Background: The timed 25-foot walk (T25FW) is a key clinical outcome measure in multiple sclerosis patient management and clinical research. Objectives: To evaluate T25FW performance and factors associated with its change in the Multiple Sclerosis Outcome Assessments Consortium (MSOAC) Placebo Database ( n = 2465). Methods: We created confirmed disability progression (CDP) variables for T25FW and Expanded Disability Status Scale (EDSS) outcomes. We used intraclass correlation coefficients (ICCs) and Bland Altman plots to evaluate reliability. We evaluated T25FW changes and predictive validity using a mixed-effects model, survival analysis, and nested case–control analysis. Results: The mean baseline score for the T25FW in this study population was 9.2 seconds, median = 6.1 (standard deviation = 11.0, interquartile range (IQR) = 4.8, 9.0). The T25FW measure demonstrated excellent test–retest reliability (ICC = 0.98). Walk times increased with age, disability, disease type, and disease duration; relapses were not associated with an increase. Patients with T25FW progression had a faster time to EDSS-CDP compared to those without (hazards ratio (HR): 2.6; confidence interval (CI): 2.2, 3.1). Changes in the T25FW were more likely to precede changes in EDSS. Conclusion: This research confirms the association of the T25FW with disability and provides some evidence of predictive validity. Our findings support the continued use of the T25FW in clinical practice and clinical trials.
Background As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease. Methods and findings We conducted a retrospective cohort study of individuals with MS ages 18–64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36–55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025–1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010–1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005–1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live—and therefore the extent of their exposure to anomalously warm weather—as well as their propensity to seek treatment for neurologic symptoms. Conclusions Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.
ObjectiveTo describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.MethodsWe designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.ResultsPrecurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9–3.1), proposing system changes (3.1, 2.3–3.9), writing a problem statement (9.9, 6.2–13.5), studying a process (3.1, 2.3–3.8), identifying resources (3.1, 2.3–3.8), identifying appropriate measures (2.5, 1.9–3.0), collaborating with other providers to make improvements (4.9, 3.5–6.4), and making changes in a system (3.1, 2.3–3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.ConclusionsOur multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.
CE INFORMATION ACTIVITY AVAILABLE ONLINE: To access the article and evaluation online, go to https://www.highmarksce.com/mscare. TARGET AUDIENCE: The target audience for this activity is physicians, advanced practice clinicians, nursing professionals, mental health professionals, rehabilitation professionals, and other health care providers involved in the management of patients with multiple sclerosis (MS). LEARNING OBJECTIVES: After completing this activity, the learner should be able to describe the attributes associated with engagement in physical activity in persons with MS across multiple definitions of physical activity. ACCREDITATION: In support of improving patient care, this activity has been planned and implemented by the Consortium of Multiple Sclerosis Centers (CMSC) and Intellisphere, LLC. The CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. This activity was planned by and for the healthcare team, and learners will receive 0.75 Interprofessional Continuing Education (IPCE) credit for learning and change. PHYSICIANS: The CMSC designates this journal-based activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NURSES: The CMSC designates this enduring material for 0.75 contact hour of nursing continuing professional development (NCPD) (none in the area of pharmacology). PSYCHOLOGISTS: This activity is awarded 0.75 CE credits. SOCIAL WORKERS: As a Jointly Accredited Organization, the CMSC is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 0.75 continuing education general credits. DISCLOSURES: It is the policy of the Consortium of Multiple Sclerosis Centers to mitigate all relevant financial disclosures from planners, faculty, and other persons that can affect the content of this CE activity. For this activity, all relevant disclosures have been mitigated. Francois Bethoux, MD, editor in chief of the International Journal of MS Care (IJMSC), has served as physician planner for this activity. He has disclosed no relevant financial relationships. Alissa Mary Willis, MD, associate editor of IJMSC, has disclosed no relevant financial relationships. Authors Nina Bozinov, MD MS, Farren B. S. Briggs, PhD, ScM, and Emily E. Tyszka, MPH, have disclosed no relevant financial relationships. The staff at IJMSC, CMSC, and Intellisphere, LLC who are in a position to influence content have disclosed no relevant financial relationships. Laurie Scudder, DNP, NP, continuing education director CMSC, has served as a planner and reviewer for this activity. She has disclosed no relevant financial relationships. METHOD OF PARTICIPATION: Release Date: September 1, 2022; Valid for Credit through: September 1, 2023 In order to receive CE credit, participants must: 1) Review the continuing education information, including learning objectives and author disclosures.2) Study the educational content.3) Complete the evaluation, which is available at https://www.highmarksce.com/mscare. Statements of Credit are awarded upon successful completion of the evaluation. There is no fee to participate in this activity. DISCLOSURE OF UNLABELED USE: This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. The CMSC and Intellisphere, LLC do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the CMSC or Intellisphere, LLC. DISCLAIMER: Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health care professionals without first evaluating their patients’ conditions, considering possible contraindications or risks, reviewing any applicable manufacturer’s product information, and comparing any therapeutic approach with the recommendations of other authorities.
Kleine-Levin syndrome (KLS) is a rare disorder characterized by recurrent episodic hypersomnia, cognitive changes, and neuropsychiatric symptoms between months of interictal normality (table). Triggers include infection, sleep deprivation, or alcohol intake, and diagnosis requires exclusion of other medical etiologies. 1 Urea cycle disorders are most commonly diagnosed via newborn screening or during workup of early, life-threatening hyperammonemia. We describe a young man with a late-onset urea cycle disorder who initially presented with phenomenology akin to KLS. Case reportA 24-year-old man presented with his second discrete episode of hypersomnolence, executive dysfunction, and irritability. Both episodes, separated by one year, occurred while visiting family for holiday break and was preceded by increased protein and alcohol consumption.After drinking 5-6 beers, the patient awoke in the middle of the night with vomiting. This resolved, but the next day his family noticed slumped posture and slowed speech. He began sleeping 12-16 hours per day, becoming agitated when awoken. The family noted that when awake, he was talking about the opposite sex. He required assistance with walking and dressing. Four days after symptom onset, he presented to our emergency department for evaluation.On examination, the patient was disoriented and had impairments in short-term memory, language comprehension, and visual-spatial tasks. He also exhibited mild ideomotor apraxia, psychomotor retardation, and la belle indifférence. Cranial nerve examination revealed sharp optic discs, miosis, saccadic pursuits, hypometric saccades, gaze-evoked nystagmus, and mildly dysarthric speech. Reflexes were brisk. Cerebellar findings included square wave jerks with central gaze, overshoot on finger chase, terminal dysmetria, dysdiadochokinesia, and a widebased, ataxic gait with decreased arm swing. MRI brain demonstrated small subcortical white matter lesions, frontal more than parietal, and decreased blood flow on arterial spin labeling sequence in the posterior brain and cerebellum. Continuous EEG was negative for seizure and demonstrated a well-defined posterior rhythm in the awake state with nonspecific slowing. SPECT revealed delayed perfusion in bilateral thalami and right occipital temporal regions (figure).CSF showed elevated citrulline (557 nmol/mL; ref 0-2 nmol/mL) and glutamine (1,203 nmol/mL; ref 376-652 nmol/mL), with low ornithine (0 nmol/mL). Serum studies showed high serum methionine (57 nmol/mL) and α-Aminobutyric acid (45 nmol/mL). Otherwise, CSF was negative/normal for profile, flow cytometry, oligoclonal bands, paraneoplastic antibodies, viral panel, and Aβ/tau ratio. Serum studies were negative/normal for HIV, rapid
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