Moderate-severe Disease Research Articles

Warfarin therapy in atrial fibrillation: assessment of patient knowledge of risks and benefits

ABSTRACT Patients with atrial fibrillation are at an increased risk for stroke, and many benefits from anticoagulation. Despite the emergence of direct oral anticoagulants, many patients continue to rely on warfarin for their anticoagulation due to logistical, pharmacokinetic, clinical, or patient preference issues. Previous work has suggested that outcomes of warfarin therapy are related to patient education/knowledge. We assessed knowledge of indications, benefits, and complications of warfarin therapy in 99 randomly selected patients enrolled in the Warfarin Anticoagulation Clinic at the Mayo Clinic in Florida who were taking warfarin for non-valvular atrial fibrillation. Patients were labeled as ‘knowledgeable’ or ‘not knowledgeable’ regarding warfarin therapy according to the results of a cross-sectional questionnaire. The majority of patients in both the knowledgeable and not knowledgeable groups displayed understanding that they were taking warfarin for atrial fibrillation (valvular vs non-valvular atrial fibrillation was not an included answer choice). However, there was a clear lack of knowledge amongst patients with atrial fibrillation in both groups about their stroke risk while on and off warfarin, and their risk of major bleeding or adverse events related to their warfarin therapy. There was only a significant difference between the two groups regarding their knowledge of what increases or decreases the risk of bleeding while on warfarin. There was no major difference between the groups with regards to demographic and medical characteristics, except that ‘not knowledgeable’ patients tended to have more peripheral vascular disease, ulcer disease, and moderate-severe renal disease compared to ‘knowledgeable’ patients.

Impaired circadian heart rate variability in Parkinson\u2019s disease: a time-domain analysis in ambulatory setting

BackgroundHeart rate variability (HRV) decreases in Parkinson’s disease (PD) and it can be considered a marker for cardiovascular dysautonomia. The purpose of this pilot study is to evaluate long-term time-domain analysis of HRV of PD patients and compare the results with those of matched healthy individuals.MethodsIdiopathic PD patients without comorbidity impairing HRV, and age-matched healthy individuals were recruited in a pilot study. A long-term time domain analysis of HRV using 24-h ambulatory ECG was performed.ResultsOverall, 18 PD patients fulfilling inclusion criteria completed the evaluation (mean age was 55.6 ± 8.8, disease duration: 5.0 ± 4.7). Mean SCOPA-AUT score was 10.1 ± 7.3. Patients were on Hoehn & Yahr stage 1–2 and mean Levodopa Equivalent Dose (LED) was 311 ± 239.9. Mean of the 5-min standard deviation (SD) of R-R intervals distribution (SDNN) for all 5 min segments of the entire recording (ISDNN) was significantly lower in patients compared to controls. ISDNN was significantly different between Parkinson’s disease patients and healthy controls.ConclusionsIn our population characterized by mild to moderate disease severity, time-domain assessment of HRV seemed to be a potential tool to characterize cardiovascular dysautonomia. Decrease of ISDNN in PD may reflect an autonomic derangement extending all day and night long.

Long-term Outcomes and Survival in Moderate-severe Portopulmonary Hypertension After Liver Transplant

Portopulmonary hypertension is present in an estimated 5.3% to 8.5% of liver transplant candidates. Untreated, 5-year survival is estimated between 14% and 28%. Moderate-severe disease is a contraindication to liver transplant due to the high perioperative mortality, but patients optimized with pulmonary vasodilator therapy can become eligible for transplant. There is minimal data regarding posttransplant outcomes and ability to discontinue pulmonary vasodilator therapy posttransplant. We performed a single-center retrospective analysis to evaluate long-term outcomes of patients with moderate-severe portopulmonary hypertension who were optimized with pulmonary vasodilator therapy, became eligible for liver transplant, and subsequently underwent transplant. We identified 24 patients optimized with pulmonary vasodilator therapy who underwent subsequent liver transplantation and 25 patients who were treated with pulmonary vasodilator therapy alone. In the transplanted cohort, 1-year survival from portopulmonary hypertension diagnosis date: 95.8%, 3-year survival: 90.9%, and 5-year survival: 90.9%. Posttransplant; 1-, 3-, and 5-year survival was 86.9%. Among transplanted patients, 41.6% (10/24) were optimized with nonparenteral therapy. Following transplantation, 100% (14/14) of the surviving patients were able to discontinue parenteral therapy; median time: 7.2 months (interquartile range: 5.1-8.9 mo), while 61.9% (13/21) were able to discontinue pulmonary vasodilator therapy altogether; median time: 13.9 months (interquartile range: 5.1-17.6 mo). Patients who are optimized with pulmonary vasodilator therapy before liver transplant can have excellent long-term outcomes posttransplant. Oral pulmonary vasodilator therapy can be effective treatment to qualify a patient for transplant, and the majority are able to wean from pulmonary vasodilator therapy entirely posttransplant.

Bronchiectasis in patients with chronic obstructive pulmonary disease in a tertiary care center in North-East India

Bronchiectasis in patients with chronic obstructive pulmonary disease in a tertiary care center in North-East India

Persistent chikungunya arthritis in Roraima, Brazil.

The Amazon region of Brazil experienced a large epidemic of East Central South African (ECSA) chikungunya virus (CHIKV) in 2017 and continuous transmission of CHIKV persists. The impact of chronic arthritis caused by ECSA CHIKV is unknown. The study aim was to describe the duration, severity, and characteristics of CHIKV arthritis in Roraima, Brazil, in comparison with local controls to further understand the long-term rheumatologic impact of ECSA CHIKV infection. We performed a cross-sectional analysis comparing clinical arthritis outcomes among 40 cases with chronic (> 3months) arthritis attributed to their CHIKV disease (n = 40) with control participants who were exposed to CHIKV but did not develop chronic arthritis (n = 40), rheumatoid arthritis controls (n = 40), and healthy controls lacking CHIKV exposure and arthritis (n = 40). Our primary finding is that over 2years post-infection, patients report moderate arthritis disease severity comparable with rheumatoid arthritis with the most significant impact on decreased quality of life from pain. These findings suggest that chronic arthritis caused by ECSA CHIKV infection has had a moderate impact in the Americas. Key Points • Chikungunya infection is responsible for moderate arthritis disease severity. • The East Central South African (ECSA) strain of CHIKV is a cause of persistent arthritis in Roraima, Brazil.

A Multimodal Eye Assessment in Psoriatic Arthritis Patients sine-Psoriasis: Evidence for a Potential Association with Systemic Inflammation.

Background: Ocular involvement in Psoriatic Arthritis (PsA) patients is mainly associated with uveitis but there remains a paucity of data on dry eye and retinal abnormalities. We aimed to analyze dry eye and subclinical retinal abnormalities in a cohort of PsA patients sine-psoriasis (PsO). Methods: PsA patients sine-PsO were enrolled. Best-corrected-visual-acuity, ocular-surface-disease-index (OSDI), Schirmer test, tear film breakup-time, standard-automated-perimetry (SAP, mean deviation—MD, pattern standard deviation—PSD), fundus-perimetry (FP), and spectral-domain-optical-coherence-tomography (SD-OCT) were performed. Results: A total of 80 eyes from 40 PsA patients with moderate-severe disease activity, and 70 eyes from 35 healthy control (HC) were evaluated. Higher dry eye prevalence occurred in PsA than HC (p < 0.0001). ESR was positively related with OSDI (p < 0.001) and negatively related with Schirmer (p = 0.007). In PsA, SAP registered higher MD (p < 0.0001) and higher PSD (p = 0.005) in comparison with HC. PSD resulted positively correlated with ESR (p = 0.04) and CRP (p = 0.01), while MD showed a negative correlation with CRP (p = 0.01). Both FP mean differential sensitivity and mean defect were lower in PsA then HC (p < 0.0001). In PsA, FP differential sensitivity was directly related with cumulative steroids (p = 0.02). Conclusions: In PsA patients sine-PsO, dry eye and subclinical abnormalities in visual functions occurred being potentially related to systemic inflammation.

Cervical Spondylotic Myelopathy: A Guide to Diagnosis and Management.

Cervical spondylotic myelopathy (CSM) is a neurologic condition that develops insidiously over time as degenerative changes of the spine result in compression of the cord and nearby structures. It is the most common form of spinal cord injury in adults; yet, its diagnosis is often delayed. The purpose of this article is to review the pathophysiology, natural history, diagnosis, and management of CSM with a focus on the recommended timeline for physicians suspecting CSM to refer patients to a spine surgeon. Various processes underlie spondylotic changes of the canal and are separated into static and dynamic factors. Not all patients with evidence of cord compression will present with symptoms, and the progression of disease varies by patient. The hallmark symptoms of CSM include decreased hand dexterity and gait instability as well as sensory and motor dysfunction. magnetic resonance imaging is the imaging modality of choice in patients with suspected CSM, but computed tomography myelography may be used in patients with contraindications. Patients with mild CSM may be treated surgically or nonoperatively, whereas those with moderate-severe disease are treated operatively. Due to the long-term disability that may result from a delay in diagnosis and management, prompt referral to a spine surgeon is recommended for any patient suspected of having CSM. This review provides information and guidelines for practitioners to develop an actionable awareness of CSM.

A longitudinal study of CMT1A using Rasch analysis based CMT neuropathy and examination scores.

To evaluate the sensitivity of Rasch analysis-based, weighted Charcot-Marie-Tooth Neuropathy and Examination Scores (CMTNS-R and CMTES-R) to clinical progression in patients with Charcot-Marie-Tooth disease type 1A (CMT1A). Patients with CMT1A from 18 sites of the Inherited Neuropathies Consortium were evaluated between 2009 and 2018. Weighted CMTNS and CMTES modified category responses were developed with Rasch analysis of the standard scores. Change from baseline for CMTNS-R and CMTES-R was estimated with longitudinal regression models. Baseline CMTNS-R and CMTES-R scores were available for 517 and 1,177 participants, respectively. Mean ± SD age of participants with available CMTES-R scores was 41 ± 18 (range 4-87) years, and 56% were female. Follow-up CMTES-R assessments at 1, 2, and 3 years were available for 377, 321, and 244 patients. A mixed regression model showed significant change in CMTES-R score at years 2 through 6 compared to baseline (mean change from baseline 0.59 points at 2 years, p = 0.0004, n = 321). Compared to the original CMTES, the CMTES-R revealed a 55% improvement in the standardized response mean (mean change/SD change) at 2 years (0.17 vs 0.11). Change in CMTES-R at 2 years was greatest in mildly to moderately affected patients (1.48-point mean change, 95% confidence interval 0.99-1.97, p < 0.0001, for baseline CMTES-R score 0-9). The CMTES-R demonstrates change over time in patients with CMT1A and is more sensitive than the original CMTES. The CMTES-R was most sensitive to change in patients with mild to moderate baseline disease severity and failed to capture progression in patients with severe CMT1A. NCT01193075.

Apolipoproteins B and A1 in Ischemic Stroke Subtypes

Introduction: Elevated serum apolipoprotein B and the apolipoprotein B/A1 ratio have been associated with ischemic stroke and intracranial atherosclerotic disease. We sought to assess the relationship between serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio with ischemic stroke subtypes and large artery atherosclerosis location. Materials and Methods: We evaluated serum apolipoprotein B and apolipoprotein A1 levels in consecutive, statin-naïve, adult ischemic stroke patients admitted to an academic medical center in southern India. We evaluated for differences in the mean serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio between patients with ischemic stroke attributed to intracranial atherosclerotic disease, extracranial atherosclerotic disease, small vessel disease, and cardioembolism. In secondary analysis, we assessed for differences in these serum apolipoproteins between patients with moderate-severe intracranial atherosclerotic disease and extracranial atherosclerotic disease, irrespective of ischemic stroke subtype. Results: Among the 156 ischemic stroke patients enrolled in this study, there were no significant differences in serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio between patients with distinct ischemic stroke subtypes. No significant differences were found in serum levels of apolipoprotein B, A1 and the apolipoprotein B/A1 ratio between patients with moderate-severe intracranial atherosclerotic disease and moderate-severe extracranial atherosclerotic disease. Discussion: Serum levels of apolipoprotein B and A1 did not differ between ischemic stroke subtypes. Additional studies are needed to validate our findings and to better understand the relationship between serum apolipoproteins and stroke.

P101 SARCOPENIA IS ASSOCIATED WITH INCREASED RISK OF INFECTION IN IBD PATIENTS OLDER THAN 50 YEARS STARTING BIOLOGIC MEDICATIONS

Abstract Background The relationship between sarcopenia and clinical outcomes outside of the post-operative setting has not been well-studied in IBD patients. We aimed to characterize the prevalence of sarcopenia and its association with adverse events and clinical response in IBD patients starting on new biologic medications. Methods We identified a retrospective cohort of adult (≥18 years old) IBD patients at the University of Minnesota with an abdominal CT or MRI within 6 months prior to or one month after starting a new biologic medication. Baseline demographics, disease severity (based on Physician’s Global Assessment from GI encounters), laboratory values and clinical outcomes for one year after the start of medications were obtained from chart review. The primary endpoint was incidence of adverse events (defined as infection, need for surgery, or hospitalization) within one year after medication start. The secondary outcome was clinical response as assessed based on clinical, endoscopic, and radiographic follow-up. Skeletal muscle index (SMI) measures were obtained from CT/MRI images at the L3 vertebral level. Published cut-offs (SMI of 38.5 cm2/m2 for women and 52.4 cm2/m2 for men) were used to determine the presence of sarcopenia. Associations between sarcopenia and outcomes were analyzed using logistic regression and age stratification was performed. Results Ninety-four patients (74 CD, 20 UC, 47% male, mean age 38 years) were included in the analysis. The majority of patients had moderate disease severity or worse (83%) at the time of medication start, and 75% were started on anti-TNF medications. Overall prevalence of sarcopenia was 57% (57% CD, 60% UC). In the entire cohort, sarcopenia was not associated with increased rates of adverse events (OR = 0.516, 95% CI 0.217–1.225; p= 0.1334). However, in patients ≥ 50 years of age (n=23), those with sarcopenia had higher risk of infection at 1 year compared to those without sarcopenia (85% vs. 20%; OR = 21.99, 95% CI 3.086–262.515; p = 0.0051). The majority of infections were those that required antibiotics or antivirals, but not hospitalization. Examples included sinusitis, upper respiratory infections, periodontitis, urinary tract infection, herpes simplex, and two cases of C. difficile. Furthermore, when controlling for disease duration and concomitant steroid use, the association between sarcopenia and infection remained significant. In this age subgroup, there was no association between sarcopenia and clinical response to therapy. Conclusions In our cohort, sarcopenia was present in the majority of adult IBD patients starting new biologic medications. In patients ≥ 50 years old, sarcopenia was associated with an increased risk of infections. Further work is needed to validate these findings and to understand which patients may benefit from sarcopenia assessment prior to biologic start.

P117 CONTENT VALIDITY OF THE SUBCUTANEOUS ADMINISTRATION ASSESSMENT QUESTIONNAIRE (SQAAQ) IN ADULT AND ADOLESCENT PATIENTS WITH MODERATE TO SEVERE CROHN’S DISEASE

Abstract Background Subcutaneous (SC) delivery of biologic therapies is typically via a prefilled syringe or an auto-injector designed to offer a more convenient and more consistent administration of drug product. There is currently no gold standard instrument that is used to assess the usability and patient confidence and preference for an injection device in Crohn’s disease (CD). The Subcutaneous Administration Assessment Questionnaire (SQAAQ) was developed to evaluate ease of use and confidence in SC administrations of therapy. The SQAAQ (Figure 1) features 12 items scored on a 7-point Likert scale (1= Strongly Disagree to 7= Strongly Agree). Higher scores indicate better usage experience. The recall period is immediately after patients auto-inject. This study aimed to establish evidence of the content validity of the SQAAQ among patients with moderate to severe CD. Methods A semi-structured interview guide was used to conduct face-to-face qualitative interviews with adult (18+ years) and adolescent (12–17 years) patients from the US with a clinician confirmed diagnosis of CD. Cognitive debriefing interviews were structured into sections that explored patients’ opinions, interpretation, and acceptance of the SQAAQ. Data were coded using Atlas.ti using a framework approach where pre-defined codes were applied to quotes that demonstrated patients’ understanding/interpretation, acceptance, and usage of the instructions, items, response scale/options, and recall period. Results Twenty-four patients (adults, n=16; adolescents, n=8) participated in the interviews. Thirteen adults and 3 adolescents experienced moderate disease severity (reported by clinicians). Adult and adolescent groups contained an equal proportion (50%) of male and female participants. Adults had a mean age 50.3 years (range 27.0–75.0), adolescents with mean age 15.6 years (range 14.0–17.0). Overall, two-thirds (n=16, 67%) of patients were white, and the mean duration for CD diagnosis was 8.0 years (range 1.0–23.7). Ten (42%) patients had been on SC treatment for a mean 4.5 years (range 0.2–16.9), all self-administered. Seven (29%) patients had been receiving intravenous treatment for a mean 2.1 years (range 0.2–5.4). The SQAAQ was found to be conceptually relevant, understandable and usable by adults and adolescents with CD. Notably the measurement concepts were confirmed as relevant by patients who currently used SC treatment devices. The patients with no SC experience (n=7, 29%), understood the item wording, response scales, and recall period and had few difficulties completing the measure. Conclusion Content validity of the SQAAQ was established in this sample of adolescent and adult patients with CD. The SQAAQ is appropriate for inclusion in CD clinical trials for SC treatment devices with adult and adolescent patients.

P387 Real-world clinical outcomes of biologic-naïve non-complicated Crohn’s disease patients treated with vedolizumab: Results from the EVOLVE study

Abstract Background Crohn’s disease (CD) can lead to complications that impact treatment (Tx) decisions and its clinical effectiveness. The objective of this analysis was to compare clinical effectiveness outcomes of CD patients treated with first-line biologic vedolizumab (VDZ) who did not have a complicated disease phenotype (non-complicated) to VDZ patients who had complications (complex disease). Methods This was a retrospective real-world cohort study of biologic-naïve CD patients (≥18 years old) in Canada, Greece and the USA who initiated VDZ Tx between May 2014 and March 2018. Data were collected from Tx initiation to the earliest of chart abstraction date or death. The non-complicated CD was defined as patients who had mild or moderate disease severity and no active fistula at Tx initiation, had no prior CD-related surgeries since diagnosis and no CD-related hospitalisations within 12 months prior to Tx initiation. The complex disease cohort encompassed all other CD patients. Cumulative rates of clinical effectiveness outcomes over 24 months (Tx persistence, clinical response and clinical remission) were estimated using the Kaplan–Meier method. Using pre-defined hierarchical algorithms, clinical response and clinical remission were assessed from standard disease measures reported in the medical records. Results This analysis included 218 CD patients treated with VDZ (non-complicated: 64 (29.3%); complex: 154 (70.6%) from 37 sites. Mean (SD) age at Tx initiation: non-complicated, 46.2 (15.8); complex, 54.0 (16.7); male: non-complicated, 45.3%; complex, 55.2%. Cumulative rates of clinical response were significantly greater in non-complicated than complex disease patients over 24 months (non-complicated: 93.0%, complex: 76.0%, p &amp;lt; 0.01) (Figure 1). Tx persistence (non-complicated: 76.7%, complex: 66.6%, p = 0.68) (Figure 2) and clinical remission (non-complicated: 81.9%, complex: 73.5%, p = 0.36) (Figure 1) were not significantly different between the two cohorts over 24 months. Fewer patients had data for mucosal healing over 24 months, and it was also not significantly different between groups at 12 months (non-complicated: 66.4%, complex: 60.2%, p = 0.95). Conclusion A high proportion of patients (70%) had a complex disease when VDZ Tx was initiated but those with non-complicated phenotype had a higher response rate. To help guide physicians in positioning the optimal Tx for biologic-naïve CD patients, it is important to identify the sub-group of patients who can most benefit from VDZ Tx. The results of this real-world study suggest that the biologic-naïve, non-complicated CD patients benefit more from VDZ treatment compared with those with disease complications.

Cost and Quality Impacts of Treatment Loci for Type 2 Diabetes Patients with Moderate Disease Severity: Hospital- vs. GP-Basedmonitoring

Objectives: This study investigates cost and quality implications of pushing regular monitoring of moderateseverity type 2 diabetes (T2D) patients away from specialized hospital clinics into general practice (GP). Methods: 152,630 hospital- and 21,361 GP-monitored T2D patients with moderate disease severity werealgorithmically identified in Danish administrative databases in 2016. Total annual healthcare costis decomposed into GP, medication, nonhospital-specialist, hospital outpatient and inpatient costs. Emergency hospitalizations are used to proxy for quality of care. Cost and quality impacts oftreatment loci are assessed using an instrumental variable (IV) analysis. A wide range of patientconfounders are used to reduce selection bias, with distance to nearest hospital diabetes clinic usedas an instrument to control for remaining endogeneity of treatment locus. Two-part models areused for zero-inflated outcomes. Results: Hospital monitoring is associated with higher total annual healthcare costs (64.0%, p Conclusion: For type 2 diabetes patients with moderate disease severity, IV analysis controlling for treatmentlocus endogeneity bias identifies an expected efficiency improvement (average cost reductionwithout reduction of quality) of moving regular disease management from hospital-based settingto primary care.

Characteristics and outcomes of 231 COVID-19 cases admitted at a tertiary facility in India: An observational cohort study.

Background:Ongoing pandemic because of COVID-19 has spread across countries, with varied clinical features and severity. Awareness of clinical course among asymptomatic and symptomatology in symptomatic cases is essential for patients’ management as well as optimal utilization of health services (in resource limited settings) based on clinical status and risk factors. This study aimed to describe the clinical characteristics and outcomes of patients admitted with COVID-19 illness in the initial phase of the pandemic in India.Methods:It was an observational study. Patients aged 18 years or more, with confirmed SARS-CoV-2 infection, asymptomatic or mildly ill, were included. Patients with moderate-severe disease at admission or incomplete clinical symptomatology records were excluded. Data regarding demography, comorbidities, clinical features and course, treatment, results of SARS-CoV-2 RT-PCR, chest radiographs, and laboratory parameters were obtained retrospectively from hospital records. The outcome was noted in terms of course, patients discharged, still admitted (at the time of the study), or death.Results:Out of 231 cases, most were males (78.3%) with a mean age of 39.8 years. Comorbidities were present in 21.2% of patients, diabetes mellitus and hypertension being the most common. The most common symptoms were dry cough (81, 35%), fever (64, 27.7%), sore throat (36, 15.6%); asymptomatic infection noted in 108 (46.8%) patients. The presence of comorbidities was an independent predictor of symptomatic disease (OR-2.66; 95%CI 1.08–6.53, P = 0·03). None of the patients progressed to moderate-severe COVID-19, and there were no deaths.Conclusions:A large proportion of patients remained asymptomatic whereas those with comorbidities were more likely to be symptomatic. Most with mild disease had a stable disease course, barring few complication in those with comorbidities. The pandemic continues to grow as large number of asymptomatic cases may go undiagnosed.

Effect of Combined Inoculation of Xanthomonas and Meloidogyne Pathogens on the Development of Tomato Root Knot Disease

Bacteria (Xanthomonas campestris pv. vesicatoria) and root-knot nematode (Meloidogyne incognita) independently can damage and cause considerable damage to tomato (Solanum lycopersicum L.). In a disease complex, interrelationship of 2 or more pathogenic species can produce different symptoms on the same host plant. Generally simultaneous occurrence of these pathogens in a field can infect hosts plant at the same time. During development of a disease complex pathogens could influence and/or suppress each other, through synergism and or antagonism respectively. In this study the pathogens (Meloidogyne incognita and Xanthomonas campestris pv. vesicatoria), were used to determine how co-occurrence affects development of pathogens and disease severity, and define prerequisites for interrelation between pathogens. Root knot infection did not occur when tomato plants were inoculated with Xanthomonas campestris 1 week prior to inoculation with Meloidogyne incognita. When M. incognita was inoculated 1 week prior to X. campestris, infection by root knot nematode was highest compared to bacterial spot incidence in susceptible plants. Simultaneous inoculation of M. incognita + X. campestris caused severe gall production with moderate severity of bacterial spot disease. The reproduction of 1 pathogen can be affected by a subsequent inoculation of other pathogen. It is suggested that bacterial spot disease enhances the development of root knot disease.

Multicentre longitudinal study of the nutritional status and swallowing difficulties in children with severe neurological diseases

Nutritional problems are common in children with neurological diseases, especially if they have significant motor impairment. Oropharyngeal dysphagia is very prevalent in these patients, and can contribute to worsening nutritional status and produce pulmonary aspirations. Longitudinal assessment of the nutritional status of a sample of pediatric patients with moderate-severe neurological disease and establish the prevalence of oropharyngeal dysphagia in that sample. An observational multicenter prospective study was conducted. We included children under 16 years of age with moderate-to-severe neurological impairment from four hospitals, with clinical and anthropometric monitoring for one year. Questions were asked to conduct oropharyngeal dysphagia screening. Sixty-eight children were included, the main diagnosis obtained was cerebral palsy. In the anthropometric assessment, 42 patients (62%) showed weight z scores below -2, and 29 (43%) height z scores below -2, while body mass index, mid upper arm circumference and triceps and subscapular skinfolds remained less affected. We found an oropharyngeal dysphagia prevalence of 73.5% in our sample, increasing with greater motor impairment. These patients showed lower weight and height than children without neurological impairment. However, with a correct follow-up they remain stable with an adequate body composition. It is important to proactively investigate the presence of oropharyngeal dysphagia, especially in those with greater motor impairment, as it occurs very frequently and an adequate diagnosis can improve clinical evolution and prevent complications.

Methods of Hydrokinesis Therapy for Children 3-5 Years with Cerebral Palsy of Spastic Form

Today there is a need to develop a method of hydrokinesis therapy as a means of gradual formation of motor skills in children with spastic diplegia of cerebral palsy of the chronic-residual stage of the disease in a comprehensive program of physical rehabilitation. The purpose of the study is to develop a method of hydrokinesis therapy for children 3-5 years with cerebral palsy of spastic form. The main novelties of the developed technique of hydrokinesis therapy: development of application of complexes of exercises in hydrokinesis therapy, which differs in structure from the generally accepted methods for patients with cerebral palsy of spastic form in the chronic-residual stage of the disease; combination of means of physical rehabilitation with the technique of hydrokinesis therapy during the annual cycle. The study involved 24 children 3-5 years of age with a diagnosis of "cerebral palsy, spastic diplegia" of the chronic-residual stage of the disease of moderate severity. To achieve this goal, theoretical analysis and generalization of data from scientific and methodological literature were used; pedagogical experiment and observation; medical and biological methods (used anthropometry and Pinier index; goniometry, assessment of basic motor functions (ABMF) on the Likert scale, muscle tone on the Ashfort scale, muscle strength on the Lovett scale; assessment of manipulative activity and speed response of the hands on trapping- the test made it possible to determine the level of development of fine motor skills); sociological methods (surveys of parents on questionnaires of social and emotional state and level of children's play activities); methods of mathematical statistics were used to process the actual experimental material, assess the reliability of the data. There were significant (p &lt;0.01) changes in the indicators of social and emotional state in children with main group (MG) by 15.5%, in comparative group (CG) - by 11.7%, and there was a slight improvement in play activity in children with MG by 9.6%, in CG - by 5.75%. The developed method of hydrokinesiotherapy is effective and helps to improve the functions of general and fine motor skills, socio-emotional state and the level of activity of play activities of children 3-5 years with cerebral palsy of spastic form.

Viability and validity of the bispectral index to measure sleep in patients in the intensive care unit.

ObjectiveTo investigate the viability of the bispectral index in the sleep evaluation of critically ill patients and to quantify the associations of sleep parameters measured by this index with the Richards-Campbell Sleep Questionnaire and environmental noise.MethodsThis was a cross-sectional observational study that evaluated critically ill adults with diseases of low or moderate severity. The following were measured: total sleep volume and time, deep sleep volume and time, continuous sleep volume and time, sleep onset latency, and environmental sound pressure level. The subjective perception of sleep was evaluated with the Richards-Campbell Sleep Questionnaire the morning after each night of observation.ResultsPatients had a low total sleep time (234 minutes), a predominance of superficial sleep stages, and little deep sleep (1.7 minutes). The total, deep, and continuous sleep volumes were 3,679, 9.4, and 3,143 (bispectral index units × minutes), respectively. The sleep latency was 94 minutes. The mean score of the Richards-Campbell Sleep Questionnaire was 57.9. Total sleep volume, total sleep time, and continuous sleep volume were weakly correlated with the Richards-Campbell Sleep Questionnaire depth of sleep domain score, overall sleep quality domain score, and total score. Total volume, total time, and continuous volume were moderately correlated with the occurrence of awakenings domain score.ConclusionThe bispectral index is an instrument with limited viability to monitor the sleep of lucid patients and patients with low to moderate disease severity in the intensive care unit. Patients with higher total sleep volume, total sleep time, and continuous sleep volume had better overall sleep perception.

Study on the evaluation of rheumatoid arthritis via doppler ultrasonography and anti-cyclic citrullinated peptide antibody analysis

Objective:This study aims to discuss the value of ultrasonic analysis and anti-cyclic citrullinated peptide (CCP) antibody analysis in evaluating the state of rheumatoid arthritis (RA).Methods:This study was conducted during March 2016 to December 2016. Total 82 patients with RA who sought treatment in the Affiliated Hospital of Hebei University were included in this study. Data on ultrasonic and anti-CCP antibody, ESR, and RF were collected and compared. The RA patients were divided into two groups of mild disease activity (DAS28 ≤ 3.2) and moderate-severe disease activity (DAS28 > 3.2) to compare the changes in synovial thickness of joints. The changes of joint ultrasonography were also compared between positive and negative anti-CCP antibodies group.Results:It is found that the number of patients suffering from joint involvement in the negative anti-CCP antibody group was larger than that of the anti-CCP positive antibody group (P <0.05); the thickness of the synovium of joints of patients in the group with moderate-severe disease activity evaluated via ultrasonography was significantly larger than that of the group with mild disease activity (P <0.05).Conclusion:It is possible to observe the degree of disease activity dynamically by combining ultrasonography with anti-CCP antibody and make a better assessment of patients to facilitate treatment.

Invariant natural killer T cells are reduced in peripheral blood of bullous pemphigoid patients and accumulate in lesional skin.

iNKT (invariant natural killer T) cells are unconventional immunoregulatory T cells which contribute to B cell maturation, antibody and cytokine production. iNKT cells are implicated in the control of autoimmune inflammation in different disorders. For bullous pemphigoid (BP), the most frequent bullous autoimmune dermatosis, the role of iNKT cells has not yet been studied. We, therefore, aimed at investigating the frequency of iNKT cells in peripheral blood and biopsies from lesional and non-lesional skin from patients with BP and controls. Circulating CD3+iTCR+ iNKT cells were assessed by flow cytometry in peripheral blood from 30 patients with BP and from 29 controls (19 patients with skin tumors and 10 healthy controls). In 34 lesional and 13 non-lesional skin biopsies from BP patients and 17 biopsies from control individuals the number of Vα24+Vβ11+ iNKT cells was investigated by immunofluorescence staining. BP patients showed a significantly lower frequency of circulating iNKT cells compared to the control group. Patients with severe disseminated blistering tended to display lower iNKT cell numbers than patients with moderate disease severity. In lesional skin of BP patients, an enrichment of iNKT cells was detected compared to skin biopsies from controls. Similarly to control biopsies, non-lesional biopsies of BP patients contained only few iNKT cells. In conclusion, the deficiency of circulating iNKT cells associated with enrichment at the site of cutaneous inflammation suggests that iNKT cells may play a pathophysiologically relevant role in BP.