Stefan Sillau

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis

Objective (1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP. Study Design Case series with chart review. Setting Academic hospital specializing in respiratory and allergic disease. Subjects Patients with CRSwNP treated from 2008 to 2010. Methods Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity. Results Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05). Conclusions Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.

Provider Perspectives on Integrating Primary and Behavioral Health: A Report from the High Plains Research Network

Background: Integrated primary care, a health care delivery model that combines medical and behavioral health services, provides better patient access to care at a lower cost, with better outcomes compared with usual nonintegrated care models. The perspectives of primary care providers (PCPs) and behavioral health care providers (BHPs) toward integration are especially valuable because their input and endorsement are key to successful and sustained integration. However, there is little research assessing or comparing PCP and BHP perspectives on integration, especially in rural areas. The objective of this study was to identify rural PCP and BHP perspectives on integration. Methods: Written and electronic surveys were distributed to PCPs and BHPs in the High Plains Research Network in rural eastern Colorado. Items included perspectives on improving behavioral health care, barriers to integration, and confidence in the ability to integrate primary and behavioral care. Results: Surveys were completed by 88 PCPs (60%), and 49 BHPs (63%), for an overall response rate of 61%. PCPs were significantly more likely than BHPs to prefer improving referral methods (odds ratio [OR], 2.2; P = .03) and significantly less likely to prefer colocation (OR, 0.2; P < .0001), warm hand-offs (OR, 0.3; P < .01), improved behavioral health training for PCPs (OR, 0.4; P < .01), and shared visits (OR, 0.4; P =.03) as ways to improve health care. Lack of sufficient methods of payment for behavioral health care services was the most commonly selected barrier to integration by both groups. PCPs were significantly more likely than BHPs to select recruitment (OR, 3.8; P < .001) and retention (OR, 2.7; P < .01) of behavioral health care staff as a major barrier. BHPs were slightly more optimistic than PCPs about the achievability of integration. Conclusions: Important differences of perspective exist between rural PCPs and BHPs regarding the best ways to improve behavioral health care, barriers to integration, and the achievability of integration. These differences may have important implications for rural communities and health care systems considering a transition to an integrated primary care model.

Assessing the validity of proxy caregiver reporting for potential palliative care outcome measures in Parkinson’s disease

Background: There is increasing interest in applying palliative care approaches for patients with Parkinson’s disease. Methodological studies are needed to validate palliative care outcome measures for Parkinson’s disease to build this evidence base. As many patients with Parkinson’s disease have cognitive and/or communication issues, proxy outcome measures may improve the inclusivity and relevance of research. Aim: To assess the validity of proxy caregiver reports for several potential palliative care outcome measures. Design: A cross-sectional study of Parkinson’s disease patients and caregivers completed a battery of outcome measures relevant to palliative care including the Memorial Symptom Assessment Scale, Hospital Anxiety and Depression Scale, Prolonged Grief Questionnaire 12, Parkinson Disease Questionnaire 39, Functional Assessment of Chronic Illness Therapy–Spiritual Wellbeing, and Schwab and England. Intraclass correlation coefficients were used to assess agreement. Setting/participants: A total of 50 Parkinson’s disease patient and caregiver dyads recruited at an academic medical center, Veterans Affairs Medical Center, and community support groups. Results: There was moderate to good agreement for Schwab and England, Parkinson Disease Questionnaire 39 total, and majority of Parkinson Disease Questionnaire 39 subscales; moderate to good agreement for the Hospital Anxiety and Depression Scale, Functional Assessment of Chronic Illness Therapy–Spiritual Wellbeing, Prolonged Grief Questionnaire 12, and Memorial Symptom Assessment Scale; and poor to moderate agreement for the Parkinson Disease Questionnaire 39 stigma, social support, and bodily pain subscales. Caregivers tended to attribute higher symptom severity than patients. We did not detect differences in intraclass correlation coefficient based on cognitive status but patients with advanced illness had significantly lower intraclass correlation coefficients for several outcomes. Conclusions: Caution is indicated when considering caregiver proxy reporting for most outcomes assessed, particularly in Parkinson’s disease patients with advanced disease.

Isolated focal dystonia phenotypes are associated with distinct patterns of altered microstructure

Objective Isolated adult-onset focal dystonia is considered a network disorder with disturbances to the motor basal ganglia and cerebellar circuits playing a pathophysiological role, but why specific body regions become affected remains unknown. We aimed to use diffusion tensor imaging to determine if the two most common phenotypes of focal dystonia are associated with distinguishing microstructural changes affecting the motor network. Methods Fifteen blepharospasm patients, 20 cervical dystonia patients, and 30 age- and sex-matched healthy controls were recruited. Maps of fractional anisotropy and mean diffusivity were analyzed using a voxel-based approach and an automated region-of-interest technique to evaluate deep gray matter nuclei. Correlations between diffusion measures and dystonia severity were tested, and post hoc discriminant analyses were conducted. Results Voxel-based analyses revealed significantly reduced fractional anisotropy in the right cerebellum and increased mean diffusivity in the left caudate of cervical dystonia patients compared to controls, as well as lower fractional anisotropy in the right cerebellum in cervical dystonia patients relative to blepharospasm patients. In addition to reduced fractional anisotropy in the bilateral caudate nucleus of cervical dystonia patients relative to controls and blepharospasm patients, region-of-interest analyses revealed significantly reduced fractional anisotropy in the right globus pallidus internus and left red nucleus of blepharospasm patients compared to both controls and cervical dystonia patients. Diffusivity measures in the red nucleus of blepharospasm patients correlated with disease severity. In a three-group discriminant analysis, participants were correctly classified with only modest reliability (67–75%), but in a two-group discriminant analysis, patients could be distinguished from each other with high reliability (83–100%). Conclusions Different focal dystonia phenotypes are associated with distinct patterns of altered microstructure within constituent regions of basal ganglia and cerebellar circuits.

Association of MRI Measurements with Cognitive Outcomes After STN-DBS in Parkinson's Disease: Association of Quantitative Measures with Cognitive Outcomes of STN-DBS

Subthalamic nucleus deep brain stimulation (STN‐DBS) is an effective treatment for improving the motor symptoms of Parkinsons disease (PD). Overall, cognitive function remains stable after STN‐DBS in most patients. However, cognitive decline, specifically in the verbal fluency domain, is seen in a subset of STN‐DBS patients. Currently, predictors of cognitive decline in PD patients treated with STN‐DBS are not well known. Thus, identification of presurgical predictors might provide an important clinical tool for better risk‐to‐benefit assessment. This study explores whether whole brain white matter lesion (WML) volume, or hippocampal and forebrain volumes, measured quantitatively on MRI, are associated with cognitive changes following STN‐DBS in PD patients.

Transcranial magnetic stimulation does not improve mild cognitive impairment in Parkinson's disease: Rtms For PD-MCI

Current treatments minimally impact Parkinson’s disease’s (PD) cognitive decline. Repetitive transcranial magnetic stimulation (rTMS) is a potential therapy for PD mild cognitive impairment (PD-MCI) that can improve cognitive functioning in healthy older adults and PD patients with normal cognition. The dorsolateral prefrontal cortex is a key node in cognitive networks affected by PD and is a common therapeutic target for neuromodulation. We thus studied the potential benefits of bilateral dorsolateral prefrontal cortex 20 Hz rTMS for 2 weeks in a randomized sham-controlled clinical trial in 46 PD-MCI patients (real, 22; sham, 24; see supplementary material for Consolidated Standards of Reporting Trials figure, Clinical and Demographic Characteristics and detailed Methods). No significant group difference was found for our primary outcome: change from baseline to post-TMS on the total score of the Dementia Rating Scale-2 (DRS-2; Table 1). There was no significant difference between groups on the Clinical Global Impression of Improvement (v; P 5 .83) with 45% of rTMS and 58% of sham-treated participants reporting at least minimal improvement, and 23% of rTMS and 29% of sham-treated participants reporting “much” or “very much” improvement. Regarding secondary outcomes, there was a significant group difference on the initiation/perseveration subscore of the DRS-2 and the Symbol Digit Modalities Test favoring the sham group. Although there were no other significant group differences, the real rTMS group significantly worsened on the total and conceptualization subscore of the DRS-2 and significantly improved on the Delis-Kaplan Executive Function System Color-Word Interference and Symbol Digit Modalities Test tasks while the sham group significantly increased their scores in the Trails making test, part B, and the Boston Naming Test. There were no group differences in the perception of received treatment (v, p 5 0.31), Hospital Anxiety and Depression Scale, Parkinson’s Disease Questionnaire-39, or Parkinson’s Disease Sleep Scale scores (P> .10). There were no significant adverse events (Supplementary Table 2). Contrary to our hypothesis, bilateral dorsolateral prefrontal cortex high-frequency rTMS did not improve cognitive functioning in PD-MCI, at least with the rTMS parameters chosen. It is possible that the beneficial effects of rTMS rely only on intact executive networks, as seen in PD with normal cognition but not in PD-MCI, where those networks demonstrate both structural and functional disruption. Alternatively, other cognitive targets such as the ventrolateral prefrontal cortex or frontoparietal networks may be more suitable because of their involvement in cognition and their dysfunction in PD. Last, if mood improvement is an important mediator of rTMS cognitive benefits, especially in the context of PD, our cognitive findings may be explained by our lack of rTMS benefit on mood and exclusion of depressed participants. Recommended outcome measures for PD dementia may not be translatable to PD-MCI trials (see Supplementary Reference e1). It is possible that our primary outcome, the DRS-2, may have suffered from ceiling effects as average PD-MCI cut-points are more than 90% of the maximum score (see Supplementary Reference e2). Although the lack of change in other neuropsychological tests provides reassurance that our negative results were not entirely a result of test selection, future studies may consider using outcomes specifically validated in PD-MCI populations (see Supplementary Reference e3).

Preoperative evaluation for epilepsy surgery: Process improvementAuthors Respond:

I read with interest the results of the Drees et al.1 study and agree with the process improvements highlighted to reduce the time for epilepsy surgery (ES) evaluation. My personal experience working in a level IV comprehensive epilepsy center has been as follows. Potential ES patients are identified relatively early and time for ES evaluation is relatively short provided patients are seen in the office practice setting of individual epileptologists. Patients seen in this setting tend to be more involved in their care, they have commercial medical insurance, and the treating …

Preoperative evaluation for epilepsy surgery: Process improvement

Background: Epilepsy surgery (ES) can improve seizure outcome. A prolonged duration of presurgical evaluation contributes to epilepsy-related morbidity and mortality. We introduced process changes to decrease evaluation time (ET) and increase ES numbers (excluding vagus nerve stimulation). Methods: The University of Colorado Hospital patient database was searched for ESs between January 2009 and May 2016. Measures to reduce ET included (1) increasing patient care conference (PCC) frequency; (2) faster intracarotid amobarbital test (IAT) scheduling; (3) dedicated ES clinic; and (4) adding a nurse navigator. ET from noninvasive video-EEG monitoring (P1) to IAT, PCC, and ES, and ES volume were determined and compared for a baseline group (P1 January 2009–March 2013) and a group exposed to process changes (P1 after March 2013), the postchanges group, to assess the effect of these measures. Results: ES number was 61 for the baseline group and 77 for the postchanges group, increasing the annual rate at 3 years after changes from 14.4 to 36.8 (p = 0.0008; 37% yearly increase postchanges). Interventions lowered average ET by 96 days (p ⩽ 0.0001), P1 to IAT by 39 days (p = 0.0011), and P1 to PCC by 58 days (p = 0.0002). Conclusions: Simple process changes, including more frequent patient care conferences, faster scheduling, a dedicated ES clinic, and a nurse navigator significantly decreased evaluation times and increased ES numbers. Centers could utilize similar strategies to improve process and surgical volume and thereby increase patient seizure control and safety.