Exploratory analysis of the relationship between pain and mood disturbances in Parkinson\u27s disease

Pain and mood disturbances are distressing non-motor symptoms (NMS) in Parkinson\u27s disease (PD). There is inconsistent data about the correlation between pain, depression, and anxiety in PD, and little information about the relationship between apathy and pain in PD. This study aims to investigate the relationship between pain and mood disturbances in PD, in the hopes that characterizing these may be helpful in providing holistic treatment options for patients. This is a cross-sectional, observational study of consecutive patients with idiopathic PD, ages 18-85, evaluated at two academic centers. Subjects were assessed with the UPDRS III, King\u27s PD Pain Scale (KPPS), Non-Motor Symptoms Scale (NMSS) and Beck Depression Inventory (BDI). Exclusion criteria included atypical Parkinsonism, cognitive impairment (MMSE \u3c 24/30), severe disability (H&Y stage \u3e4), or other diseases causing acute or chronic pain. Spearman\u27s rank correlation coefficient, ρ, was used for data analysis. 167 patients were enrolled and 88% (n=148) experienced pain (defined as KPPS total \u3e 0). Pain correlated significantly with mood/cognition disturbances on NMSS-3 (ρ=0.29, P\u3c0.001) and depression on BDI (ρ=0.37, P\u3c0.001). Pain subtypes of musculoskeletal (ρ=0.21, P=0.009) and chronic pain (ρ=0.18, P=0.032) had a significant correlation with mood disturbances (NMSS-3). Selective serotonin reuptake inhibitor (SSRI) use by 46 patients did not lower KPPS, BDI, or NMSS-3 scores. NMSS-3 questions were classified as representing depression, apathy, or anxiety based on DSM V criteria and peer-reviewed definitions. Of the mood disturbances, apathy had the strongest correlation with pain. The presence of pain in PD is associated with various mood disturbances, including depression, anxiety and apathy. Our data shows that apathy may contribute significantly to this relationship, which was not previously recognized. Future studies using tools specifically assessing apathy might further elucidate this relationship between apathy and pain in PD

Understanding Nurse, Family, & Interpreter Involvement in Family-Centered Rounds at Children’s National Medical Center

Family-Centered Rounds (FCR) is a model that emphasizes bedside rounding with intentional inclusion of the patient and family in partnership with physicians, nurses, and staff. Challenges to conducting successful FCR include language barriers and a lack of a reliable notification system for all parties. These barriers can be overcome through the development of a FCR mobile application to improve communication and coordination between the stakeholders involved in a child’s care. This study analyzed data on nurse, interpreter, and family inclusion in FCR. Objective observations of daily FCR - measures of medical team communication with nurses, stakeholder presence, and licensed interpreter use for limited-English proficiency (LEP) families - were recorded using REDCap. REDCap was also used to survey physicians and nurses for a subjective measure of team communication and nurse presence at FCR. Physicians self-reported contacting nurses 80% of the time for FCR. However, objective measures showed that they contacted nurses only 59% of the time. When contacted before rounds started, more nurses were present for the entire duration of FCR. Additionally, their presence any time during FCR increased by 31% compared to nurses who were contacted at/after the start of rounds. This indicates the importance of early notification, a task which can be better facilitated by a mobile app. The most common barrier reported by physicians is nurses not answering their phones. The leading reason nurses self-report for missing FCR is patient care duties, which could explain their inability to answer their phones at all times. The mobile app will resolve this dilemma by providing a text notification option, a method which more than 55% of nurses and doctors are willing to use. Language is another barrier to conducting successful FCR. Although LEP families were present more often than English proficient (EP) families, they were offered FCR less frequently. Also, a licensed interpreter was only offered 58% of the time. This study demonstrates a need to better facilitate FCR among doctors, nurses, families and interpreters at Children’s National. The data shows low nurse attendance, disparities in FCR being offered to LEP vs EP families, and a lack of licensed interpreter use. We propose that technology such as a mobile app notification system can facilitate better communication and coordination between all parties, ultimately improving patient care

Opportunistic infections and AIDS malignancies early after initiating combination antiretroviral therapy in high-income countries

Background: There is little information on the incidence of AIDS-defining events which have been reported in the literature to be associated with immune reconstitution inflammatory syndrome (IRIS) after combined antiretroviral therapy (cART) initiation. These events include tuberculosis, mycobacterium avium complex (MAC), cytomegalovirus (CMV) retinitis, progressive multifocal leukoencephalopathy (PML), herpes simplex virus (HSV), Kaposi sarcoma, non-Hodgkin lymphoma (NHL), cryptococcosis and candidiasis. Methods: We identified individuals in the HIV-CAUSAL Collaboration, which includes data from six European countries and the US, who were HIV-positive between 1996 and 2013, antiretroviral therapy naive, aged at least 18 years, hadCD4+ cell count and HIV-RNA measurements and had been AIDS-free for at least 1 month between those measurements and the start of follow-up. For each AIDS-defining event, we estimated the hazard ratio for no cART versus less than 3 and at least 3 months since cART initiation, adjusting for time-varying CD4+ cell count and HIV-RNA via inverse probability weighting. Results: Out of 96 562 eligible individuals (78% men) with median (interquantile range) follow-up of 31 [13,65] months, 55 144 initiated cART. The number of cases varied between 898 for tuberculosis and 113 for PML. Compared with non-cART initiation, the hazard ratio (95% confidence intervals) up to 3 months after cART initiation were 1.21 (0.90-1.63) for tuberculosis, 2.61 (1.05-6.49) for MAC, 1.17 (0.34-4.08) for CMV retinitis, 1.18 (0.62-2.26) for PML, 1.21 (0.83-1.75) for HSV, 1.18 (0.87-1.58) for Kaposi sarcoma, 1.56 (0.82-2.95) for NHL, 1.11 (0.56-2.18) for cryptococcosis and 0.77 (0.40-1.49) for candidiasis. Conclusion: With the potential exception of mycobacterial infections, unmasking IRIS does not appear to be a common complication of cART initiation in high-income countries

Cardiovascular Efficacy and Safety of Bococizumab in High-Risk Patients

Bococizumab is a humanized monoclonal antibody that inhibits proprotein convertase subtilisin- kexin type 9 (PCSK9) and reduces levels of low-density lipoprotein (LDL) cholesterol. We sought to evaluate the efficacy of bococizumab in patients at high cardiovascular risk. METHODS In two parallel, multinational trials with different entry criteria for LDL cholesterol levels, we randomly assigned the 27,438 patients in the combined trials to receive bococizumab (at a dose of 150 mg) subcutaneously every 2 weeks or placebo. The primary end point was nonfatal myocardial infarction, nonfatal stroke, hospitalization for unstable angina requiring urgent revascularization, or cardiovascular death; 93% of the patients were receiving statin therapy at baseline. The trials were stopped early after the sponsor elected to discontinue the development of bococizumab owing in part to the development of high rates of antidrug antibodies, as seen in data from other studies in the program. The median follow-up was 10 months. RESULTS At 14 weeks, patients in the combined trials had a mean change from baseline in LDL cholesterol levels of -56.0% in the bococizumab group and +2.9% in the placebo group, for a between-group difference of -59.0 percentage points (P<0.001) and a median reduction from baseline of 64.2% (P<0.001). In the lower-risk, shorter-duration trial (in which the patients had a baseline LDL cholesterol level of ≥70 mg per deciliter [1.8 mmol per liter] and the median follow-up was 7 months), major cardiovascular events occurred in 173 patients each in the bococizumab group and the placebo group (hazard ratio, 0.99; 95% confidence interval [CI], 0.80 to 1.22; P = 0.94). In the higher-risk, longer-duration trial (in which the patients had a baseline LDL cholesterol level of ≥100 mg per deciliter [2.6 mmol per liter] and the median follow-up was 12 months), major cardiovascular events occurred in 179 and 224 patients, respectively (hazard ratio, 0.79; 95% CI, 0.65 to 0.97; P = 0.02). The hazard ratio for the primary end point in the combined trials was 0.88 (95% CI, 0.76 to 1.02; P = 0.08). Injection-site reactions were more common in the bococizumab group than in the placebo group (10.4% vs. 1.3%, P<0.001). CONCLUSIONS In two randomized trials comparing the PCSK9 inhibitor bococizumab with placebo, bococizumab had no benefit with respect to major adverse cardiovascular events in the trial involving lower-risk patients but did have a significant benefit in the trial involving higher-risk patients

Cardiovascular Efficacy and Safety of Bococizumab in High-Risk Patients

BACKGROUN

Stress neuropeptide levels in adults with chest pain due to coronary artery disease: potential implications for clinical assessment

: Substance P (SP) and neuropeptide Y (NPY) are neuropeptides involved in nociception. The study of biochemical markers of pain in communicating critically ill coronary patients may provide insight for pain assessment and management in critical care. Purpose of the study was to to explore potential associations between plasma neuropeptide levels and reported pain intensity in coronary critical care adults, in order to test the reliability of SP measurements for objective pain assessment in critical care

Rivaroxaban with or without aspirin in stable cardiovascular disease

BACKGROUND: We evaluated whether rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary cardiovascular prevention. METHODS: In this double-blind trial, we randomly assigned 27,395 participants with stable atherosclerotic vascular disease to receive rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg once daily). The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction. The study was stopped for superiority of the rivaroxaban-plus-aspirin group after a mean follow-up of 23 months. RESULTS: The primary outcome occurred in fewer patients in the rivaroxaban-plus-aspirin group than in the aspirin-alone group (379 patients [4.1%] vs. 496 patients [5.4%]; hazard ratio, 0.76; 95% confidence interval [CI], 0.66 to 0.86; P<0.001; z=−4.126), but major bleeding events occurred in more patients in the rivaroxaban-plus-aspirin group (288 patients [3.1%] vs. 170 patients [1.9%]; hazard ratio, 1.70; 95% CI, 1.40 to 2.05; P<0.001). There was no significant difference in intracranial or fatal bleeding between these two groups. There were 313 deaths (3.4%) in the rivaroxaban-plus-aspirin group as compared with 378 (4.1%) in the aspirin-alone group (hazard ratio, 0.82; 95% CI, 0.71 to 0.96; P=0.01; threshold P value for significance, 0.0025). The primary outcome did not occur in significantly fewer patients in the rivaroxaban-alone group than in the aspirin-alone group, but major bleeding events occurred in more patients in the rivaroxaban-alone group. CONCLUSIONS: Among patients with stable atherosclerotic vascular disease, those assigned to rivaroxaban (2.5 mg twice daily) plus aspirin had better cardiovascular outcomes and more major bleeding events than those assigned to aspirin alone. Rivaroxaban (5 mg twice daily) alone did not result in better cardiovascular outcomes than aspirin alone and resulted in more major bleeding events