Nivedita Nadkarni

The impact of non‐motor symptoms on the quality of life of Parkinson's disease patients: a longitudinal study

Non‐motor symptoms (NMSs) are common amongst patients with Parkinsons disease (PD); however, little is known about their influence on the health‐related quality of life (QoL) over a defined follow‐up period. The study was aimed to establish the impact of NMSs on the QoL of patients with PD over a 2‐year follow‐up period.

Association between asthma control and asthma cost: Results from a longitudinal study in a primary care setting.

Asthma control can be assessed with the Asthma Control Test (ACT) and a score of 20 or higher indicates good asthma control. Patients pay for their consultation and treatment in the fee‐for‐service primary healthcare system in Singapore. We hypothesized that achieving asthma control would result in lower asthma costs through reduced acute exacerbations, fewer physician consultations and lower lost productivity. The study compared the healthcare costs of patients who achieved asthma control and those with suboptimal asthma control based on ACT scores. Factors influencing asthma control and healthcare expenditure over time were also examined.

The Low Fall as a Surrogate Marker of Frailty Predicts Long-Term Mortality in Older Trauma Patients.

Background Frailty is associated with adverse outcomes including disability, mortality and risk of falls. Trauma registries capture a broad range of injuries. However, frail patients who fall comprise a large proportion of the injuries occurring in ageing populations and are likely to have different outcomes compared to non-frail injured patients. The effect of frail fallers on mortality is under-explored but potentially significant. Currently, many trauma registries define low falls as less than three metres, a height that is likely to include non-frailty falls. We hypothesized that the low fall from less than 0.5 metres, including same-level falls, is a surrogate marker of frailty and predicts long-term mortality in older trauma patients. Methods Using data from the Singapore National Trauma Registry, 2011–2013, matched till September 2014 to the death registry, we analysed adults aged over 45 admitted via the emergency department in public hospitals sustaining blunt injuries with an injury severity score (ISS) of 9 or more, excluding isolated hip fractures from same-level falls in the over 65. Patients injured by a low fall were compared to patients injured by high fall and other blunt mechanisms. Logistic regression was used to analyze 12-month mortality, controlling for mechanism of injury, ISS, revised trauma score (RTS), co-morbidities, gender, age and age-gender interaction. Different low fall height definitions, adjusting for injury regions, and analyzing the entire adult cohort were used in sensitivity analyses and did not change our findings. Results Of the 8111 adults in our cohort, patients who suffered low falls were more likely to die of causes unrelated to their injuries (p<0.001), compared to other blunt trauma and higher fall heights. They were at higher risk of 12-month mortality (OR 1.75, 95% CI 1.18–2.58, p = 0.005), independent of ISS, RTS, age, gender, age-gender interaction and co-morbidities. Falls that were higher than 0.5m did not show this pattern. Males were at higher risk of mortality after low falls. The effect of age on mortality started at age 55 for males, and age 70 for females, and the difference was attributable to the additional mortality in male low-fallers. Conclusions The low fall mechanism can optimize prediction of long-term mortality after moderate and severe injury, and may be a surrogate marker of frailty, complementing broader-based studies on aging.

Deterministic Tractography of the Nigrostriatal-Nigropallidal Pathway in Parkinson’s Disease

We hypothesized that deterministic tractography is practical and sensitive to changes in the complex nigrostriatal and nigropallidal pathway (NSP) in Parkinson’s disease (PD). Using diffusion tensor imaging (DTI) tractography, we investigated the NSP to evaluate differences between PD patients and controls, and examined their clinico-radiologic correlation. Structural and DTI brain scans were obtained in 40 subjects (21 PD patients and 19 healthy controls). We isolated the NSP using a user-friendly DTI toolkit based on deterministic brute-force tractography. DTI parameters of fractional anisotropy (FA), mean, axial, and radial diffusivity, and streamline count of the NSP were measured. Average FA (p < 0.01) and streamline count (p < 0.001) were significantly lower in the PD compared to control group. Mean diffusivity and radial diffusivity were significantly higher in the PD group (p < 0.05). Average streamline count correlated with the United Parkinson’s Disease Rating Scale motor score (p < 0.05). Point-to-point FA profiles of the tract demonstrated peak divergence between PD and control towards the tract midpoint rather than the distal grey matter. Our findings demonstrated a clinically and radiologically practical application of DTI tractography to the NSP in PD, without requiring complex imaging sequences for anatomical localization or segmentation software.

A longitudinal study of non-motor symptom burden in Parkinson's disease after a transition to expert care

BACKGROUND Non-motor symptoms (NMS) are common among patients with Parkinsons disease (PD) however little is known about their progression in terms of severity or burden after referral to expert care. OBJECTIVE This study was aimed to establish the progression of NMS burden in PD patients after referral to tertiary healthcare centre and factors affecting it. METHODS Newly referred PD patients were prospectively enrolled and follow-up for up to 18 months. Non-motor symptoms scale (NMSS) was used to evaluate the burden of non-motor symptoms. RESULTS There was a significant median reduction of total NMS burden over the follow-up period. Similarly all NMS domains except domains 2 (sleep/fatigue), 3 (mood/cognition), 6 (gastrointestinal) and 7 (urinary) showed significant median reduction of scores. In the univariate regression analysis, Hoehn & Yahr staging, disease duration, visit, Schwab & England Activities of Daily Living score and UPDRS motor scores were individually predictive of change in total NMS burden. However, in the multivariable regression analysis only the latter three were significantly predictive of change in the total NMS burden. CONCLUSION There was a significant reduction of total NMS burden over the study period. The severity of motor and activity of daily living impairments as well as subsequent visit were the best predictors of NMS change.

Inferior Alveolar Nerve Injury in Trauma-Induced Mandible Fractures

PURPOSE This prospective observational cohort study sought to determine the prevalence of inferior alveolar nerve (IAN) injury after mandibular fractures before and after treatment and to elucidate factors associated with the incidence of post-treatment IAN injury and time to normalization of sensation. MATERIALS AND METHODS Consenting patients with mandibular fractures (excluding dentoalveolar, pathologic, previous fractures, or mandibular surgery) were prospectively evaluated for subjective neurosensory disturbance (NSD) and underwent neurosensory testing before treatment and then 1 week, 1.5, 3, 6, and 12 months after treatment. RESULTS Eighty patients (men, 83.8%; mean age, 30.0 yr; standard deviation, 12.6 yr) with 123 mandibular sides (43 bilateral) were studied. Injury etiology included assault (33.8%), falls (31.3%), motor vehicle accidents (25.0%), and sports injuries (6.3%). Half the fractures (49.6%) involved the IAN-bearing posterior mandible; all condylar fractures (13.0%) had no NSD. Treatment included open reduction and internal fixation (ORIF; 74.8%), closed reduction and fixation (22.0%), or no treatment (3.3%). Overall prevalence of IAN injury was 33.7% (95% confidence interval [CI], 24.8-42.6) before treatment and 53.8% (95% CI, 46.0-61.6) after treatment. In the IAN-bearing mandible, the prevalence was 56.2% (95% CI, 43.2-69.2) before treatment and 72.9% (95% CI, 63.0-82.7) after treatment. In contrast, this prevalence in the non-IAN-bearing mandible was 12.6% (95% CI, 4.1-21.1) before treatment and 31.6% (95% CI, 20.0-43.3) after treatment. Factors associated with the development of post-treatment IAN injury included fracture site and gap distance (a 1-mm increase was associated with a 27% increase in odds of post-treatment sensory alteration). Time to normalization after treatment was associated with type of treatment (ORIF inhibited normalization) and fracture site (IAN-bearing sites took longer to normalize). CONCLUSION IAN injury was 4 times more likely in IAN-bearing posterior mandibular fractures (56.2%) than in non-IAN-bearing anterior mandibular fractures (12.6%). After treatment, IAN injury prevalence (in 12 months) was higher (72.9% in posterior mandible, 31.6% in anterior mandible).

Trends and predictors of asthma costs: results from a 10-year longitudinal study

Research on asthma costs often focuses on estimating average asthma costs. Trends in asthma costs and patterns of medication use, especially for those who have been followed up and under treatment, have received much less attention. This studys objective was to document asthma costs over time for asthma patients who are enrolled in an asthma care programme in Singapore and to identify its predictors, using a 10-year longitudinal dataset. The study population comprised different cohorts of 939 asthma patients entering the programme at different times during 2004–2013. Average asthma costs were estimated and the trends over time examined graphically, within and across patient cohorts. Regression analyses were conducted to examine cost predictors, with a focus on the relationship between risk factors at programme enrolment and subsequent asthma costs. The results indicate that 10-year average annual asthma cost was GBP 341 per patient. The main drivers of costs were asthma medications and consultation fees. Use of combined inhaled corticosteroid/long-acting β-agonist medications increased over time, but this was accompanied by declines in controller drug use, doctor visits and total asthma drug costs. Obesity, smoking and asthma severity were the main predictors of subsequent asthma costs, especially for females. Most asthma costs were due to drugs and consultations; the shift from controller to combination drugs was beneficial http://ow.ly/TqLcF

Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups

Background Evidence on long term effectiveness of public health strategies for lowering blood pressure (BP) is scarce. In the Control of Blood Pressure and Risk Attenuation (COBRA) Trial, a 2 x 2 factorial, cluster randomized controlled trial, the combined home health education (HHE) and trained general practitioner (GP) intervention delivered over 2 years was more effective than no intervention (usual care) in lowering systolic BP among adults with hypertension in urban Pakistan. However, it was not clear whether the effect would be sustained after the cessation of intervention. We conducted 7 years follow-up inclusive of 5 years of post intervention period of COBRA trial participants to assess the effectiveness of the interventions on BP during extended follow-up. Methods A total of 1341 individuals 40 years or older with hypertension (systolic BP 140 mm Hg or greater, diastolic BP 90 mm Hg or greater, or already receiving treatment) were followed by trained research staff masked to randomization status. BP was measured thrice with a calibrated automated device (Omron HEM-737 IntelliSense) in the sitting position after 5 minutes of rest. BP measurements were repeated after two weeks. Generalized estimating equations (GEE) were used to analyze the primary outcome of change in systolic BP from baseline to 7- year follow-up. The multivariable model was adjusted for clustering, age at baseline, sex, baseline systolic and diastolic BP, and presence of diabetes. Findings After 7 years of follow-up, systolic BP levels among those randomised to combined HHE plus trained GP intervention were significantly lower (2.1 [4.1–0.1] mm Hg) compared to those randomised to usual care, (P = 0.04). Participants receiving the combined intervention compared to usual care had a greater reduction in LDL-cholesterol (2.7 [4.8 to 0.6] mg/dl. Conclusions The benefit in systolic BP reduction observed in the original cohort assigned to the combined intervention was attenuated but still evident at 7- year follow-up. These findings highlight the potential for scaling-up simple strategies for cardiovascular risk reduction in low- and middle- income countries. Trial Registration ClinicalTrials.gov NCT00327574

The modified respiratory index score (RIS) guides resource allocation in acute bronchiolitis

Bronchiolitis is a common disease in early childhood with increasing healthcare utilization. We aim to study how well a simple and improved respiratory score (the modified Respiratory Index Score [RIS]) would perform when predicting for a warranted admission.

Survival of patients with head and neck squamous cell carcinoma by housing subsidy in a tiered public housing system

Socioeconomic status affects survival in patients diagnosed with head and neck squamous cell carcinoma (HNSCC), even in health systems with universal health care. Singapore has a tiered subsidized housing system, in which income determines eligibility for subsidies by size of apartment. The objective of this study was to assess whether a patients residential type (small/heavily subsidized, medium/moderate subsidy, large/minimal or no subsidy) influenced mortality. A secondary analysis examined whether patients in smaller subsidized apartments were more likely to present with advanced disease.