes in the Caribbean are scarce and the characteristics of their residents have not been previously documented. This study aimed to describe the clinical profiles of residents living in nursing homes in Guadeloupe and Martinique (French West Indies). This is a cross-sectional study of the baseline screening data from the KASEHPAD (Karukera Study of Ageing in nursing homes) study. Clinical characteristics and geriatric scale scores, including the Activities of Daily Living (ADL), Mini-Mental State Examination (MMSE), Mini Nutritional Assessment Short-Form (MNA-SF) and Short Physical Performance Battery (SPPB) were collected and analysed. A total of 332 older adults were recruited between September 2020 and November 2022. The mean age of the residents was 81.3 ± 10.1, with a male-female ratio of 1:1. Diabetes was reported in 28.3% of the residents, hypertension in 66.6% and heart disease in 18.4%. Dementia was diagnosed in 52.3% of the residents and 74.9% had a MMSE score ≤18. The prevalence of Parkinson's disease was 9.0%. Additionally, 18.4% were unable to perform any basic activities of daily living (ADL score of 0). The prevalence of physical impairment (SPPB < 8) was 90.0%. One-quarter of the residents were classified as undernourished (MNA-SF score ≤ 7). Residents in Caribbean nursing homes are younger than in metropolitan France, whereas they present quite similar clinical profiles. Notably, a high prevalence of diabetes, cardiovascular diseases and neurodegenerative diseases was observed. This study represents a preliminary effort to address the knowledge gap regarding the aging trajectories of older adults in the Caribbean and could guide the development of future nursing homes in these countries.

A - 35 Effects of Childhood Trauma Exposure on Psychological Symptom Endorsement among Adult ADHD Referrals

Abstract Objective Adults with attention-deficit/hyperactivity disorder (ADHD) are more likely to have childhood trauma exposure. Trauma exposure evaluations are not always standard practice for adult ADHD evaluations, but personality inventories like the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) are more commonly used to differentiate neurodevelopmental symptoms from psychiatric disorders. This study assessed the impact of childhood trauma exposure on MMPI-2-RF profiles among adults referred for ADHD evaluation. Method Cross-sectional data from 222 patients referred for neuropsychological evaluation for attention concerns and administered the Adverse Childhood Experiences (ACE) Checklist and MMPI-2RF were examined. Patients were racially diverse with a Mage 29.15 (SD = 7.63) and Meducation 16.15 years (SD = 2.13). Patients were divided into low (0–3 ACEs) and high (&amp;gt;3 ACEs) ACE groups. ACEs groups’ MMPI-2RF Restructured Clinical (RC) scale scores were compared via multivariate analyses of variance (MANOVAs) for the overall sample and subsample of those who ultimately received an ADHD diagnosis. Results The sample had 52% low ACEs/48% high ACEs, and 65% ADHD diagnosis/35% non-ADHD diagnosis. Overall, there was a significant multivariate effect (Wilks Λ =0.812; F(9,212) = 5.45, p &amp;lt; 0.001; np2 = 0.188); those with high ACE scores had significantly higher RC1, RC4, RC6, RC7, and RC8 scores. Significant MANOVA effects remained when the sample with subdivided. Across ADHD and non-ADHD subgroups, significantly higher RC4 and RC6 scores were consistent. Conclusions Exposure to childhood trauma had a significant impact on the MMPI-2-RF profile of adults being evaluated for ADHD. Screening for trauma exposure should be incorporated into standard neuropsychological batteries to inform the interpretation of personality inventories used to differentiate psychopathology.

The effect of frailty on mortality and functional outcomes in spontaneous intracerebral haemorrhage

IntroductionLimited data in patients with spontaneous intracerebral haemorrhage (SICH) showed that frailty was associated with mortality; however, there was insufficient data on functional outcomes. This study aimed to investigate the effect of frailty on overall mortality and 90-day functional outcomes in SICH. Materials and methodsWe conducted a retrospective study of 1223 patients diagnosed with SICH from January 2014 to December 2020. Frailty was defined as a clinical frailty scale (CFS) score of 4–9. Binary cut-offs were defined using receiver operating curve analysis. 90-day poor functional outcomes (PFO) were defined as modified Rankin Scale (mRS) ≥3, and utility-weighted mRS (UW-mRS) were based on previous validated studies respectively. Regression analyses were conducted to investigate the association between frailty and outcomes. Confounders adjusted for included demographics, cardiovascular risk factors and haematoma characteristics. Results1091 patients met the inclusion criterion. 167 (15.3 %) had 30-day mortality and 730 (66.9 %) had 90-day PFO. Frailty was significantly associated with lower overall survival (HR: 1.54; 95 % CI: 1.11–2.14, p=0.010), 90-day PFO (OR: 1.90; 95 % CI: 1.32–2.74; p<0.001) and poorer UW-mRS (β: −0.06; 95 % CI: (-0.08 to −0.04); p<0.001) even after adjusting for confounders. ConclusionsFrailty was significantly associated with greater mortality and PFO after incident SICH, even after adjusting for a priori confounders. Frail male individuals may be predisposed to poorer outcomes from higher prevalence of cortical atrophy. The use of CFS in younger individuals may aid management by predicting outcomes after incident SICH. Identifying frail individuals with incident SICH could aid in decision-making and the surgical management of SICH.

Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine

BackgroundTreating opioid use disorder has reached a new level of challenge. Synthetic opioids and xylazine have joined the non-medical opioid supply, multiplying the complexities of caring for individuals in emergency departments (ED). This combination, known as ‘tranq dope,’ is poorly described in literature. Inadequate withdrawal treatment results in a disproportionately high rate of patient-directed discharges (also known as against medical advice dispositions, or AMA). This study aimed to describe a cohort of individuals who received a novel order set for suspected fentanyl and xylazine withdrawal in the ED. MethodsThis is a descriptive study evaluating a cohort of ED patients who received withdrawal medications from a novel protocol and electronic health record order set. Individuals being assessed in the ED while suffering from withdrawal were eligible. Individuals under age 18, on stable outpatient MOUD or who were pregnant were excluded. Treatment strategies included micro-induction buprenorphine, short acting opioids, non-opioid analgesics, and other adjunctive medications. Data collected included: demographics including zip code, urine toxicology screening, order set utilization and disposition data. Clinical Opiate Withdrawal Scale (COWS) scores were recorded, where available, before and following exposure to the medications. ResultsThere were 270 patient encounters that occurred between September 14, 2022, and March 9, 2023 included in the total study cohort. Of those, 66 % were male, mean age 37 with 71 % residing within Philadelphia zip codes. 100 % of urine toxicology screenings were positive for fentanyl. Of the 177 patients with both pre- and post-exposure COWS scores documented, constituting the final cohort, patients receiving medications had their COWS score decrease from a median of 12 to a median of 4 (p < 0.001). The AMA rate for this cohort was 3.9 %, whereas the baseline for the population with OUD was 10.7 %. Recorded adverse effects were few and resolved without complication. ConclusionsFentanyl and xylazine withdrawal are challenging for patients and providers. A novel tranq dope withdrawal order set may reduce both COWS scores and rate of patient-directed discharge in this cohort of patients, though further investigation is needed to confirm findings.

Buprenorphine-Precipitated Withdrawal Among Hospitalized Patients Using Fentanyl

Buprenorphine treatment of opioid use disorder (OUD) is safe and effective, but opioid withdrawal during treatment initiation is associated with poor retention in care. As fentanyl has replaced heroin in the drug supply, case reports and surveys have indicated increased concern for buprenorphine-precipitated withdrawal (PW); however, some observational studies have found a low incidence of PW. To estimate buprenorphine PW incidence and assess factors associated with PW among emergency department (ED) or hospitalized patients. This retrospective cohort study at 3 academic hospitals in Philadelphia, Pennsylvania, included adults with OUD who underwent traditional or high-dose buprenorphine initiation between January 1, 2020, and December 31, 2021. Exclusion criteria included low-dose buprenorphine initiation and missing documentation of opioid withdrawal severity within 4 hours of receiving buprenorphine. Buprenorphine initiation with an initial dose of at least 2 mg of sublingual buprenorphine after a Clinical Opiate Withdrawal Scale (COWS) score of 8 or higher. Additional exposures included 4 predefined factors potentially associated with PW: severity of opioid withdrawal before buprenorphine (COWS score of 8-12 vs ≥13), initial buprenorphine dose (2 vs 4 or ≥8 mg), body mass index (BMI) (<25 vs 25 to <30 or ≥30; calculated as weight in kilograms divided by height in meters squared), and urine fentanyl concentration (0 to <20 vs 20 to <200 or ≥200 ng/mL). The main outcome was PW incidence, defined as a 5-point or greater increase in COWS score from immediately before to within 4 hours after buprenorphine initiation. Logistic regression was used to estimate the odds of PW associated with the 4 aforementioned predefined factors. The cohort included 226 patients (150 [66.4%] male; mean [SD] age, 38.6 [10.8] years). Overall, 26 patients (11.5%) met criteria for PW. Among patients with PW, median change in COWS score was 9 points (IQR, 6-13 points). Of 123 patients with confirmed fentanyl use, 20 (16.3%) had PW. In unadjusted and adjusted models, BMI of 30 or greater compared with less than 25 (adjusted odds ratio [AOR], 5.12; 95% CI, 1.31-19.92) and urine fentanyl concentration of 200 ng/mL or greater compared with less than 20 ng/mL (AOR, 8.37; 95% CI, 1.60-43.89) were associated with PW. In this retrospective cohort study, 11.5% of patients developed PW after buprenorphine initiation in ED or hospital settings. Future studies should confirm the rate of PW and assess whether bioaccumulated fentanyl is a risk factor for PW.

Buprenorphine for the Treatment of Pain in Cancer Patients.

Opioids remain the cornerstone for the treatment of moderate to severe cancer pain. Due to benefits over full agonist opioids (FAO), buprenorphine has emerged as an alternative treatment. Buprenorphine is only approved for the treatment of pain that is chronic non-cancer. Cancer-related pain is often progressive with breakthrough pain. There is limited evidence for using short-acting FAO in combination with buprenorphine. There are concerns about withdrawal and the efficacy of pain control using buprenorphine. We hypothesize buprenorphine, in combination with short-acting FAOs, can adequately control cancer- related pain without causing withdrawal symptoms. Procedures/data/observations: Our prospective, single-arm, open-label study enrolls patients with cancer-related pain who are on buprenorphine in combination with an FAO at > 30 mg OME/day, either requiring long-acting pain relief or their pain is not controlled with an FAO alone. Our study is ongoing, with 15 patients enrolled and a target of 50. The patient's pain is self-assessed daily using a mobile application. Withdrawal is assessed regularly using a modified Clinical Opioid Withdrawal Scale (COWS) score. Buprenorphine appears to be effective for the treatment of cancer pain without causing withdrawal in combination with short-acting FAO >30 mg/day.

Motor unit number index in Bell's palsy: A potential electrophysiological biomarker for early evaluation.

Reliable, noninvasive early diagnostics of neuromuscular function in Bell's palsy, which causes facial paralysis and reduced quality of life, remain to be established. Here, we aimed to evaluate the utility of the motor unit number index (MUNIX) for the quantitative electrophysiological assessment of early-stage Bell's palsy, its correlation with clinical assessments, changes following treatment, and association with clinical prognosis. MUNIX measures were recorded from the bilateral zygomaticus, orbicularis oculi, and orbicularis oris muscles of 10 healthy individuals and 64 patients with Bell's palsy. The patients were assessed by two specialist neurologists using the House-Brackmann and Sunnybrook Facial Grading Systems. Repeat assessments were performed on 20 patients with Bell's palsy who received treatment. Additionally, the 64 patients were reassessed using clinical scales after a 1-month interval. The MUNIX values of the main affected muscles on the affected side were lower than those on the healthy side in patients with Bell's palsy (p<.05). The MUNIX measurements significantly correlated with the clinical facial nerve palsy scale scores (p<.05). Significant improvements were observed in the MUNIX values on repeat testing following treatment (p<.05). The baseline motor unit size index (the compound muscle action potential amplitude divided by MUNIX) was positively associated with improved clinical presentation after 1 month (p<.05). MUNIX can be used as an electrophysiological biomarker for the quantitative assessment of facial nerve palsy and treatment response, and as a prognostic biomarker, in patients with early Bell's palsy, and is recommended as a complement to conventional neurophysiological examinations.

Efficacy of Clonidine Adhesive Patch for Patients With Tourette Syndrome: A Randomized, Double-blind, Placebo-Controlled, Multicenter Clinical Trial.

This study aimed to explore the efficacy of the clonidine adhesive patch for participants with Tourette syndrome (TS). This randomized, double-blind, placebo-controlled, multicenter phase IV clinical trial included participants with TS at 20 centers between May 2012 and March 2015. Treatment efficacy at week 8 was the primary outcome. The Clinical Global Impression-Severity scale and Improvement scale were the secondary endpoints. This trial included 488 participants, with 121 participants in the 2.0-mg/wk group, 119 participants in the 1.5-mg/wk group, 126 participants in the 1.0-mg/wk group, and 122 participants in the placebo group. For Yale Global Tic Severity Scale score reduction rate, compared with the placebo group (39.60 ± 25.56), those of the 2.0-mg/wk group (63.21 ± 32.60) and the 1.5-mg/wk group (68.16 ± 25.88) were statistically significantly different (all P < 0.001). For total Yale Global Tic Severity Scale score, compared with the placebo group (17.0 ± 8.03), the score for the 2.0-mg/wk group was 9.9 ± 8.36 ( P < 0.001); 1.5-mg/wk group, 9.6 ± 8.03 ( P < 0.001); and 1.0-mg/wk group, 10.5 ± 9.28 ( P < 0.001). The Clinical Global Impression-Severity scale and Improvement scale scores were statistically significantly different in the 3 clonidine (or experimental) groups compared with the placebo group (all P < 0.001). Larger doses of the clonidine adhesive patch such as 1.5 and 2.0 mg/wk are effective in improving the symptoms and overall function of participants with TS.

A hybrid model for predicting response to risperidone after first episode of psychosis.

Patient response to antipsychotic drugs varies and may be related to clinical and genetic heterogeneity. This study aimed to determine the performance of clinical, genetic, and hybrid models to predict the response of first episode of psychosis (FEP). patients to the antipsychotic risperidone. We evaluated 141 antipsychotic-naïve FEP patients before and after 10 weeks of risperidone treatment. Patients who had a response rate equal to or higher than 50% on the Positive and Negative Syndrome Scale were considered responders (n = 72; 51%). Analyses were performed using a support vector machine (SVM), k-nearest neighbors (kNN), and random forests (RF). Clinical and genetic (with single-nucleotide variants [SNVs]) models were created separately. Hybrid models (clinical+genetic factors) with and without feature selection were created. Clinical models presented greater balanced accuracy 63.3% (confidence interval [CI] 0.46-0.69) with the SVM algorithm than the genetic models (balanced accuracy: 58.5% [CI 0.41-0.76] - kNN algorithm). The hybrid model, which included duration of untreated psychosis, Clinical Global Impression-Severity scale scores, age, cannabis use, and 406 SNVs, showed the best performance (balanced accuracy: 72.9% [CI 0.62-0.84] - RF algorithm). A hybrid model, including clinical and genetic predictors, can provide enhanced predictions of response to antipsychotic treatment.

Cognitive, Neuropsychological and Biological Effects of Oxygen-Ozone Therapy on Frailty: A Study Protocol for a 5-Week, Randomized, Placebo-Controlled Trial.

Cognitive frailty (CF) is a heterogeneous syndrome that is becoming one of the most serious health problems as the world's population age is increasing. Elucidating its biological mechanisms as well as prevention and treatments is becoming increasingly significant, particularly in view of the associated health costs. We presented the study protocol of a research project funded by the Italian Ministry of Health (grant number RF-2016-02363298) aiming to investigate the cognitive and neuropsychological effects of a 5-week treatment with therapy based on the regenerative properties of ozone (O3) in a cohort of subjects stratified according to CF scores. We also studied the potential effects of O3 on blood-based biomarkers indicative of specific biological systems that may be altered in CF. Seventy-five older persons were recruited and randomly assigned to receive the active treatment (150 cc of oxygen-O2-O3 mixture at the concentration of 30 µg of O3 per cc of O2), O2, or the placebo (air) for 5 weeks. The main endpoints were the change in the scores of clinical scales from baseline (T0) to weeks 3 (T3), 9 (T9), and 15 (T15) after treatment and the change in biomarker levels resulting from transcriptomics, proteomics, and metabolomic patterns at the same times. The positive results from this study could have important clinical implications.

Association between changes in nutritional status and ability to perform activities of daily living in older patients with heart failure: A stratified analysis by frailty status

ObjectivesWe aimed to determine the association between changes in nutritional status and the activities of daily living (ADL) at discharge, considering frailty status of older patients with heart failure (HF). MethodsThis study included 491 older inpatients with HF categorized into the following groups based on their clinical frailty scale (CFS) scores: low, intermediate, and high. Changes in nutritional status were assessed using the Controlling Nutritional Status score at admission and discharge. The outcome variable was Barthel Index (BI) at discharge. ResultsMultivariate logistic regression analysis indicated an association between improvement in nutritional status and high BI at discharge in both the low and intermediate CFS groups (odds ratio [OR], 2.18 [95% confidence interval, 1.04–4.58]), (OR, 2.45 [1.21–4.95]), respectively. ConclusionsImprovement in the ADL at discharge in older patients with HF was associated with improved nutritional status during hospitalization in the low and intermediate CFS groups.