Needs of an uninsured equity-deserving minority patient cohort with physical disabilities during the first wave of the COVID-19 pandemic

Background

Patients with disabilities and those from diverse equity-deserving backgrounds have been disproportionately affected by the SARS COV-2 ("COVID-19") pandemic.

Objective

To describe the significant needs and social determinants of health that affected a group of uninsured patients (from equity-deserving groups) with rehabilitation diagnoses during the early months of the COVID-19 pandemic.

Design

Retrospective cohort study utilizing a telephone-based needs assessment from April to October, 2020.

Setting

Free interdisciplinary rehabilitation clinic serving patients with physical disabilities from equity-deserving minority backgrounds.

Participants

51 uninsured, diverse patients with spinal cord injuries, brain injuries, amputations, strokes, and other diagnoses requiring interdisciplinary rehabilitation care.

Methods

Using a non-structured approach, telephone-based needs assessments were collected monthly. Reported needs were summarized into themes and the frequencies of each theme were recorded.

Results

From the total number of concerns, medical issues were reported with the highest frequency (46%), followed by equipment needs (30%) and mental health concerns (30%). Other frequently mentioned needs centered around themes of rent, employment, and supplies. Rent and employment were more frequently cited in earlier months, and equipment problems were more frequently cited in later months. A minority of patients reported they had no needs, some of whom had acquired insurance.

Conclusions

Our objective was to describe the needs of a racially and ethnically diverse set of uninsured individuals with physical disabilities seen at a specialized interdisciplinary rehabilitation pro bono clinic during the early months of COVID-19. Medical issues, equipment needs, and mental health concerns were the top three needs. To optimally serve them, care providers must be aware of current and future needs for their underserved patients, especially if future lockdowns occur.

The German trial on Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE): a multicenter, randomized, double-blind, placebo-controlled trial

Introduction

Comprehensive treatment of Herpes-simplex-virus-encephalitis (HSVE) remains a major clinical challenge. The current therapy gold standard is aciclovir, a drug that inhibits viral replication. Despite antiviral treatment, mortality remains around 20% and a majority of survivors suffer from severe disability. Experimental research and recent retrospective clinical observations suggest a favourable therapy response to adjuvant dexamethasone. Currently there is no randomized clinical trial evidence, however, to support the routine use of adjuvant corticosteroid treatment in HSVE.

Methods

The German trial of Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE) studied the effect of adjuvant dexamethasone versus placebo on top of standard aciclovir treatment in adult patients aged 18 up to 85 years with proven HSVE in German academic centers of Neurology in a randomized and double blind fashion. The trial was open from November 2007 to December 2012. The initially planned sample size was 372 patients with the option to increase to up to 450 patients after the second interim analysis. The primary endpoint was a binary functional outcome after 6 months assessed using the modified Rankin scale (mRS 0-2 vs. 3-6). Secondary endpoints included mortality after 6 and 12 months, functional outcome after 6 months measured with the Glasgow outcome scale (GOS), functional outcome after 12 months measured with mRS and GOS, quality of life as measured with the EuroQol 5D instrument after 6 and 12 months, neuropsychological testing after 6 months, cranial magnetic resonance imaging findings after 6 months, seizures up to day of discharge or at the latest at day 30, and after 6 and 12 months.

Results

The trial was stopped prematurely for slow recruitment after 41 patients had been randomized, 21 of them treated with dexamethasone and 20 with placebo. No difference was observed in the primary endpoint. In the full analysis set (n = 19 in each group), 12 patients in each treatment arm achieved a mRS of 0-2. Similarly, we did not observe significant differences in the secondary endpoints (GOS, mRS, quality of life, neuropsychological testing).

Conclusion

GACHE being prematurely terminated demonstrated challenges encountered performing randomized, placebo-controlled trials in rare life threatening neurological diseases. Based upon our trial results the use of adjuvant steroids in addition to antiviral treatment remains experimental and is at the decision of the individual treating physician. Unfortunately, the small number of study participants does not allow firm conclusions.

Trial registration

EudraCT-Nr. 2005-003201-81.

Muskeldehnungsreflexe

Es gibt nur wenige klassische Geräte, mit denen Ärzte charakterisiert und karikiert werden, das hölzerne Stethoskop, der Augenspiegel und der Reflexhammer. Jeder Neurologe hat schon einmal die Erfahrung gemacht, dass Patienten aber auch ärztliche Kollegen der Untersuchung von Muskeldehnungsreflexen verwundert zusehen und staunen, wie aus dieser Prozedur etwas diagnostisch Wichtiges abgeleitet werden kann. Diese Reflexe waren lange ein Gegenstand der neurowissenschaftlichen Forschung, und sie sind tatsächlich auch heute noch diagnostisch in vielen Situationen von entscheidender Bedeutung.

Accuracy enhanced and synthetic wavelength adjustable optical metrology via spectrally resolved digital holography

This paper demonstrates the usefulness of spectrally resolved digital holography for dual-wavelength optical metrology. Based on the large degree of phase information available, multiple de-correlated dual-wavelength phase maps can be generated, which, when averaged, result in a signal-to-noise-ratio improvement. Compared with single-wavelength averaging, no further post-processing of the reconstructed dual-wavelength phase map is required. Moreover, the constraint imposed on the wavelength stability, as experienced in the conventional dual-wavelength method, can be relaxed, and the corresponding synthetic wavelength is adapted to the object under investigation. In addition, the possibility of optical sectioning based on the narrow-width coherence envelope is also demonstrated in transmission mode.

Surface relief and refractive index gratings patterned in chalcogenide glasses and studied by off-axis digital holography

Surface relief gratings and refractive index gratings are formed by direct holographic recording in amorphous chalcogenide nanomultilayer structures As₂S₃-Se and thin films As₂S₃. The evolution of the grating parameters, such as the modulation of refractive index and relief depth in dependence of the holographic exposure, is investigated. Off-axis digital holographic microscopy is applied for the measurement of the photoinduced phase gratings. For the high-accuracy reconstruction of the wavefront (amplitude and phase) transmitted by the fabricated gratings, we used a computational technique based on the sparse modeling of phase and amplitude. Both topography and refractive index maps of recorded gratings are revealed. Their separated contribution in diffraction efficiency is estimated.

[Neurological and psychiatric journals during the Third Reich : National socialistic and racist contents]

The aim of this study was to investigate scientific articles in three German journals for national socialist and racist contents. The three journals evaluated for the period of the Third Reich were the Der Nervenarzt, Deutsche Zeitschrift für Nervenheilkunde and the Archiv für Psychiatrie und Nervenkrankheiten. The specialist disciplines of neurology and psychiatry were united in the year 1935 and Ernst Rüdin, a neurological geneticist, was appointed as president (Reichsleiter) of the society. The universal idea of a degenerative development, which was believed to exert a negative influence on public health, was widely accepted in this time period; therefore, in some articles measures were called for, such as termination of pregnancy, sterilization and castration of diseased people and also of criminals. National socialist ideals became part of articles on nervous diseases, works of art of the mentally ill and suicidal tendencies. The recruitment of volunteers and informed consent for participation in human experiments were not described in scientific publications.

[Neuromuscular diseases were always difficult to diagnose]

The Deutsche Zeitschrift fuer Nervenheilkunde (German Journal for Neurology) was founded as a specifically neurological journal at the end of the nineteenth century and soon became a European platform for scientific discussion of neurological topics. Papers also came from the USA, Scandinavia and Russia. The difficulties of the diagnosis and definition of clinical entities are illustrated in cases of botulism, myotonic dystrophy and myasthenia gravis.

Validation of an educational booklet targeted to patients candidate for total knee arthroplasty

BACKGROUND

Knee osteoarthritis is a highly prevalent condition and the leading reason for total knee arthroplasty (TKA). No consensus exists about the optimal content of preoperative patient information and, to the best of our knowledge, no validated information document is available. Our objective here was to obtain validation by healthcare professionals and patients of an educational booklet for patients awaiting TKA.

MATERIALS AND METHODS

The booklet was developed and validated in six phases: systematic literature review, drafting of the first version, critical revision by a panel of experts, modification of the booklet, validation by a multidisciplinary panel of experts, and validation by two groups of patients, one composed of patients awaiting TKA and the other of patients in the immediate post-TKA period. We assessed the impact of the booklet based on knowledge and belief scores before and 2 days after receiving the booklet.

RESULTS

Critical revision of the first draft led to changes to meet the concerns voiced by the experts. Knowledge improved only in the patient group given the booklet preoperatively (from 6/10 to 9/10, P=0.005). The booklet did not modify beliefs in either patient group.

DISCUSSION

We used a rigorous methodology to develop and validate the contents of an educational booklet. Receiving this document before TKA resulted in improved patient knowledge but had no impact on beliefs.

LEVEL OF EVIDENCE

Level IV.

Sporosarcina halophila sp. nov., an Obligate, Slightly Halophilic Bacterium from Salt Marsh Soils

Twenty-two strains of endospore-forming sarcinae have been isolated from salt marsh soils. The isolates differ phenotypically from Sporosarcina ureae, the only species of the genus Sporosarcina which has been validly described, and are distinct from S. ureae in the composition of the cell walls of their vegetative cells. Lysine, found in the tetrapeptide of the murein of S. ureae, is replaced by ornithine in the new isolates. The interpeptide bridge consists of an aspartic acid residue instead of D-glutamylglycine as is found in S. ureae. The mol% G + C of the DNA of the new isolates is in the range of 40.1-40.9 (S. ureae 40.0-41.5). DNA hybridization studies revealed a high DNA-DNA homology within the new isolates but only a low relationship to S. ureae. The main menaquinone is of the MK-7 type as in S. ureae and other aerobic sporeformers. The spores of the new isolates are very similar to spores of S. ureae and Bacillus species in respect of their heat resistance, composition and ultrastructure. None of the new isolates grows on complex media unless supplemented with sodium, magnesium and chloride ions. Strains are slight halophiles as they grow best in the presence of 30 to 50 g NaCl/1 and 5 g MgCl(2)/l. The new isolates thus belong to a new species, for which the name Sporosarcina halophila is proposed. Strain DSM 2266 (= strain 3) is the type strain.

Decreased heart rate variability parameters in amitriptyline treated depressed patients: biological and clinical significance

One hundred-four depressed patients treated with amitriptyline (mean dosage: 163 mg/d; mean plasma level: 239 ng/ml) and 52 normal control subjects matched for age and sex underwent a standardized cardiovascular test battery (various autonomic cardiac parameters, which are largely independent from heart rate, namely the coefficients of variation (CV) while resting and during deep respiration, a spectral analysis of heart rate, the Valsalva ratio, and a posture index were determined). The tests included the determination of time and frequency-derived measurements of heart rate variability (HRV), which is rather independent from heart rate. As compared to the controls the patients showed a significant plasma concentration-dependent decrease of R-R variation in the electrocardiogram (p < 0.0001), while their heart rate was significantly elevated (p < 0.0001). The markedly reduced parameters of sinus arrhythmia in amitriptyline treated patients are suggested to be mainly due to the anticholinergic effect of this drug, although it can not be excluded that the affective disorder itself might be associated with low heart rate variability. The results indicate that autonomic heart rate parameters are a valuable tool for the detection of tricyclic antidepressant (TCA) intake in unconscious patients, especially in intensive care and emergency wards.

Cutaneous norepinephrine application in complex regional pain syndrome

Patients with complex regional pain syndrome (CRPS) (n=20) were examined in order to evaluate cutaneous reactions to norepinephrine (NE) on both the affected and the unaffected limb in comparison to healthy controls. Sixteen female and four male patients suffering from very acute and therefore untreated CRPS with a mean duration of 5.5 weeks were included in this study. Two groups of healthy volunteers served as control groups: the first group (n=18) according to the same study protocol as CRPS patients, and the second group (n=10) after warming up one limb. Norepinephrine was iontophoresized (0.2 mA, 120 s) and vasoconstriction was recorded by laser-doppler flowmetry. Pain sensations were simultaneously rated on a visual analogue scale (VAS). Five patients underwent a second trial with higher intracutaneous NE concentrations in order to study possible dose-dependent effects of NE on pain sensation. After acclimatization, skin temperature was recorded by infra-red thermography. The NE-induced reduction of skin blood flow was significantly higher in the affected limb in the patient group (33.0 vs 11.2%, p<0.005). None of the patients reported pain or hyperalgesia. The skin temperature of CRPS patients was significantly higher in the affected limb (34.7 vs 32.5 degrees C, p<0.001). The first control group did not show any difference between left and right sides concerning NE-induced vasoconstriction or skin temperature. The second control group had an increased unilateral skin temperature after warming up (35.0 vs 34.3 degrees C, p<0.006) and demonstrated a significantly increased vasoconstriction on the warmer side (52.0 vs 20.2%, p<0.03) corresponding to findings in patients with acute CRPS. The present study proves that there are signs of decreased sympathetic activity in the affected limb in very acute CRPS. However, no indication was found for increased sensitivity of vascular alpha-receptors in the very acute stages of CRPS, and there was also no indication for a significant direct contribution of the sympathetic nervous system to pain in very acute CRPS.

Proximal row carpectomy: Is early postoperative mobilisation the right rehabilitation protocol?

PURPOSE OF THE STUDY

To determine the feasibility and interest of an early rehabilitation protocol with no initial immobilisation after proximal row carpectomy.

MATERIAL AND METHODS

Thirteen patients were included in this retrospective study. Range of motion (ROM) and wrist strength (grip strength and grasp strength) were evaluated 3 and 6 weeks after surgery on the both wrists (operated and non-operated). Postoperatively, patients had no immobilisation of the wrist, and began a rehabilitation program immediately after surgery in the department of Physical Therapy and Rehabilitation under multidisciplinary team supervision. The same surgical technique was used for all patients by the same surgeon.

RESULTS

Six weeks after PRC, there was a 25-51% deficit in passive ROM and 54-64% deficit in active ROM compared to the corresponding non-operated wrist. Six weeks after PRC, mean overall grip strength was nearly 55% and Jamar dynamometer grip strength was 51% of the contralateral side.

DISCUSSION

This study shows that immediate immobilisation following PRC is unnecessary, and that early rehabilitation is of the essence. Early rehabilitation could reduce the delay necessary to recover range of motion and strength, and probably the time to return to work.

LEVEL OF EVIDENCE

Level 4, prospective cohort study.

[Billing based on a case-based lump sum for stroke. Did this lead to discharge of patients in a worse clinical condition?]

BACKGROUND

It has been supposed that the introduction of a new inpatient reimbursement system starting in 2004 in Germany using the German diagnosis-related groups (G-DRG) may lead to false incentives with encouragement of premature hospital discharge of patients. Exploring a large database on stroke patients, we addressed the question whether length of stay (LOS) and discharge in more severe condition were associated with the introduction of the G-DRG. We further examined other factors with probable effect on LOS such as variations of patient characteristics and treatment during the observation period.

PATIENTS AND METHODS

All stroke patients treated in 2003-2006 in the German state of Hesse (6,100,000 inhabitants) were assessed with respect to stroke severity, symptoms on admission and discharge, LOS and stroke-related deficits on discharge. We compared LOS and outcome in 2003 (before introduction of the G-DRG) with 2004 when the G-DRG had recently been introduced and with 2006 when the G-DRG was already well established in the clinical routine. The effects of LOS and treatment year on outcome were assessed using a logistic regression model.

RESULTS

During the observation period, we evaluated 37,396 stroke patients. The length of stay was reduced significantly from 12.2 to 10.4 days (p<0.001). Both severity of stroke on admission and outcome on discharge decreased during the observation period. A multivariate analysis revealed a minor but significant association [odds ratio (OR): 1.020 per day of hospital treatment; 95% confidence interval (CI): 1.016-1.024] of LOS on outcome. Treatment in 2006 compared to 2003 led to good outcome with an OR of 1.378 (95% CI: 1.279-1.485). Subgroup analysis limited to patients with severe stroke revealed that LOS was significantly lower in 2006 compared to 2003 also in this patient subgroup; moreover, the proportion of patients discharged with severe outcome was lower in 2006 compared to 2003.

CONCLUSIONS

This study reveals a significant reduction of LOS during the years after introduction of the G-DRG. However, reduction of LOS was not associated with more severe outcome on discharge, possibly due to changes in stroke treatment implemented during the observational period. Our results do not support the conjecture that changes in the reimbursement system were associated with compromised patient care.

Paraneoplastic neurological syndromes in patients with carcinoid

BACKGROUND

Paraneoplastic neurological syndromes (PNS) are mainly associated with small-cell lung cancer, gynaecological tumours and lymphomas. Few studies report the association of neurological syndromes with a carcinoid, the majority being a serotonin-related myopathy. We report four patients with a PNS associated with carcinoid.

PATIENTS AND RESULTS

The clinical syndromes were sensory neuropathy, limbic encephalitis, myelopathy and brain stem encephalitis. Two patients had antineuronal autoantibodies (one anti-Hu, one anti-Yo), one patient had antinuclear antibodies, and one patient had no autoantibodies. For two of the carcinoids, expression of HuD in the tumour could be demonstrated.

CONCLUSION

This study demonstrates that carcinoids can also be associated with classical antineuronal antibody-associated PNS.

Evaluation of the autonomic nervous system using the FAN device -- range of normal and examples of abnormal

Different components of the autonomic nervous system may be affected by different disorders to varying degrees. The aim of this study is to report first experiences with a new device (FAN®, Schwarzer, Germany) which measures heart rate variability (HRV), sympathetic skin responses (SSR) and the pulse wave transit time (PTT). We examined 190 healthy volunteers (102 men, 88 women) and in 89 subjects (46 men, 43 women) PTT during VM was investigated. In a subset of 24 subjects PTT was compared to conventional blood pressure recording. Thereafter, normal data were compared to patients with polyneuropathy (PNP) and Parkinson syndromes. All parameters of HRV decreased with age. 6 parameters for HRV at rest, during deep respiration and the valsalva ratio were reclassified into three age categories: under 40 (n=96), 40 – 60 (n=71) and 60 or older (n=23). Applying the lower limits of normal (5%-tile) subjects did not have more than 2 of these 6 parameters in the pathological range PTT reduction during phase IV of the valsalva manoeuvre was greater than 7.7 ms (5%-tile) but not age dependent. Patients with PNP had reduced HRV and SSR, Parkinson patients had more frequently impaired blood pressure regulation according to PTT assessment. Our investigation shows that the FAN® might be useful for clinicians to detect autonomic disorders.

Stages of sleep pathology in spinocerebellar ataxia type 2 (SCA2)

BACKGROUND

Autosomal dominant spinocerebellar ataxia type 2 (SCA2) bears clinical and neuropathologic similarities to sporadic multisystem atrophy (MSA) or Parkinson disease, in which sleep pathology is well documented. However, those clinical entities have a marked variability of the reported sleep disturbances, and their etiology is heterogeneous. In contrast, the study of SCA2 provides an opportunity to examine a molecularly homogeneous patient group, in which disease stages can be defined not only based on disease duration and ataxia scores, but also with regard to modulatory effects of mutation size.

OBJECTIVE

To examine the presence and progression of sleep pathology in SCA2.

METHODS

We analyzed eight patients with disease durations of 3 to 31 years, all with medium size SCA2 expansions (CAG 38 to 49), using clinical scores, sleep interviews, and video-polysomnography (VPSG) recordings.

RESULTS

Almost all patients reported good subjective sleep quality and negated incidents of REM behavior disorder (RBD). At early disease stages, however, REM without atonia in four patients' VPSG suggested subclinical RBD. This was accompanied by a consistent reduction of REM density. In three patients at later SCA2 stages, REM sleep was undetectable, whereas slow wave sleep (SWS) was markedly increased at the cost of light sleep. Periodic leg movements, apnea, or hypopnea were not prominent.

CONCLUSIONS

Progressive loss of dream recall in spinocerebellar ataxia type 2 was found and correlated with stages of REM more than non-REM pathology in video-polysomnography. These stages correspond to the progressive atrophy from the pons, nigrostriatal projection, and locus ceruleus to the thalamus.