Tertiary Clinic Research Articles

Clinical characteristics of non-infectious uveitis treated with and without systemic immunomodulatory therapy

ObjectifComparer les caractéristiques des patients et les résultats à long terme dans l'uvéite non infectieuse (UNI) soumise ou non à un traitement immunomodulateur (TIM) administré par voie générale. NatureÉtude de cohorte rétrospective. ParticipantsTous les adultes consécutifs présentant une UNI qui ont été soignés entre 2010 et 2021 à l'une de 5 cliniques de soins tertiaires spécialisées dans l'uvéite. MéthodesLes résultats cliniques ont été évalués lors de la visite initiale et lors de la dernière visite de suivi. Les caractéristiques initiales et l'acuité visuelle finale constituaient les principaux paramètres de mesure. RésultatsOn a recensé un total de 914 patients présentant une UNI (dont 418 patients ont reçu un TIM et 496 patients n'en ont pas reçu); l’âge médian était de 51,0 ans, et 57,4 % étaient de sexe féminin. L'atteinte était bilatérale chez plus de la moitié des patients, et une proportion significativement plus élevée de cas bilatéraux se trouvaient dans le groupe TIM, comparativement au groupe sans TIM (p < 0,001). Les patients du groupe TIM étaient plus susceptibles d'avoir une uvéite chronique (p < 0,001), et une proportion plus élevée de ces derniers présentaient des cataractes et un œdème maculaire cystoïde (p < 0,001 pour les 2 mesures). Par ailleurs, une proportion significativement plus élevée de patients sans TIM présentaient une uvéite antérieure d’étiologie idiopathique (p < 0,001). L'acuité visuelle s'est significativement améliorée entre la visite initiale et la dernière visite de suivi chez l'ensemble de notre cohorte (p < 0,001); on a noté une amélioration légèrement plus importante dans le groupe TIM. Selon l'analyse de régression linéaire multivariée, l'acuité visuelle initiale et la présence d'une panuvéite étaient des facteurs de prédiction significatifs de l'acuité visuelle finale (p < 0,001 pour les 2 mesures). ConclusionsLes patients qui présentent une UNI et qui reçoivent un TIM sont souvent plus jeunes, ont une atteinte bilatérale et chronique et sont plus susceptibles de subir des complications oculaires. Les patients qui ne reçoivent pas de TIM sont plus susceptibles de présenter une UNI antérieure idiopathique. L'acuité visuelle initiale et la présence d'une panuvéite sont les principaux facteurs prédictifs de l'acuité visuelle finale en présence d'UNI.

The role of the peripheral chemoreceptor reflex in non-hospitalised patients with post-COVID-19 syndrome

Abstract Background Long COVID (post COVID-19 syndrome) is a common debilitating illness. Little is known regarding the underlying mechanisms driving ongoing symptoms, which include lethargy, breathlessness, dysregulated breathing, and exercise intolerance. The carotid body is important in the control of breathing, is abundant in ACE2 (cell entry mechanism for SARS-CoV-2) and is known to drive similar symptoms in patients with heart failure (HF). We hypothesised that the carotid chemoreflex becomes hyperreactive in patients with long COVID-19 syndrome, which could be important in driving several ongoing symptoms. Purpose We aimed to examine whether carotid chemoreflex sensitivity was elevated in patients with long COVID (with initial mild-moderate symptoms) versus an age-matched control group and whether this could help to explain dysregulated breathing and poor exercise tolerance in long COVID. Methods Long COVID participants (n=14; 12F) were prospectively recruited from a tertiary cardiology long COVID clinic (after being cleared for cardiac conditions) and from advertising publicly. Patients were non-hospitalised and had received a diagnosis of long COVID via their GP or long COVID clinic. Participants had a positive PCR or sero-positive antibody test for their initial infection. Controls were healthy with no diagnosed comorbidities (n=14; 11F). Eight controls had a confirmed previous infection and did not develop ongoing symptoms. Participants completed baseline spirometry, a resting 12-lead electrocardiogram, and an incremental cardiopulmonary exercise test (CPET) to volitional exhaustion on a cycle ergometer. On a separate day, the carotid chemoreflex sensitivity was measured using the hypoxic ventilatory response (HVR) [1]. Averaged group data were compared using statistical software (GraphPad, Prism). Data are mean ± SD unless stated otherwise. Results Age and body mass index were similar between groups (Table 1). Resting spirometry indicated that lung function was similar between groups (Table 1). The long COVID group had a lower maximum volume of inspired oxygen (VO2 peak) and a similar maximum heart rate (as a % of predicted) vs. controls (Table 1). Ventilatory efficiency (VE/VCO2) slope, VE/VCO2 ratio at anaerobic threshold (AT), and VE/VCO2 nadir were higher in the long COVID group, indicating poor breathing efficiency, similar to the level observed in HF (Table 1) [2]. Finally, the HVR was elevated in the long COVID group (-0.45±0.23 l/min/SpO2%) versus the control group (-0.18±0.13 l/min/SpO2%, Figure 1, P=0.0007). The HVR correlated with the VE/VCO2 slope (r=0.54, P=0.0012). Conclusions These data suggest that the carotid chemoreflex is sensitised in people with long COVID and may help to explain dysregulated breathing in these patients. The carotid chemoreflex could be a viable target to help improve symptoms in people suffering with ongoing symptoms following even a mild original SARS-CoV-2 infection, but more research is needed.Table 1Figure 1

Analysis of routine molecular genetic diagnostics of familial hypercholesterolemia at tertiary care lipid clinics

Abstract Background Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease, causing dyslipidemia and premature atherosclerotic cardiovascular disease (ASCVD), with currently ∼2,000,000 unidentified adult cases as well as ∼500,000 children cases in Europe. Purpose Aim of this study is to analyse the current yield of routine molecular genetic diagnostics for FH and the spectrum of mutations in two specialist lipid clinics. Methods We investigated all genetic tests performed for FH in our clinics over a 4-year period. Reports of causative mutations in the main FH-causing genes including LDLR, APOB, PCSK9 were collected. Variants were classified based on HGVS nomenclature using the mutation database ClinVar. For clinical classification, the Dutch Lipid Clinic Network Score (DLCNS) was used, which is based on off-treatment low-density lipoprotein cholesterol (LDL-C) ranges, family and patient history as well as pathognomonic signs. Results Of 473 patients tested, 102 (21.6%) had a causative mutation (LDLR=84%, APOB=9%, PCSK9=5%), three of which were novel. 14 further, previously unreported variants of unknown significance were identified. The detection rate was 64% in patients with clinically definite FH i.e. DLCNS &amp;gt;8 (10.7% of the cohort), 30% in those with a DLCNS between 6 and 8 (20.6%), 16% in those with a DLCNS between 3 and 5 (47.2%) and 4% in DLCNS &amp;lt;3 (21.5%). The detection rate among those with an off-treatment LDL-C ≥190 mg/dL was 30.5%, and 7.5% in those &amp;lt;190 mg/dL. Median DLCNS at testing was 4, in positively tested 6. Mean off-treatment LDL-C levels were significantly higher in positively compared to negatively tested (266±67 mg/dl vs 198±61 mg/dl; p&amp;lt;0.001), and in those with DLCNS ≥6 compared to &amp;lt;6 (284±67 mg/dl vs 190±53 mg/dl p&amp;lt;0.001). The currently established LDL-C cut-off of 190 mg/dL showed a sensitivity of 90.6% [80.1 - 96.1] and a specificity of 35.9% [29.5 - 42.9], while a DLCNS cut-off of ≥6 shows a sensitivity of 60.3% [48.1 – 71.3], a specificity of 76.7% [71.0 – 81.6]. Both performed well in ROC analyses with an AUC of 0.632 for the LDL-C cut-off of 190 mg/dL vs 0.707 for DLCNS≥6, with an insignificant difference in AUC between the two (-0.075; p=0.053). Conclusions Practically, a simple off-treatment LDL-C cut-off of 190 mg/dL, performing comparably to the more time-consuming DLCNS might enhance the identification of suspected cases especially by non-specialists and in primary care, allowing for a much needed surge in referrals to specialist centers for diagnostic workup, thereby possibly improving diagnosis rates in this severely underdiagnosed disease.Mutation detection within DLCNS groupsOff-treatment LDL-C by mutation status

Abstract 15161: Prediction of Decompensated Heart Failure Using an Implanted Cardiac Device Risk Analysis

Introduction: TriageHF is a Heart Failure Risk Status (HFRS) diagnostic tool available on Medtronic implantable cardiac devices which reports dynamic statuses of risk of Heart Failure related Hospitalization (HFH) within the next 30 day, as high, medium or low. We investigated the accuracy of TriageHF in predicting 30-day HFH for patients attending a tertiary heart failure clinic. Methods: We retrospectively recorded HFRS between November 2021 and May 2023, from patients implanted with Medtronic Cardiac Resynchronization Therapy (CRT) or Internal Cardioverter Defibrillator (ICD) devices. We then correlated HFRS with HHF within 30 days of these alerts. Two thresholds were tested: T1 where High &amp; Medium HFRS were considered a positive alert and Low HFRS a negative alert and T2 where High HFRS was considered a positive alert and Medium &amp; Low HFRS a negative alert. The sensitivity and specificity of each threshold in predicting 30-day HFH was tested in a contingency table. Results: Over 18-months, we recorded 135 consecutive alerts from 32 patients. Median age was 72 years, 25% were female and 56% had an ischaemic substrate. 36, 88 and 11 alerts were high, medium, and low risk respectively. 0% of low HFRS and 19% of the high HFRS resulted in a 30-day HHF. 10 high HFRS alerts led to clinical interventions which was associated with a higher rate of HHF, compared to 26 high HFRS alerts where no contact was made (HHF 40% vs 11% p=0.05). The sensitivity and specificity of TriageHF in predicting 30-day HFH was 46.7% and 76.03% respectively for T1 and 100% and 9.1% respectively for T2. Conclusions: This real-world analysis suggests that TriageHF risk prediction using T2 correctly predicted HHF at 30 days with the caveat of a high false positive rate. The potential exists for viable clinical use, however research into the amalgamation of clinical data may improve it and consequently lead to better utilisation of limited clinical resources.

Abstract 12982: Underutilization of Intravenous Iron in a Contemporary Population of Ambulatory Heart Failure Patients in Canada

Background: Intravenous iron has been shown to improve quality of life and exercise capacity in patients with heart failure and reduced ejection fraction (HFrEF) with iron deficiency anemia. We undertook this study to understand the utilization rates of IV iron in a Canadian heart function clinic. Methods: This retrospective analysis was carried out on all heart failure (HF) patients referred to a tertiary care Heart Function Clinic (HFC) who would have been eligible for intravenous iron therapy from January 2020 until December 2022. Our inclusion and exclusion criteria were based on the FAIR HF trial. Inclusion criteria was left ventricular ejection fraction (LVEF) of ≤40% for patients with New York Heart Association (NYHA) class II or ≤45% for NYHA class III, hemoglobin level of 95 to 135 g/L and iron deficiency. The data and decision to recommend IV iron was based on initial HFC consultation and pre-appointment investigations. Results: Out of 1360 charts reviewed, 920 patients had a complete data set in order to determine eligibility. Of those, 127 (13.8%) met IV iron eligibility criteria as per the FAIR HF trial. Of those eligible, 64.6% were male, 98.4% had HFrEF and 1.6% had heart failure with mildly reduced ejection fraction (HFmrEF) (p&lt;0.001). The mean LVEF for those meeting criteria for IV iron was 28.3±7.6% vs 36.1±13.7% for those ineligible (p&lt;0.001). Mean NYHA class for those meeting criteria for IV iron was 2.3±0.5 vs 2.1±0.7 for those ineligible (p&lt;0.001). Only 3 (2.4%) of the eligible patients were recommended or received IV iron, while 2 (1.6%) others had received IV iron prior to HFC visit (Fig). There were no significant differences in the proportion of patients receiving optimal quadruple therapy HF management between both cohorts (p=0.07). Conclusion: Our study demonstrates a significant underutilization of IV iron administration in eligible HFC patients, presenting many missed opportunities to improve patient quality of life.

Abstract 12012: Adverse Social Determinants of Health Are Associated With Increased Risk of Uncontrolled Hypertension Among Cancer Patients in Rural Georgia: A Prospective Cohort Study

Introduction: The role of social determinants of health (SDOH) in the short-term control of hypertension (HTN) in cancer patients is unknown. Understanding the role of SDOH is important for equitable care of cancer patients, especially in the rural US. Hypothesis: High SDOH scores are associated with uncontrolled HTN in hypertensive cancer patients. Methods: We performed a prospective observational study at a tertiary care cancer center cardio-oncology clinic. Patients with cancer and HTN were asked to complete the Protocol for Responding to &amp; Assessing Patients' Assets, Risks &amp; Experiences (PRAPARE) questionnaire on their first visit. Blood pressure (BP) readings were taken at 2 follow-up visits. Uncontrolled HTN was defined as SBP≥130 mmHg and/or DBP≥80 mmHg with corroborated home blood pressure readings. Patients who did not perform home readings but had elevated BP at 2 nd visit were considered uncontrolled. The goals were the same regardless of cancer treatment. The SDOH score was calculated using PRAPARE SDH Risk Tally Score. We performed Cox proportional hazards regression adjusting for age, gender, and metastasis to identify the role of SDOH on short-term HTN control. The adversity cutoff for the SDOH score was informed by spline regressions. Results: In the cohort of 175 patients, median age was 66 (IQR 58-75) years, 55% were females, 42.2% were Non-Hispanic Black patients and 20.5% had breast cancer. Mean SDOH score was 6±3. The median duration of follow-up was 91 days (55-139). Uncontrolled HTN was noted in 59.4% of patients at their 2nd visit. For each 1-point increase in the SDOH score, uncontrolled hypertension increased by 9% (HR=1.09, 95% CI=1.03-1.15, p=0.002). Conclusions: Rural cardio-oncology patients with HTN have a high burden of SDOH. These study findings help identify contributors of SDOH that limit optimal HTN control in this population, allowing for better risk stratification and preventive intervention in clinical practice.

The Causes of Optic Disc Edema in Patients Presenting With Significantly Compromised Vision.

To evaluate the most common causes of optic disc edema (ODE) in patients with significantly compromised vision (initial best-corrected visual acuity [BCVA] of 20/400 or worse) at presentation. Retrospective chart review over a 5-year period of consecutive patients presenting to tertiary neuro-ophthalmology clinics at the University of Toronto. A total of 656 patients with ODE were included, and 49 patients (7.47%) had an initial BCVA of 20/400 or worse. There were 54 eyes included at baseline and 49 eyes at final follow-up. There were 29 female and 20 male patients. The mean age at first visit across patients was 55.9 years. Female patients (n = 29) were significantly older than male patients (n = 20) (P < 0.05). The causes of ODE were optic neuritis (ON) (n = 22; 40.7%), nonarteritic anterior ischemic optic neuropathy (NAION) (n = 22; 40.7%), arteritic anterior ischemic optic neuropathy (AAION) (n = 5; 9.26%), uveitis-related (n = 3; 5.56%), papilledema from idiopathic intracranial hypertension (IIH) (n = 1; 1.85%), and Vogt-Koyanagi-Harada disease (n = 1; 1.85%). Initial BCVA was not significantly different between ON and NAION groups (P = 0.52); however, final BCVA was significantly better in the ON group (P < 0.0001). The mean initial BCVA was worst in the AAION group (2.62 ± 0.54 logarithm of the minimum angle of resolution). The most common cause of ODE in patients <40 years old was ON (83.3%), whereas the 2 most common causes in patients >80 were NAION (60%) and AAION (40%). In patients between the ages of 60-80, NAION (100%) was the only cause. Patients with ODE and poor vision at presentation represent a minority of cases seen in neuro-ophthalmology clinics (<10%). Optic neuritis and NAION are the 2 most common causes of ODE with poor vision at presentation. These findings are limited by a small sample size and potential sampling bias.

Exploring the origins of decreased sound tolerance in tinnitus patients.

This study aimed to confirm the characteristics of auditory function alterations in tinnitus patients with concomitant decreased sound tolerance (ST) and provide insights for developing tailored therapeutic approaches. A retrospective analysis was conducted on patient records from a tertiary university hospital's tinnitus clinic between March 2020 and June 2023. Demographic attributes and audiological profiles were reviewed. Patients were categorized into Group 1 if loudness discomfort level test outcomes were 77 dB or below, measured using an average of frequencies from 250 Hz to 8 kHz. The remaining patients were allocated to Group 2. Among the 434 tinnitus patients, 115 (26.5%) demonstrated decreased ST and were classified as Group 1. This group exhibited higher DPOAE amplitudes (p < 0.001), shortened latency, and decreased threshold of ABR wave V bilaterally (p < 0.05). No significant disparities were observed in gender, age, tinnitus handicap inventory, visual analog scale, and pure-tone audiometry results except subjective hyperacusis. Binary logistic regression analysis utilizing the forward conditional method revealed that the difference between groups was independently linked to DPOAE response at 7,277 Hz on the left side [B = 0.093, p < 0.001, EXP(B) = 1.07, 95% CI = 1.044-1.153]. Increased DPOAE amplitude and shorter and decreased ABR wave V in tinnitus patients with decreased ST might suggest a possible association with lesions in or around the superior olivary complex or higher central auditory pathway, potentially linked to the inhibition of medial olivocochlear efferents.

Dysphonia in Pediatric Professional Voice Users: Is It Just Nodules?

Objectives/HypothesisProfessional voice users of any age are often concerned about nodules, particularly in pediatric singers. However, an accurate diagnosis allows formulation of an optimal management plan and a successful continuation of these young patients’ careers. There is very little literature regarding pediatric professional singers; we aimed to share our experience of over a decade of referrals to our tertiary pediatric voice clinic. Study DesignThis was a retrospective review. MethodsA retrospective review was undertaken of all consecutive patients aged 0–18 years who self-identified as professional voice users and attended our tertiary pediatric voice clinic between December 2010 and December 2021. We analyzed demographics, professional singing status, diagnosis, management, and clinical voice scores. The patients were subdivided into those aged 0–9, 10–16, and 17–18 years. ResultsA total of 113 pediatric professional voice users attended the tertiary voice clinic in the study period. The commonest self-reported voice use was as a singer. Within the 0–9 years age group, there was a strong male predominance (22 males and three females) and mostly organic (52%) causes. For ages 10–16 years, there was a noted female predominance (15 males and 29 females). In the 17–18 years age group, there was a strong female predominance (10 males and 34 females), with predominantly functional diagnoses (48%). Of significance, only five of the 113 patients had nodules (4.4%). ConclusionsWe present a large data set of pediatric professional voice users and demonstrate the numerous underlying diagnoses for their dysphonia, particularly functional disorders. Our experience highlights the need for adequate vocal training for pediatric professional voice users and the need for a multidisciplinary diagnostic and management approach.

Overview of asthma patients followed up in a tertiary clinic.

Background. Asthma is a disease that combines different biological mechanisms, inflammatory pathways, and phenotypic features. Our aim was to investigate the demographic and disease characteristics of patients with asthma and to reveal the distribution with different phenotypes according to endotype groups. Methods. Patients were identified as eosinophilic if the absolute eosinophil count was measured at least once ≥ 300/μL during the oral corticosteroid free period or ≥ 150/μL under oral corticosteroids. Patients sensitive to at least one inhalant allergen with skin prick test and/ or spIgE measurement were defined as allergic. They were categorized into four main endotypes. Results. Data of 405 asthma patients with a median age of 50.9 years were analyzed. The prominent clinical and phenotypic characteristics of the study group were being obese (43.2%) or overweight (32%), severe asthma (49.6%), adult-onset (56.1%) or late-onset asthma (35.3%). The distribution of the four main endotypes according to eosinophilic and/or allergic status, is as follows: 22.7% allergic-eosinophilic (AE), 27.9% nonallergic-eosinophilic (NAE), 22.9% allergic-noneosinophilic (ANE), 26.4% nonallergic-noneosinophilic (NANE). While most severe asthma patients were in the AE and NAE groups, those with early-onset asthma were in AE and ANE, and those with late-onset asthma were in the NAE and NANE groups. The proportion of uncontrolled patients was higher in the NAE group. Among the severe asthma patients, the rate of uncontrolled disease was higher in those with NANE asthma. Conclusions. Different phenotypes were more closely related to some endotypes. This may allow the clinicians to identify patients and predict appropriate treatment modalities and response for individualized care.

Predictors of treatment response in therapy-resistant enuresis

The voiding chart is part of the initial evaluation of enuresis, since the data gathered this way are assumed to carry predictive information. However, there is little evidence that the voiding chart actually does predict therapy response. Lundmark & Nevéus performed a pilot investigation in 2020 and found that anamnestic and voiding chart data did not predict response to second-line therapies. This study aims at evaluating whether these findings could be replicated. This is an evaluation of clinical practice. All patients in a tertiary outpatient clinic with enuresis resistant to first-line therapy (i.e. the enuresis alarm and desmopressin medication) during the evaluation period were included in the study. Baseline anamnestic data focused on bladder and bowel habits, were gathered and the families were instructed to complete a voiding chart including measurements of nocturnal urine production. The children were then treated in accordance with international guidelines, which are anticholinergics and antidepressants as second- and third-line treatment, respectively. Desmopressin was added if needed. In total, 70 patients were included. At the end of the study 37 of these patients were dry, 11 patients were still wetting their beds and 22 patients were lost to follow-up. Of the dry patients 21 became dry on anticholinergics (and/or mirabegron, with or without desmopressin), five on tricyclic antidepressants (with or without desmopressin), seven after a new attempt with the alarm and five became dry spontaneously. The only statistically significant differences between responders and non-responders to the various treatments were that children responsive to anticholinergics had harder and more infrequent stools (p=0.04 and p=0.03, respectively). This study found that anamnestic and voiding chart data do not predict response to treatment in children with therapy-resistant enuresis. Because of this and the fact that we lose some children who need our help by demanding that they complete a voiding chart before initiating treatment, we question the use of this instrument in the evaluation of therapy-resistant enuresis.

A Case Series of 11 Patients With Subacute Serotonin Syndrome

Serotonin syndrome is an acute, life-threatening illness characterized by mental status changes, neuromuscular symptoms, and autonomic instability. Some patients taking serotonergic antidepressants have been noted to have unexplained mental status changes and/or neuromuscular changes without autonomic instability raising the possibility of a more chronic or attenuated form of serotonin syndrome. Assessment of antidepressant blood levels to support the diagnosis of a subacute serotonin syndrome. At a tertiary psychiatric outpatient clinic, patients with unexplained mental status and/or neuromuscular changes without autonomic instability had antidepressant blood levels assessed. Eleven patients were identified with signs and symptoms partially consistent with serotonin syndrome. Nine patients had cognitive changes, while four patients had motor changes, and three patients had psychosis. All patients had elevated blood levels of a single serotonergic antidepressant. Limited follow-up suggests that symptoms improve with reduction of antidepressant medication. These cases suggest that a more chronic, attenuated form of serotonin syndrome exists. Diagnostic criteria are proposed for a distinct clinical entity: subacute serotonin syndrome (SSS). Further research is required to validate these criteria. Clinicians should consider drawing antidepressant levels for patients with symptoms and signs suggestive of SSS-especially those at increased vulnerability for excessive serotonergic agonism. Given the high prevalence of antidepressant medication use, the awareness of SSS could lead to improved patient outcomes and public health.

16 Relative Contributions of Motor and Non-Motor Symptoms to Caregiver Burden in Parkinson’s Disease Patients Being Evaluated for Deep Brain Stimulation

Objective:Parkinson’s disease (PD) is a neurodegenerative disorder affecting over 10 million people worldwide. PD is characterized by both motor (e.g., tremor, rigidity, and bradykinesia) and non-motor (including cognitive impairment and neuropsychiatric symptoms such as apathy, disinhibition, executive dysfunction) symptoms. Caregiver burden is prevalent in those providing care for patients with PD and can result in negative health complications. Past work shows associations between motor symptoms, cognitive impairment, neuropsychiatric symptoms, and caregiver burden in PD. However, their relative contributions are poorly understood. This study examined these relationships, hypothesizing that while motor symptoms, cognitive impairment, and neuropsychiatric symptoms would all affect caregiver burden, neuropsychiatric symptoms would predict burden above and beyond the contribution of the other factorsParticipants and Methods:Participants were 42 people living with PD who were assessed at a hospital-based tertiary movement disorders specialty clinic for deep brain stimulation (DBS) candidacy evaluation with their caregiver. Motor exam was assessed by a PD specialist using the Unified Parkinson’s Disease Rating Scale (UPDRS). The Mini Mental State Examination (MMSE) assessed global cognition. Frontal Systems Behavior Scale (FrSBe) Family Form captured caregiver ratings of neuropsychiatric symptoms under 3 subscales: apathy, disinhibition, and executive dysfunction. The Multidimensional Caregiver Strain Index (MCSI) captured caregiver burden. Linear regression analyses examined relationships between caregiver burden (MCSI) and motor symptoms (UPDRS), cognitive impairment (MMSE), and neuropsychiatric symptoms (FrSBe).Results:Using linear regression analyses, cognitive impairment (R2=0.08, F(1,41)=4.42, p=0.04) and neuropsychiatric symptoms (R2=0.35, F(1, 41)=21.0, p&lt;0.01) predicted caregiver burden but motor symptoms did not (R2=0.03, F(1,41)=1.30, p=0.26). Hierarchical linear regression revealed that neuropsychiatric symptoms predicted caregiver burden above and beyond the contribution of cognitive impairment (AR2=0.28, AF(1)=12.7, p=0.001), accounting for an additional 28% of the variance in caregiver burden. Follow-up linear regression to examine the relationships between caregiver burden and the FrSBe subscales indicated that apathy (p&lt;0.001), versus disinhibition (p=0.16) and dysexecutive behaviors (p=0.80), was the driver of the significant relationship.Conclusions:Consistent with our hypothesis, results revealed that cognitive impairment and neuropsychiatric symptoms (specifically apathy) were independent predictors of caregiver burden, with neuropsychiatric symptoms predicting caregiver burden above and beyond the contribution of cognitive impairment. Somewhat surprisingly, motor symptoms were not a predictor of caregiver burden contrary to some previous research, though findings are mixed. Results highlight the importance of assessing for neuropsychiatric symptoms in PD, which may be overlooked by care providers relative to motor or cognitive symptoms, but which appear stressful to caregivers. Future directions include reexamining results in a larger more heterogenous sample including people living with PD at different disease stages (i.e., everyone in the present sample had severe enough symptoms to be considering DBS). Cognitive measures of executive functioning (which are more specific to PD than measures of global cognition) should also be included in future works. Development of supportive caregiver interventions specifically targeting apathy in PD may be useful. Longitudinal designs would be helpful to reexamine relationships following DBS surgery, as there are some reports of increased neuropsychiatric symptoms following the procedure.

Evaluation of ALBA device for upper extremity motor function in adults with subacute and chronic acquired brain injury: a randomised controlled trial protocol in a tertiary clinic of the metropolitan region of Chile

IntroductionStroke is a significant worldwide cause of death and a prevalent contributor to long-term disability among adults. Survivors commonly encounter a wide array of motor, sensory and cognitive impairments. Rehabilitation...

Dementia, stroke, age, use of medical devices and antipsychotic drugs may increase the risk of nosocomial infections among elderly patients hospitalized at Neurology Clinics

Healthcare-acquired infections (HCAI) represent a major health problem worldwide. Stroke and dementia are considered risk factors for HCAI. Preliminary data suggest that use of antipsychotic drugs also increase the risk for HCAI. Here, we performed a retrospective study aimed at investigating the major risk and protective factors for HCAI in a cohort of elderly subjects hospitalized at an Italian tertiary Neurology Clinics. We included all patients with age ≥ 65 years hospitalized at Neurology Clinics of National Institute on Ageing, Ancona, Italy from 1st January 2018 to 31st December 2021. For each patient, the following data were collected: age, sex, use of medical devices, comorbidities, use of antipsychotic medications, development of HCAI. We included 1543 patients (41.4% males; median age 85 years [80–89]). According to multivariable analysis, age, stroke, duration of urinary catheter placement (for all p < 0.001) and midline placement (p = 0.035) resulted to be risk factors for HCAI, Diabetes resulted to be a protective factor for pneumonia (p = 0.041), while dementia and nasogastric tube were risks factor for this condition (p = 0.022 and p < 0.001, respectively). Urinary catheter was a risk factor for urinary tract infections (p < 0.001). Duration of placement of vascular catheters and use of antipsychotic drugs resulted to significantly increase the risk for bloodstream infections. Stroke, age and use of medical devices were confirmed to be risk factors for HCAI. Antipsychotic drugs resulted to increase risk for bloodstream infections. Further prospective studies will be needed to confirm these findings.

A quality assessment of inflammatory bowel disease nursing care in Finland: a nationwide cross-sectional descriptive study

Objectives of the article Inflammatory bowel disease (IBD) nursing has been identified as a crucial component in the IBD service delivery. This article aims to provide a comprehensive overview of the state of IBD nursing care in Finland, and to identify areas that would benefit from further research. Materials and methods Tertiary IBD outpatient clinics nationwide were invited to participate in a cross-sectional descriptive study conducted using an electronic survey. The quality of IBD nursing services was assessed using the Nursing Care Quality in IBD (NCQ-IBD) evaluation tool. Results Of the 34 identified clinics, 27 participated (79.4%) in the study. The NCQ-IBD tool classifies the clinics in four categories, where A indicates the highest level of quality, and D the lowest. In this study, 26 clinics (96.3%) were classified at level C, and one clinic (3.7%) at level D. Nursing responsibilities in IBD management and informing the patients were at a high level of quality, whereas nursing research in IBD was at a low level. An IBD database (i.e. clinical IBD registry) was in use only in 10 clinics. Although training in the clinical aspects of IBD was readily available, there was a lack of training plans for IBD, and clinics seldom held an annual review of the IBD nursing activities and outcomes. There were very few clinics using structured indices and questionnaires, and only 16 clinics (59.3%) applied a written IBD protocol. Conclusion In the Finnish IBD nursing service, as measured with the NCQ-IBD tool, several areas for future improvement were identified.

The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study.

Although treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy is effective, adherence is often poor. Understanding the patient perspective is needed to inform adherence-promoting interventions. This qualitative study assessed the experiences, preferences, facilitators, and barriers surrounding PAP therapy for the management of OSA in patients from adolescence to older adulthood. Eligible participants ages 19 and older were identified from administrative health care claims; adolescent participants ages 12-18 and their parents/caregivers were identified via electronic health records of a tertiary sleep specialty clinic at a large children's hospital. Forty English-speaking patients and 10 parents of adolescents diagnosed with OSA and prescribed PAP therapy completed semistructured 60-minute telephone interviews conducted by a trained facilitator. Common themes and illustrative quotes were identified. Themes around OSA diagnosis, initiating OSA treatment, learning about OSA/PAP, decision to start PAP, PAP benefits and challenges, and reasons for nonadherence were identified. Participants suggested design and delivery changes to improve PAP devices. Issues unique to adolescents and their parents were discussed. The unique perspectives of patients regarding PAP therapy should be taken into consideration when developing interventions to increase PAP adherence and improve clinical care. Based on identified themes, opportunities for intervention may exist at all stages of care, from diagnosis to treatment initiation. Involving partners, parents, and other caregivers in PAP therapy may be beneficial for optimizing adherence. Simon SL, Stephenson JJ, Haynes K, etal. The lived experience of positive airway pressure therapy in patients with obstructive sleep apnea across the lifespan: a qualitative study. J Clin Sleep Med. 2024;20(3):407-416.

Phenotype and disease course differences in monogenic and sporadic childhood lupus.

To report the differences in phenotypic characteristics, disease course, and outcome in monogenic and sporadic childhood lupus (SC-lupus) from a single tertiary childhood lupus clinic. A descriptive, observational, cross-sectional study was conducted. Data were retrospectively collected at the last follow-up visit on patients with monogenic lupus proven by genetic variants and SC-lupus seen between June 1997 and July 2022. SC-lupus patients were selected by systematic sampling from lupus patients presenting to our lupus clinic; the first patient was chosen randomly, and the subsequent patients were chosen at intervals of three. Data comprised the clinical and laboratory findings, disease activity using the SLEDAI, and damage measured by the pSDI. A total of 54 patients with a median disease duration of 6.8 (IQR 3.5-10.5) years were included. There were 27 patients with monogenic lupus and 27 patients with SC-lupus, with a median age at disease onset of 3.5 (IQR 1.0-6.0), and 9.5 (IQR 7.0-11.8), respectively. (p < 0.05). The rate of consanguinity and family history of lupus were higher in monogenic lupus patients. The two groups were comparable. However, monogenic lupus patients showed more gastrointestinal tract symptoms, and failure to thrive (p < 0.05). They also had more infections. The frequency of the autoantibody profile was higher in monogenic lupus patients. Belimumab was more frequently used in monogenic lupus while rituximab in SC-lupus patients. Monogenic lupus patients had a higher mean SLEDAI, but statistically, it was insignificant. Patients with monogenic lupus had greater disease damage, with a higher mean pSDI and a higher mortality rate (p < 0.05). Patients with monogenic lupus are likely to have an early disease onset and a strong family history of lupus, as well as a guarded prognosis, which is likely due to the disease's severity and frequent infections. These differences may be related to the high consanguinity rate and underlying genetic variants.

Charcot arthropathy outcomes after early referral to a regional tertiary care foot clinic.

Community physicians may not encounter Charcot arthropathy frequently, and its symptoms and signs may be nonspecific. Patients often have a delay of several months before receiving a formal diagnosis and referral for specialty care. However, limited Canadian data are available. We evaluated the clinical history, treatment and outcomes of patients treated for Charcot arthropathy after prompt referral and diagnosis. We performed a retrospective chart review of 76 patients with diabetes (78 feet) who received nonoperative treatment for Charcot arthropathy in a specialty foot clinic between Jan. 20, 2009, and Mar. 26, 2018. Patients were referred to the foot clinic by community physicians for evaluation or were pre-existing patients at the foot clinic with new-onset Charcot arthropathy. Of the 78 feet included in our analyses, 52 feet (67%) were evaluated initially by a community physician and referred to the foot clinic, where they were seen within 3 ± 5 weeks. The remaining 26 feet (33%) were already being treated at the foot clinic. Most feet had swelling, erythema, warmth, a palpable pulse and loss of protective sensation. Ulcers were present initially in 23 feet (29%). Sixty-four feet (82%) with Charcot arthropathy were in Eichenholtz classification stage 1 and most had midfoot involvement. Nonoperative treatment included total contact casting (60 feet, 77%). Mean duration of nonoperative treatment until resolution for 55 feet (71%) was 6 ± 5 months. Surgery was performed on 20 feet (26%) for the treatment of infection and recurrent ulcer associated with deformity, including 6 (8%) lower limb amputations. Charcot arthropathy may resolve in most feet with early referral and nonoperative treatment, but remains a limb-threatening condition.

O054 What Measure of CPAP Treatment is most closely Associated with Reduced Risk of Future Major Cardiovascular Events (MACE)?

Abstract Introduction Obstructive sleep apnoea (OSA) is associated with future Major Adverse Cardiovascular Events (MACE). Continuous positive airway pressure (CPAP) is the standard treatment for OSA, but it is not known which measure of CPAP treatment is most closely associated with reduction in future MACE. We compared associations between a novel and a commonly used measure of CPAP treatment and future MACE. Materials and Methods Participants: 2717 adults with moderate-severe OSA attending a tertiary sleep clinic 2006-2010 completed baseline assessments and followed-up for 7years. CPAP treatment: Month-long CPAP trial and periodic review post-trial. Outcomes Time to cardiac death or non-fatal hospitalisations due to MACE, or end of follow-up, using Cox proportional hazards models. Predictors Average nightly CPAP use and the SARAH index (Sleep-Adjusted Residual AHI), using all available device downloads SARAH index=([AHITreatment×HoursTreatment]+[AHIUntreated×HoursUntreated])/HoursTotalSleepTime Covariates Demographics/comorbidities associated with MACE. Results MACE occurred in 18% participants. Average nightly use: Compared to zero use, each tertile of increasing use predicted reduction in risk of MACE (tertile-0:ref, tertile-I:HR 0.632, 95%CI 0.484-0.824, p&amp;lt;0.001, tertile-II:HR 0.772, 95%CI 0.602-0.990, p=0.042, tertile-III:HR 0.708, 95%CI 0.553-0.905, p=0.006). SARAH A dose-response decreasing risk of MACE with decreasing SARAH index tertiles (tertile-I:ref, tertile-II:HR 0.827, 95%CI 0.658-1.039, p= 0.102, tertile-III:HR 0.772, 95%CI 0.614-0.969, p=0.026). Conclusions Average nightly CPAP use and SARAH index were associated with a decreased risk of future MACE. The SARAH index showed a dose-response relationship with MACE; suggesting that it may be a better estimate of residual OSA-related cardiovascular stress.