Neuro-QOL: brief measures of health-related quality of life for clinical research in neurology

Melatonin for Huntington's Disease (HD) gene carriers with HD-related sleep disturbance - A pilot study

BACKGROUND

Sleep disorders are common in people with Huntington's Disease (HD). Possible causes include disruptions to the body's internal clock and changes in melatonin levels. Although melatonin is known to treat sleep disruptions related to circadian rhythm disorders, its effects on HD patients have not been thoroughly explored.

OBJECTIVE

to assess the effectiveness of melatonin in improving the sleep quality of individuals with HD.

METHODS

double-blind, randomized, placebo-controlled, crossover trial with individuals with HD experiencing sleep disturbances, defined as Pittsburgh Sleep Quality Index (PSQI) > 5. Participants received 4-week treatments with 5 mg immediate-release melatonin/placebo, separated by a one-week wash-out (NCT04421339). Clinical assessments were conducted at baseline, week 5 (crossover visit), and week 9 (final visit) and included the PSQI, HD Sleep Questionnaire (HD-SQ), Epworth Sleepiness Scale (ESS), Montreal Cognitive Assessment (MoCA), Neuro-QoL™ v2.0 Cognitive Function, Neuropsychiatric Inventory Questionnaire (NPI-Q), Hospital Anxiety and Depression Scale (HADS), Unified Huntington Disease Rating Scale (UHDRS), and Clinical Global Impression (CGI).

RESULTS

Fifteen patients (46.53 ± 13.92 years old, seven females) completed the study procedures. We found no significant differences between melatonin and placebo treatments in the primary outcome (PSQI), other sleep measures (ESS and HD-SQ), neuropsychiatric symptoms (NPI-Q, HADS, Neuro-QoL, MoCA), and motor/functional measures.

CONCLUSIONS

We found that melatonin did not significantly differ from placebo in improving sleep quality in individuals with HD. Given the conflicting findings from previous research, it may be beneficial to explore alternative dosages of melatonin, increase the sample size, and consider different stages of HD in future studies.

Gut microbiota and metabolites are linked to disease progression in multiple sclerosis

Progressive multiple sclerosis (MS) is a neurological disease with limited understanding of the biology associated with transition from relapsing to progressive disease. Intestinal microbes and metabolites are altered in MS, but relation to disease progression is largely unknown. We investigate microbiota and metabolites in subjects with stable MS, those who worsened, and in those with relapsing MS who became progressive over 2 years. We find that Eubacterium hallii, Butyricoccaceae, Blautia, and other short-chain fatty-acid-producing microbes have beneficial associations with worsening of disability, 3T magnetic resonance imaging (MRI) measures, cognition, and quality of life, while Alistipes is detrimentally associated. Global metabolomics identified serum and stool metabolites that are altered in progressive MS and in relapsing subjects who transitioned to progressive disease. Most fecal metabolites associated with disease progression are decreased, suggesting a deficiency of protective factors in the gut. Using a unique MS cohort, our findings identify gut microbiome and metabolite pathways influencing progressive MS.

Utilization of CoRDS registry to monitor quality of life in patients with VCP multisystem proteinopathy

BACKGROUND

VCP disease, also known as multisystem proteinopathy, is a rare, autosomal dominant, adult-onset, neuromuscular disease that is caused by variants in the valosin-containing protein (VCP) gene. VCP disease may exhibit one or more of the following primary features: inclusion body myopathy, Paget's disease of bone (PDB), Frontotemporal dementia, and amyotrophic lateral sclerosis. Due to its progressive nature, death normally occurs in their sixties due to respiratory and cardiac failure. The purpose of this study is to utilize the Cure VCP Disease patient registry hosted by the Coordination of Rare Diseases at Sanford (CoRDS) to conduct a prospective natural history study.

METHODS

Seventy-nine participants enrolled in the patient registry and answered demographic, VCP variant type, Patient-reported outcome measures (PROMs), and quality of life (QOL) questionnaires over the course of 3 years. We additionally investigated if any sex differences existed and if genotype-phenotype correlations affected the rate of progression of the varying clinical manifestations.

RESULTS

Overall, participants' mobility declined significantly as the disease progressed. Participants reported a 0.6% decline in upper extremity function, 1.2% decline in lower extremity function, and 0.3% decline in cognitive function per year of age. Furthermore, participants reported a 1.6% decline in upper and lower extremity function and a 0.1% decline in cognitive function per year of disease duration. The highest PROMs correlations were noted between overall health and lower extremity function, upper extremity function, fatigue, and the ability to perform vigorous activities. Genotype-phenotype correlations revealed no significant differences except for the absence of PDB in the p.Arg159Cys group.

CONCLUSION

The VCP CoRDS Registry was found to be a valuable tool for monitoring the QOL in patients with VCP disease and capturing patient perspectives for future clinical trials.

Feasibility and acceptability of an online epilepsy stigma self-management program

INTRODUCTION

Stigma is a prevalent source of distress in people with epilepsy. We developed a self-paced online stigma self-management program for adults with epilepsy (Reducing Internalized Stigma in Epilepsy: A Behavioral Online Video Education, RISE ABOVETM).

MATERIALS AND METHODS

Twenty socio-demographically diverse participants completed RISE ABOVE over an average of 3.5 weeks. Acceptability was determined by whether ≥ 80 % responded favorably to the Credibility and Expectancy Questionnaire and tailored surveys. Treatment Satisfaction was determined by whether mean Client Satisfaction Questionnaire responses was ≥ 80 %. Epilepsy Stigma, Perceived Stress, Perceived Rejection, Loneliness, Self-Efficacy, and Satisfaction with Social Roles and Activities were rated pre-post-intervention. Paired sample t-tests and Hedges' g effect sizes gauged improvements.

RESULTS

Most participants (≥ 80 %) thought the intervention was logical and content was easy to understand/navigate, interesting/helpful, and planned on using learned skills. Mean satisfaction was 85.41 % ± 14.43 %. There were large improvements in Epilepsy Stigma (p < 0.001; Hedge's g = 1.052), Perceived Stress (p < 0.001; Hedge's g = 0.887) and Satisfaction with Social Roles and Activities (p < 0.001; Hedge's g = -1.010), and medium improvements in Perceived Rejection (p = 0.004; Hedge's g = 0.634) and Self-Efficacy (p = 0.008; Hedge's g = -0.568). No significant differences were observed 6-months post-program completion, despite some attenuation.

CONCLUSIONS

RISE ABOVE is a feasible and acceptable anti-stigma intervention. Markers of acceptability were evident in high rates of credibility and satisfaction. Sizable improvements in stigma and other psychosocial outcomes were seen. Future studies will establish RISE ABOVE's efficacy via a randomized controlled trial.

A Patient Centric Model for Vaso-Occlusive Crises in Sickle Cell Disease-Outcomes of a Consensus Exercise Conducted Across Patients and Experts

Sickle cell disease (SCD) is a group of inherited disorders caused by a mutation in the beta globin gene that leads to sickling of red blood cells and results in anemia and Vaso-occlusive crises (VOC). VOC are described as an acute worsening of symptoms impacting daily life and often requiring treatment to resolve. A majority of SCD interventional trial endpoints consider VOC that require attendance at a health facility and do not account for VOC managed at home. These studies report lower VOC incidence compared to those that consider VOC managed both in the healthcare setting and at home. This presents challenges to the consistent and accurate assessment of treatment effect in reducing overall VOC count. This paper outlines a USA consensus exercise conducted with patients and a scientific expert review committee to develop a patient-centric VOC model that may apply across incidences, individuals, and treatment settings. The model is supported by a monitoring biomarker specification for the objective identification and classification of VOC taking place in the healthcare setting and at home. We additionally propose hardware, software, diaries, and patient-reported outcomes for an initial instrument design to evaluate the potential of the model in a validation study.

Incidence and Prevalence of Post-COVID-19 Myalgic Encephalomyelitis: A Report from the Observational RECOVER-Adult Study

BACKGROUND

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may occur after infection. How often people develop ME/CFS after SARS-CoV-2 infection is unknown.

OBJECTIVE

To determine the incidence and prevalence of post-COVID-19 ME/CFS among adults enrolled in the Researching COVID to Enhance Recovery (RECOVER-Adult) study.

DESIGN, SETTING, AND PARTICIPANTS

RECOVER-Adult is a longitudinal observational cohort study conducted across the U.S. We included participants who had a study visit at least 6 months after infection and had no pre-existing ME/CFS, grouped as (1) acute infected, enrolled within 30 days of infection or enrolled as uninfected who became infected (n=4515); (2) post-acute infected, enrolled greater than 30 days after infection (n=7270); and (3) uninfected (1439).

MEASUREMENTS

Incidence rate and prevalence of post-COVID-19 ME/CFS based on the 2015 Institute of Medicine ME/CFS clinical diagnostic criteria.

RESULTS

The incidence rate of ME/CFS in participants followed from time of SARS-CoV-2 infection was 2.66 (95% CI 2.63-2.70) per 100 person-years while the rate in matched uninfected participants was 0.93 (95% CI 0.91-10.95) per 100 person-years: a hazard ratio of 4.93 (95% CI 3.62-6.71). The proportion of all RECOVER-Adult participants that met criteria for ME/CFS following SARS-CoV-2 infection was 4.5% (531 of 11,785) compared to 0.6% (9 of 1439) in uninfected participants. Post-exertional malaise was the most common ME/CFS symptom in infected participants (24.0%, 2830 of 11,785). Most participants with post-COVID-19 ME/CFS also met RECOVER criteria for long COVID (88.7%, 471 of 531).

LIMITATIONS

The ME/CFS clinical diagnostic criteria uses self-reported symptoms. Symptoms can wax and wane.

CONCLUSION

ME/CFS is a diagnosable sequela that develops at an increased rate following SARS-CoV-2 infection. RECOVER provides an unprecedented opportunity to study post-COVID-19 ME/CFS.

Baseline physical and cognitive functions associate with the longitudinal trajectory of stigma in patients with multiple sclerosis (MS)

BACKGROUND

Multiple sclerosis is a chronic disease, and the lived experience of a person with MS is highly heterogeneous.

OBJECTIVE

To analyze longitudinal trajectories of stigma in MS, the associated baseline predictors, and how the stigma trajectories relate to the longitudinal changes in physical disability.

METHOD

In a cohort of people from the MS Partners Advancing Technology and Health Solutions (MS PATHS) network with at least two stigma measures, we analyzed the trajectory of stigma and physical disability by applying a group-based trajectory modeling (GBTM) to longitudinal measures of Neuro-QoL stigma T-score and Patient Determined Disease Steps (PDDS), respectively.

RESULTS

We included 8,404 MS PATHS participants with a mean follow-up duration of 2.8 ± 1.4 years. We found four stigma trajectories, which remained stable over the follow-up period. Compared to the no stigma trajectory group, the odds of being in the high stigma group were higher in people with higher baseline PDDS (OR=1.9, 95 % CI: 1.7-2.1) and stigma (OR=2.4, 95 % CI: 2.3-2.5), and worse processing speed test scores (OR=0.7, 95 % CI: 0.6-0.8). The trajectory of stigma was strongly associated with the PDDS trajectory.

CONCLUSIONS

Baseline severity of stigma, physical disability, and performance on the processing speed test were the strongest predictors of belonging to a higher stigma trajectory group.

Neurocognitive and Psychosocial Outcomes in Older Adults with Obstructive Sleep Apnea Following Hypoglossal Nerve Stimulation

OBJECTIVES

To assess the impact of hypoglossal nerve stimulation (HNS) on neurocognitive, psychological, and sleep outcomes in older adults with obstructive sleep apnea (OSA).

METHODS

A retrospective analysis of 42 patients aged 50 years and older who underwent HNS for OSA was conducted. Patient-reported outcomes were collected using validated tools, including the Insomnia Severity Index (ISI), PROMIS measures (Sleep-Related Impairment, Cognitive Function, Depression, Anxiety, Anger, Physical Function), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ-10), and NIH Toolbox Loneliness survey. Pre- and post-HNS scores were compared using paired t-tests and Wilcoxon tests.

RESULTS

Significant improvements were observed in apnea-hypopnea index (AHI) (-17.6, P < .0001), ISI (-7.02, P < .0001), ESS (-3.4, P < .0001), and FOSQ (4.05, P < .0001). PROMIS measures showed significant posttreatment improvements in sleep impairment, cognitive function, depression, anxiety, anger, and loneliness (all P < .01). Physical function and pain did not change.

CONCLUSION

HNS significantly improves sleep characteristics, cognitive function, and psychosocial outcomes in older adults with OSA. Future studies should include larger and more diverse samples with longer follow-up, as well as a control condition.

Understanding Depression in People Living with Multiple Sclerosis: A Narrative Review of Recent Literature

Multiple sclerosis (MS) is a chronic neurodegenerative and autoimmune disease that affects approximately 1 million adults in the US. Psychologic disorders are typical comorbidities in people with MS (pwMS), with depression being the most common. Clinical depression in pwMS can substantially impact quality of life and factor heavily in treatment adherence. Depression can surface early in MS, becoming more prevalent as the disease progresses and the severity of clinical disability increases. The etiology of comorbid depression in pwMS is not completely understood, but recent research has indicated that structural and functional brain abnormalities, along with genetic and immunologic factors, may contribute to the pathogenesis of depression in pwMS. Although depression has a significant impact on pwMS, it is often underdiagnosed and undertreated. Furthermore, the efficacy of pharmacologic and non-pharmacologic approaches for treating depression in pwMS has not been thoroughly investigated, with most studies showing minimal or no beneficial effect. Improved evaluation and diagnosis of depression and a better understanding of its pathophysiology may provide a stronger foundation for treatment and management of pwMS suffering from depression. This review discusses recent research on the potential causes of depression, the risk factors associated with developing depression, and the overall impact of depression in pwMS. It also reviews patient-reported outcomes utilized to assess depression in pwMS and the impact of disease-modifying therapies on depression in pwMS. Consideration is also given to management of depression in pwMS (both pharmacologic and non-pharmacologic) to better facilitate the patient journey.

Effects of mental imagery training on cognitive function and brain connectivity in people with Parkinson's disease: A randomized pilot trial

Cognitive impairment is a debilitating problem in Parkinson's disease (PD) with no effective treatment. We developed a personalized mental imagery (MI) intervention focusing on goal-directed activities and examined its effect on everyday cognitive functioning and brain functional connectivity in people with PD in a pilot randomized controlled trial ( ClinicalTrials.gov identifier NCT05495997 ). Thirty nondemented people with PD were randomized to PD-MI and PD-Control groups. During the six-week training period, PD-MI received MI training and PD-Control received psychoeducation on cognitive health in PD. Participants underwent cognitive and functional MRI assessments at baseline, six weeks, and 18 weeks. The primary outcomes included changes in Neuro-QoL Cognitive Function (CF) survey scores and functional connectivity. The PD-MI compared to the PD-Control group showed (1) significant difference in Neuro-QoL-CF scores (F(1,26) = 6.802, p = 0.015) at six weeks which was not sustained at 18 weeks, (2) stronger connectivity between frontoparietal regions (T = 4.1, p = 0.009) during MI tasks at six weeks, and (3) weaker connectivity between visuospatial and motor regions at 18 weeks. Personalized MI training can be effective in facilitating cognitive preparedness for everyday tasks in people with PD. Its long-term effects and feasibility in cognitively impaired PD cohorts need further investigation.

Phase 2b program with sonlicromanol in patients with mitochondrial disease due to m.3243A>G mutation

Mitochondrial disease incorporates a group of rare conditions with no approved treatment to date, except for Leber hereditary optic neuropathy. Therapeutic options to alleviate the symptoms of mitochondrial disease are urgently needed. Sonlicromanol is a promising candidate, as it positively alters the key metabolic and inflammatory pathways associated with mitochondrial disease. Sonlicromanol is a reductive and oxidative distress modulator, selectively inhibiting microsomal prostaglandin E1 synthase activity. This phase 2b program, aimed at evaluating sonlicromanol in adults with m.3243A>G mutation and primary mitochondrial disease, consisted of a randomized controlled (RCT) study (dose-selection) followed by a 52-week open-label extension study (EXT, long-term tolerability, safety and efficacy of sonlicromanol). Patients were randomized (1:1:1) to receive 100 or 50 mg sonlicromanol or placebo twice daily (bid) for 28 days with a ≥2-week wash-out period between treatments. Patients who completed the RCT study entered the EXT study, wherein they received 100 mg sonlicromanol bid. Overall, 27 patients were randomized (24 RCT patients completed all periods). Fifteen patients entered the EXT, and 12 patients were included in the EXT analysis set. All patients reported good tolerability and favourable safety, with pharmacokinetic results comparable to the earlier phase 2a study. The RCT primary end point [change from placebo in the attentional domain of the cognition score (visual identification; Cogstate IDN)] did not reach statistical significance. Using a categorization of the subject's period baseline a treatment effect over placebo was observed if their baseline was more affected (P = 0.0338). Using this approach, there were signals of improvements over placebo in at least one dose in the Beck Depression Inventory (BDI, P = 0.0143), Cognitive Failure Questionnaire (P = 0.0113) and the depression subscale of the Hospital Anxiety and Depression Scale (P = 0.0256). Statistically and/or clinically meaningful improvements were observed in the patient- and clinician-reported outcome measures at the end of the EXT study [Test of Attentional Performance (TAP) with alarm, P = 0.0102; TAP without alarm, P = 0.0047; BDI somatic, P = 0.0261; BDI total, P = 0.0563; SF12 physical component score, P = 0.0008]. Seven of nine domains of RAND-Short Form-36-like SF-36 pain improved (P = 0.0105). Other promising results were observed in the Neuro-Quality of Life Short Form-Fatigue Scale (P = 0.0036), mini-Balance Evaluation Systems test (P = 0.0009), McGill Pain Questionnaire (P = 0.0105), EuroQol EQ-5D-5L-Visual Analog Scale (P = 0.0213) and EQ-5D-5L-Index (P = 0.0173). Most patients showed improvement in the Five Times Sit-To-Stand Test. Sonlicromanol was well-tolerated and demonstrated a favourable benefit/risk ratio for up to 1 year. Sonlicromanol was efficacious in patients when affected at baseline, as seen across a variety of clinically relevant domains. Long-term treatment showed more pronounced changes from baseline.

Cognitive Fluctuations in a Rare Disease Population: Leveraging Cognitive and Speech Ecological Momentary Assessment in Individuals with Phenylketonuria

BACKGROUND

Phenylketonuria (PKU) is a rare, hereditary disease that causes disruption in phenylalanine (Phe) metabolism. Despite early intervention, individuals with PKU may have difficulty in several different cognitive domains, including verbal fluency, processing speed, and executive functioning.

OBJECTIVE

The overarching goal of the Evaluating Fluctuations in Cognitive and Speech Characteristics in Phenylketonuria study (CSP Study) is to characterize the relationships among cognition, speech, mood, and blood-based biomarkers (Phe, Tyr) in individuals with early treated PKU. We describe our initial optimization pilot results that are guiding the ongoing CSP Study, while establishing feasibility and reliability of using ecological momentary assessment (EMA) in this clinical population.

METHODS

Twenty adults with PKU were enrolled in this study between December 2022 and March 2023 through the National PKU Alliance. Eighteen participants completed an extended baseline assessment followed by six EMAs over one month. The EMAs included digital cognitive tests measuring processing speed, sustained attention, executive functioning, as well as speech (semantic fluency) and mood measures. Participants had 60 minutes to complete the assessment; completion rates were around 70% (on average 4.78 out of 6 EMAs).

RESULTS

Completion rates of EMAs were above 70%, with stable performances across baseline measures and EMAs. Between person reliability (BPR) of the EMAs, representing the variance due to differences between individuals versus within individuals, is satisfactory with values close to (semantic fluency BPR: 0.7, sustained attention BPR: 0.72) or exceeding (processing speed: 0.93, executive functioning: 0.88) those data collected from a large normative database (N= 5039-10703), as well as slightly below or matching a prior study using a clinical group (N=18). As applicable, within person reliability was also computed; we demonstrated strong reliability for processing speed (0.87). A control analyses ensured that time of day (i.e., morning, afternoon, evening) did not impact performance; performance on tasks did not decrease if tested earlier versus later in the day (all ps>0.09). Similarly, to assess variability in task performance over the course of all EMAs, the coefficient of variability was computed: 28% for the task measuring sustained attention, 37% percent for semantic fluency, 15.8 % for the task measuring executive functioning, and 17.6% for processing speed. Performance appears more stable in tasks measuring processing speed and executive functioning than on tasks of sustained attention and semantic fluency.

CONCLUSIONS

Preliminary results of this study demonstrate strong reliability of cognitive EMA, indicating that EMA is a promising tool for evaluating fluctuations in cognitive status in this population. Future work should refine and expand the utility of these digital tools, determine how variable EMA frequencies might better characterize changes in functioning as they relate to blood-based biomarkers, and validate a singular battery that could be rapidly administered at scale and in clinical trials to determine progression of disease.

Sleep health of adults and children with Moebius syndrome

INTRODUCTION

Moebius syndrome is a rare congenital disorder with frequent anecdotal reports of sleep disturbances not sufficiently categorized by prior literature. The present mixed-methods, two-phase study aimed to characterize the sleep health and symptoms of a cohort of adults and children (via parent proxies) with Moebius syndrome.

METHODS

In Phase 1, participants were 46 adults with Moebius Syndrome (Mage=33.5[13.0]; 72 % female) and 17 parent-proxies for children with Moebius Syndrome (child Mage=10.47[3.4]; 53 % female). Participants completed a self-reported questionnaire battery. In Phase 2, five adults (Mage=25.4[6.5]; 100 % female) from Phase 1 completed 2 weeks of sleep diary and actigraphy, 2 nights of single-channel EEG, and diagnostic and qualitative interviews.

RESULTS

Adults endorsed elevated rates of self-reported sleep disorder symptoms including sleep apnea (26 %), insomnia (56 %), nightmares (35 %), excessive daytime sleepiness (30 %), cataplexy (26 %), REM sleep behavior disorder (61 %), and parasomnias (100 %). Children had elevated rates of sleep disturbances (71 %), sleep-related daytime impairment (82 %), parasomnias (76 %) and daytime sleepiness (53 %). Qualitative interviews revealed participants endorsed a history of sleep problems dating to childhood and continuing into adulthood that impacted social relationships and quality of life and had experienced little treatment success.

DISCUSSION

These findings shed light on the constellation of sleep health experiences among individuals with Moebius syndrome. Poor sleep health may represent a modifiable treatment target to improve health and well-being in individuals with Moebius syndrome. The heterogenous nature of sleep problems among people with Moebius syndrome may not respond well to a one-size-fits-all intervention, instead necessitating personalized approaches.

Multimodal Digital Phenotyping of Behavior in a Neurology Clinic: Development of the Neurobooth Platform and the First Two Years of Data Collection

Quantitative analysis of human behavior is critical for objective characterization of neurological phenotypes, early detection of neurodegenerative diseases, and development of more sensitive measures of disease progression to support clinical trials and translation of new therapies into clinical practice. Sophisticated computational modeling can support these objectives, but requires large, information-rich data sets. This work introduces Neurobooth, a customizable platform for time-synchronized multimodal capture of human behavior. Over a two year period, a Neurobooth implementation integrated into a clinical setting facilitated data collection across multiple behavioral domains from a cohort of 470 individuals (82 controls and 388 with neurologic diseases) who participated in a collective 782 sessions. Visualization of the multimodal time series data demonstrates the presence of rich phenotypic signs across a range of diseases. These data and the open-source platform offer potential for advancing our understanding of neurological diseases and facilitating therapy development, and may be a valuable resource for related fields that study human behavior.

The COVID-19 pandemic experience for patients with central nervous system tumors: Differences in patient-reported outcomes and practice recommendations

Background

This study explored differences in patient-reported outcomes (PROs) for patients with central nervous system (CNS) tumors during COVID, compared to pre-pandemic assessments, in light of impacted access to in-person care.

Methods

Patient-reported outcomes (PROMIS-Anxiety and Depression Short-Forms, EQ-5D-3L, MDASI-BT/Spine, NeuroQoL-Perceived Cognitive Functioning) were collected from 149 participants on the Neuro-Oncology Branch Natural History Study seen during the first year of COVID between March 2020 and February 2021, which were compared to assessments collected pre-COVID. Paired sample t-tests and proportion tests (z-tests) were used to compare PROs with effect sizes reported using Hedges g and Cohen's h. Logistic regression models with backwards selection were used to identify risk factors for high levels of depression and anxiety pre- and during COVID.

Results

Participants were primarily male (54%) and Caucasian (84%) with a median age of 46 (range 20-79) and 66% had high-grade tumors. More patients reported moderate-severe depressive symptoms during the COVID year, compared to pre-COVID assessments (13% vs 8%, Cohen's h = 0.17, P = .021), with modest increases in symptom burden and cognitive dysfunction reported as well. Logistic regressions revealed that during COVID, concurrent moderate-severe distress and low tumor grade predicted depression and anxiety, with psychotropic medication use also predicting depression while active treatment predicted anxiety.

Conclusion

During COVID, patients experienced higher levels of depression, which has the potential to negatively influence treatment success and survival. Future work is needed to incorporate innovative tools and interventions that can be utilized remotely to identify and target mood disturbance in these vulnerable patients.

Cognitive impairment after hemorrhagic stroke is less common in patients with elevated body mass index and private insurance

BACKGROUND

Hemorrhagic stroke survivors may have cognitive impairment. We sought to identify preadmission and admission factors associated with cognitive impairment after hemorrhagic stroke.

DESIGN

Patients with nontraumatic intracerebral or subarachnoid hemorrhage (ICH or SAH) were assessed 3-months post-bleed using the Quality of Life in Neurological Disorders (Neuro-QoL) Cognitive Function short form. Univariate and multivariate analysis were used to evaluate the relationship between poor cognition (Neuro-QoL t-score ≤50) and preadmission and admission factors.

RESULTS

Of 101 patients (62 ICH and 39 SAH), 51 (50 %) had poor cognition 3-months post-bleed. On univariate analysis, poor cognition was associated with (p < 0.05): age [66.0 years (52.0-77.0) vs. 54.5 years (40.8-66.3)]; private insurance (37.3 % vs. 74.0 %); BMI > 30 (13.7 % vs. 34.0 %); and admission mRS score > 0 (41.2 % vs. 14.0 %), NIHSS score [8.0 (2.0-17.0) vs. 0.5 (0.0-4.0)], and APACHE II score [16.0 (11.0-19.0) vs. 9.0 (6.0-14.3)]. On multivariate analysis, poor cognition was associated with mRS score > 0 [OR 4.97 (1.30-19.0), p = 0.019], NIHSS score [OR 1.14 (1.02-1.28), p = 0.026], private insurance [OR 0.21 (0.06-0.76), p = 0.017] and BMI > 30 [OR 0.13 (0.03-0.56), p = 0.006].

CONCLUSIONS

Cognitive impairment after hemorrhagic stroke is less common in patients with BMI > 30 and private insurance. Heightened surveillance for non-obese patients without private insurance is suggested. Additional investigation into the relationship between cognition and both BMI and insurance type is needed.

Real world effectiveness, persistence, tolerability, and safety of ofatumumab in clinical practice

AIMS

To describe the 12-month effectiveness, persistence, tolerability, and safety of ofatumumab (OMB), a highly effective disease-modifying therapy (DMT) for relapsing multiple sclerosis (MS), in a real-world MS population.

PATIENTS & METHODS

Electronic medical records of patients starting OMB from October 2020 to August 2022 at two comprehensive MS centers were reviewed. Demographics and disease characteristics and 6- and 12-month clinical, patient-reported, and radiologic outcome measures were analyzed.

RESULTS

A total of 175 patients started OMB with mean age 44.9 (SD 10.4) and disease duration 13.6 (SD 9.6) years. The cohort was 74% female, included 81% White and 13% Black American patients, and consisted of 80% relapsing-remitting MS or clinically isolated syndrome. Most (87%) had prior DMT exposure with 38% switching from high efficacy DMT. Over 12 months, 9.7% discontinued OMB (mean 117 days, SD 99.2), with tolerability issues being the most common reason. Thirty-nine (22%) had relapses in the year before starting OMB. By 12 months, only 1 relapse had occurred after approximately 4 months post-treatment initiation.

DISCUSSION

This real-world study demonstrated that OMB is highly effective with robust persistence and good safety and tolerability by 12-month follow-up. Further analyses are planned to examine longer-term outcomes.

Multi-domain Online Therapeutic Investigation Of Neurocognition (MOTION) - A randomized comparative-effectiveness study of two remotely delivered mind-body interventions for older adults with cognitive decline

BACKGROUND

Research suggest that mind-body movement programs have beneficial effects on cognitive outcomes for older adults with cognitive decline. However, few studies have directly compared specific approaches to mind-body movement or studied the impact of remote program delivery.

METHODS

In a 3-arm randomized controlled trial (RCT) for older adults with cognitive impairment, we are comparing a multidomain mind-body program that emphasizes movement, body awareness, personal meaningfulness, and social connection, and a traditional Chinese mind-body exercise (Tai Chi) to a health and wellness education control condition. All 3 interventions are delivered remotely two times per week (onehour per session) for 12 weeks. The two active interventions are live-streamed. Outcomes are assessed prior to, after, and 6-months after the interventions. The co-primary outcomes are changes on the Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-cog) and brain functional connectivity in the Default Mode Network (DMN). Secondary outcomes include measures of specific cognitive domains (e.g., executive function, attention), mobility, and self-report measures of general well-being, quality of life, social engagement, self- and attention-regulation.

CONCLUSION

This RCT will directly compare the effects of two mind-body movement programs versus an education control delivered remotely over 12 weeks on cognitive, neuroimaging, and participant-reported outcomes. If successful, these programs may provide scalable strategies for slowing cognitive decline, which could potentially delay dementia onset in some individuals.

TRIAL REGISTRATION ID

NCT05217849.

Distinct clinical phenotypes and their neuroanatomic correlates in chronic traumatic brain injury

Accumulating evidence of heterogeneous long-term outcomes after traumatic brain injury (TBI) has challenged longstanding approaches to TBI outcome classification that are largely based on global functioning. A lack of studies with clinical and biomarker data from individuals living with chronic (>1 year post-injury) TBI has precluded refinement of long-term outcome classification ontology. Multimodal data in well-characterized TBI cohorts is required to understand the clinical phenotypes and biological underpinnings of persistent symptoms in the chronic phase of TBI. The present cross-sectional study leveraged data from 281 participants with chronic complicated mild-to-severe TBI in the Late Effects of Traumatic Brain Injury (LETBI) Study. Our primary objective was to develop and validate clinical phenotypes using data from 41 TBI measures spanning a comprehensive cognitive battery, motor testing, and assessments of mood, health, and functioning. We performed a 70/30% split of training (n=195) and validation (n=86) datasets and performed principal components analysis to reduce the dimensionality of data. We used Hierarchical Cluster Analysis on Principal Components with k-means consolidation to identify clusters, or phenotypes, with shared clinical features. Our secondary objective was to investigate differences in brain volume in seven cortical networks across clinical phenotypes in the subset of 168 participants with brain MRI data. We performed multivariable linear regression models adjusted for age, age-squared, sex, scanner, injury chronicity, injury severity, and training/validation set. In the training/validation sets, we observed four phenotypes: 1) mixed cognitive and mood/behavioral deficits (11.8%; 15.1% in the training and validation set, respectively); 2) predominant cognitive deficits (20.5%; 23.3%); 3) predominant mood/behavioral deficits (27.7%; 22.1%); and 4) few deficits across domains (40%; 39.5%). The predominant cognitive deficit phenotype had lower cortical volumes in executive control, dorsal attention, limbic, default mode, and visual networks, relative to the phenotype with few deficits. The predominant mood/behavioral deficit phenotype had lower volumes in dorsal attention, limbic, and visual networks, compared to the phenotype with few deficits. Contrary to expectation, we did not detect differences in network-specific volumes between the phenotypes with mixed deficits versus few deficits. We identified four clinical phenotypes and their neuroanatomic correlates in a well-characterized cohort of individuals with chronic TBI. TBI phenotypes defined by symptom clusters, as opposed to global functioning, could inform clinical trial stratification and treatment selection. Individuals with predominant cognitive and mood/behavioral deficits had reduced cortical volumes in specific cortical networks, providing insights into sensitive, though not specific, candidate imaging biomarkers of clinical symptom phenotypes after chronic TBI and potential targets for intervention.

Relationship between social support, functional outcomes and health-related quality of life in working-aged adults at three months after ischemic stroke: results from the FRAILTY study

BACKGROUND

The relationship between social support and functional outcomes and health-related quality of life (HRQoL) after ischemic stroke (IS) remains unclear, especially in working-aged patients.

AIM

To assess the relationship between perceived social support, functional outcomes, post-stroke psychosocial symptoms, and HRQoL in working-aged adults three months after IS.

METHODS

A prospective and correlational design was used. Patients of working age (18-65 years) admitted for first-ever IS were enrolled in the prospective FRAILTY (Factors Affecting the Quality of Life After Ischemic Stroke in Young Adults) study (NCT04839887). HRQoL (using the Stroke Impact Scale, Quality of Life in Neurological Disorders), social support (using the Multidimensional Scale of Perceived Social Support), functional outcomes (using a modified Rankin Scale-mRS), and post-stroke psychosocial symptoms were assessed three months after IS. Descriptive statistics, Wilcoxon signed-rank test, Spearman's correlations and multiple linear regression were used for analysis.

RESULTS

A total of 121 (54.5% males, mean age 51.7 ± 8.4 years) IS patients were analyzed. Of those, 87.7% had excellent clinical outcomes (mRS 0-1) after three months. Patients reported significant improvement in all domains of self-reported HRQoL except memory and communication after three months. The overall perceived social support was not associated with HRQoL domains. Post-stroke depression was negatively associated with all domains of HRQoL. Living arrangements (living alone) and post-stroke depression were negatively associated with perceived social support after IS.

CONCLUSIONS

More insight into the relationship between variables of HRQoL in working-aged adults might increase their social participation, strengthen supportive relationships, and promote their recovery and rehabilitation process. Focusing on the management of emotional problems and supporting functional outcomes may be modifiable factors that may represent targets for strategies to improve the HRQoL. Further research is needed to clarify the relationship between pre-stroke perceived social support and its types and post-stroke psychosocial symptoms in the long term.

Building consensus on clinical outcome assessments for BCI devices. A summary of the 10th BCI society meeting 2023 workshop

Objective: The 10th International brain computer interface (BCI) Society Meeting, 'Balancing Innovation and Translation', was held from the 6th to 9th of June 2023 in Brussels, Belgium. This report provides a summary of the workshop 'Building Consensus on Clinical Outcome Assessments (COAs) for BCI Devices'. This workshop was intended to give participants an overview of the current state of BCI, future opportunities, and how different countries and regions provide regulatory oversight to support the BCI community to develop safe and effective devices for patients.Approach: Five presentations and a panel discussion including representatives from regulators, industry, and clinical research stakeholders focused on how various stakeholders and the BCI community might best work together to ensure studies provide data that is useful for evaluating safety and effectiveness, including reaching consensus on COAs that represent clinically meaningful benefits and support regulatory and payor requirements. This report focuses on the regulatory and reimbursement requirements for medical devices and how to best measure safety and effectiveness and summarizes the presentations from five experts and the discussion between the panel and the audience.Main results: Consensus was reached on the following items specifically related to BCI: (i) the importance of and need for a new generation of COAs, (ii) the challenges facing the development of appropriate clinical outcome assessments, and (iii) that improvements in COAs should demonstrate obvious and clinically meaningful benefit(s). There was discussion on: (i) clinical trial design for BCIs and (ii) considerations for payor reimbursement and other funding.Significance: Whilst the importance of building community consensus on COAs was apparent, further collaboration will be required to reach consensus on which specific current and/or novel COAs could be used for the BCI field to evolve from research to market.

A Comparison of In-Person and Telehealth Treatment Modalities using the SpeechVive Device

Telehealth is increasing popular as a treatment option for people with Parkinson disease (PD). The SpeechVive device is a wearable device that uses the Lombard effect to help patients speak more loudly, slowly, and clearly. This study sought to examine the effectiveness of the device to improve communication in people with PD, delivered over a telehealth modality as compared to in-person, using implementation science design. 66 people with PD were enrolled for 12 weeks with 34 choosing the in-person group and 32 in the telehealth group. Participants were assessed pre-, mid-, and post-treatment. Participants produced continuous speech samples on and off the device at each timepoint. Sound pressure level (SPL), utterance length, pause frequency, and total pause duration were measured. Psychosocial surveys were administered to evaluate the effects of treatment on depression, self-efficacy, and participation. The in-person group increased SPL when wearing the device while the telehealth group did not. Both groups paused less often while wearing the device. Utterance length increased post-treatment for the telehealth group, but not for the in-person group. An increase in communication participation ratings in the telehealth group, but not the in-person group, was the only significant change in the psychosocial metrics. The in-person group showed similar treatment effects as previous studies. The device was not as effective in the telehealth group. One limitation was data loss due to recording issues that impacted the telehealth group more than the in-person group.

Eye Tracking during Passage Reading Supports Precise Oculomotor Assessment in Ataxias

Abnormal eye movements occur early in the course of disease in many ataxias. However, clinical assessments of oculomotor function lack precision, limiting sensitivity for measuring progression and the ability to detect subtle early signs. Quantitative assessment of eye movements during everyday behaviors such as reading has potential to overcome these limitations and produce functionally relevant measures. In this study, we analyze eye movements in individuals with ataxia during passage reading. Binocular gaze sampled at 1000 Hz was collected from 102 individuals with ataxia diagnoses (including 36 spinocerebellar ataxias, 12 Friedreich's ataxia, and 5 multiple system atrophy among other conditions) and 70 healthy controls participating in the Neurobooth study. Longitudinal data were available for 26 participants with ataxia. Saccades were categorized as progressive (rightward) saccades, regressive saccades, or sweeps (large displacement saccades primarily generated when scanning to the beginning of the next line) based on their direction and displacement. Saccade and fixation kinematics were summarized using 28 statistical features. A linear model was trained to estimate clinician-performed ataxia rating scale scores. Model scores were reliable (ICC=0.96, p<0.001) and demonstrated convergent validity with Brief Ataxia Rating Scale total (r=0.82, p<0.001), oculomotor (r=0.52, p<0.001), and speech (r=0.73, p<0.001) scores, as well as patient surveys. The scores were also sensitive to disease progression (d=0.36, p=0.03), demonstrated strong separability between healthy controls and participants with ataxias (AUC=0.89, p<0.001), and showed evidence of the ability to detect subclinical oculomotor patterns (AUC=0.69, p=0.02). Several kinematic saccade and fixation features demonstrated strong differences across disease severity groups. Notable features included the mean angular displacement of fixations (η 2=0.44, p<0.001), the number (η 2=0.27, p<0.001) and frequency of saccades (η 2=0.25, p<0.001), and the proportion of regressive saccades (η 2=0.11, p<0.001). Quantitative assessment of eye movements during passage reading were highly informative of ataxia severity, were sensitive to disease progression, and enabled detection of subclinical signs. These properties support the inclusion of video-oculography-based measures of reading in natural history studies and clinical trials. Furthermore, this study demonstrates the feasibility of integration of oculomotor assessments in clinical workflows.

Focused Ultrasound Neuromodulation: Exploring a Novel Treatment for Severe Opioid Use Disorder

BACKGROUND

Opioid use disorder remains a critical health care challenge because current therapeutic strategies have limitations that result in high recurrence and deaths. We evaluated the safety and feasibility of focused ultrasound (FUS) neuromodulation to reduce substance cravings and use in severe opioid and co-occurring substance use disorders.

METHODS

This prospective, open-label, single-arm study enrolled 8 participants with severe, primary opioid use disorder with co-occurring substance use. Participants received a 20-minute session of low-intensity FUS (220 kHz) neuromodulation targeting the bilateral nucleus accumbens (NAc) with follow-up for 90 days. Outcome measures included safety, tolerability, feasibility, and effects of FUS neuromodulation by assessment of adverse events, substance craving, substance use (self-report, urine toxicology), mood, neurological examinations, and anatomical and functional magnetic resonance imaging (fMRI) at 1, 7, 30, 60, and 90 days post-FUS.

RESULTS

No serious device-related adverse events or imaging abnormalities were observed. Following FUS, participants demonstrated immediate (p < .002) and sustained (p < .0001; mean 91%) reductions in cue-induced opioid craving, with median ratings on a scale from 0 to 10 as follows: 6.9 (pre-FUS) versus 0.6 (90-day post-FUS). Craving reductions were similar for other illicit substances (e.g., methamphetamine [p < .002], cocaine [p < .02]). Decreases in opioid and co-occurring substance use were confirmed by urine toxicology. Seven participants remained abstinent at 30 days; 5 participants remained abstinent throughout 90 days post-FUS. Resting-state fMRI demonstrated decreased connectivity from the NAc to reward and cognitive regions post-FUS.

CONCLUSIONS

NAc FUS neuromodulation is safe and a potential adjunctive treatment for reducing drug cravings and use in individuals with severe opioid and co-occurring substance use disorders. Larger, sham-controlled, randomized studies are warranted.

Comparative Effectiveness of In-Person and Virtual Picture-Naming Treatment for Poststroke Anomia

PURPOSE

In light of COVID-19, telepractice for speech therapy has been increasingly adopted. Telepractice promotes accessibility to therapy services for those in rural environments, lowers the frequency of missed appointments, and reduces the costs of rehabilitation. The efficacy of telepractice has been scarcely explored in the aphasia literature. Preliminary research has demonstrated comparable results of telepractice and in-person therapy for people with aphasia, but the current scope of research is insufficient to guide clinical practice. The present study examined whether the virtual administration of a picture-naming therapy paradigm was as effective as in-person administration.

METHOD

The treatment effects of two similar clinical trials, one completed in-person (n = 13) and one completed virtually (n = 13), are compared. Participants were adults with chronic (> 6 months) poststroke aphasia. Both clinical trials administered Cued Picture-Naming Therapy 4 days a week for 2 weeks (eight treatment sessions). Treatment outcomes were analyzed using Tau-U effect sizes and Mann-Whitney U tests.

RESULTS

Weighted Tau-U averages showed an advantage of telepractice over in-person treatment in the acquisition effects of trained words, with participants demonstrating a very large effect (0.84, p < .01) following telepractice and a large effect (0.75, p < .01) following in-person treatment. Both telepractice and in-person rehabilitation demonstrated significant treatment effects and were not significantly different from each other per Mann-Whitney U independent-samples t tests.

CONCLUSIONS

The present study demonstrated that telepractice of a picture-naming paradigm is as effective as in-person treatment administration. This justifies the use of telepractice to overcome accessibility and cost barriers to speech therapy administration and justifies taking patient preference into account. Future research should explore the efficacy of telepractice for treatments that promote greater generalizability to functional communication.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27641031.

Management of Velopharyngeal Impairment in Adults With Dysarthria: A Systematic Review

PURPOSE

Velopharyngeal impairment (VPI) is a common manifestation of dysarthria, yet there is uncertainty regarding the evidence for treatment options. The aim of this systematic review was to identify and evaluate published intervention studies of VPI and to update the original Practice Guidelines for VPI, as part of the Dysarthria Writing Group of the Evidence-Based Clinical Research Committee of the Academy of Neurologic Communication Disorders and Sciences.

METHOD

Four electronic databases were searched for articles published through September 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. Multiple indices of methodological quality and risk of bias were used to evaluate studies.

RESULTS

The search yielded 1,347 articles, of which 31 met inclusion criteria and were reviewed by two blinded co-investigators and a third consensus reviewer. Therapeutic approaches centered on prosthetic treatment (n = 13), prosthetic treatment combined with another form of therapy (n = 7), and behavioral exercise (n = 7), with four additional studies reporting unconventional approaches (e.g., use of medication). No single treatment approach garnered strong evidence. However, converging moderate evidence suggests positive treatment outcomes for prosthetic approaches for moderate-severe speakers with flaccid/spastic dysarthria and behavioral treatment approaches for speakers spanning a range of nonprogressive dysarthrias.

CONCLUSIONS

There is a critical need for well-controlled treatment studies of VPI that incorporate comprehensive and systematic description of baseline speech function, treatment protocols, and operationally defined outcome measures, particularly related to social validity and participation goals. Suggestions for how clinicians can apply extant research findings to practice are provided.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27655566.

Optimizing rare disorder trials: a phase 1a/1b randomized study of KL1333 in adults with mitochondrial disease

Over the past two decades there has been increased interest in orphan drug development for rare diseases. However, hurdles to clinical trial design for these disorders remain. This phase 1a/1b study addressed several challenges, while evaluating the safety and tolerability of the novel oral molecule KL1333 in healthy volunteers and subjects with primary mitochondrial disease. KL1333 aims to normalize the NAD+:NADH ratio that is critical for ATP production. The trial incorporated innovative design elements with potential translatability to other rare diseases including patient involvement, adaptive design and exploratory objectives, all of which have subsequently informed the protocol of an ongoing phase 2, pivotal efficacy study of KL1333. Results indicate KL1333 is safe and well tolerated, with dose-dependent gastrointestinal side effects, and validate potential novel outcome measures in primary mitochondrial disease including the 30-s Sit to Stand, and the patient-reported fatigue scales. Importantly, the data from the trial support efficacy of KL1333 based on improvements in fatigue and functional strength and endurance. Furthermore, the study highlights the value in using phase 1 studies to capture data that helps optimize later phase efficacy trial design.

Changes in Subjective Cognitive and Social Functioning in Parkinson's Disease from Before to During the COVID-19 Pandemic

Background/Objectives: Social isolation and health-related consequences of the COVID-19 pandemic may have significantly impacted quality of life in people with Parkinson's disease (PwPD). The effect of the COVID-19 pandemic specifically on subjective cognition and social functioning in PwPD is poorly understood. We conducted a longitudinal analysis of changes in subjective cognitive and social functioning in PwPD before (T1, 2017-2019) and during (T2, 2021) the COVID-19 pandemic. Methods: At T1, 347 PwPD completed online surveys. At T2, 123 of them (54 males, 69 females) responded to follow-up questionnaires including Quality of Life in Neurological Disorders (Neuro-QoL) subscales, Beck Depression Inventory-II, Parkinson's Anxiety Scale, motor and non-motor experiences of daily living from the MDS-Unified Parkinson's Disease Rating Scale, and the Coronavirus Impact Scale. Results: T1-T2 declines in subjective cognition and social functioning both were correlated with more anxiety, fatigue, and motor symptoms. Additionally, declines in subjective cognition correlated with depression, and with decline in social functioning. Women reported greater COVID-19 impact than men, unrelated to cognition and social functioning; in men, personal experience with COVID-19 was associated with decline in subjective cognition. Conclusions: Our finding that subjective cognition and social functioning are associated with different motor and non-motor symptoms of PD suggests that the impacts of PD on subjective cognition and social functioning are complex, which has important implications for treatment.

Beyond the Nest: The Role of Financial Independence in Young Adult Health

BACKGROUND

This study aimed to examine the impact of neighborhood conditions and household material hardship experiences on young adult health outcomes, while also considering financial autonomy as a critical determinant of health.

METHOD

We employed a cross-sectional observational design with a diverse sample of young adults from a large urban university. Structural equation modeling was used to analyze the relationships between neighborhood conditions and material hardship with health outcomes by financial autonomy.

RESULTS

Material hardship and neighborhood conditions were significantly related to various health outcomes among young adults. Food insecurity emerged as a significant mediator linking neighborhood conditions to health including global physical health, cognitive functioning, and depression. Financially independent young adults showed stronger direct and indirect effects of neighborhood conditions on health compared to financially dependent counterparts.

CONCLUSION

This study underscores the complex interplay of neighborhood conditions, household material hardship, and financial autonomy in shaping young adult health. Our findings also suggest how the impact of SDOH on young adult health may have long-term effects later in life. Future research should consider these factors comprehensively to address disparities in emerging adult health.

Effects of Situational Loneliness on Mental Health and Sleep Health Outcomes among White Older Adults during the COVID-19 Pandemic

OBJECTIVES

This study examined the cross-sectional and 2-year prospective associations between situational loneliness and health outcomes in older adults during the COVID-19 pandemic.

METHODS

Data were collected using an online survey that evaluated behaviors (e.g., socialization) and health outcomes at two points (May-June 2020 and October-November 2022) during the pandemic. Logistic regression was used to analyze the cross-sectional associations between situational loneliness and health outcomes (i.e., depressive symptoms, anxiety symptoms, and sleep health) while linear regression was used to examine the prospective associations.

RESULTS

In a sample of 428 older adults (age 65 +), situational loneliness was associated with short-term, but not long-term, increases in depressive symptoms, anxiety symptoms, and problems with sleep.

CONCLUSION

Findings suggest that the older adult population demonstrates resilience in the face of short-term increases in loneliness. Thus, promoting resilience may be a promising strategy for mitigating the negative consequences of situational loneliness.

Impact of Upper Limb Function on Activities of Daily Living and Quality of Life in Huntington's Disease

Background/Objectives: Huntington's disease (HD) is a neurodegenerative movement disorder associated with significant disability and impairment of Activities of Daily Living (ADLs). The impact of upper limb disability on quality of life (QoL) and its influence on ADLs is not well known yet. The aim of this study was to describe the manipulative dexterity, strength, and manual eye coordination of patients with manifest and premanifest-HD compared to healthy individuals and to analyze its influence on ADLs and QoL. Methods: We performed an observational, cross-sectional study including 71 ambulatory participants (27 manifest-HD patients, 15 premanifest-HD, and 29 controls). We gathered sociodemographic data, as well as clinical data, including cognition (MMSE), HD motor severity (Unified HD rating scale, UHDRS-TMS), QoL (Neuro-QoL), and ADLs (HD-ADL). Hand dexterity and strength in the dominant and non-dominant hand were assessed with the Nine Hole Peg Test, Ten Neurotest, Nut and Bolt Test, dynamometry, and Late-Life FDI. Analysis of covariance (ANCOVA) models were performed to investigate differences in hand function between manifest-HD, premanifest-HD, and controls. Results: Manifest-HD patients had significantly worse performance in manual and finger dexterity, fine-motor coordination, and poorer handgrip strength than premanifest-HD and controls. Premanifest-HD required more time to complete the test than controls. Significant correlations were found between hand variables and Late-Life FDI, Neuro-QoL, HD-ADL, and UHDRS-TMS. Conclusions: HD affects manipulative dexterity and hand function in premanifest and manifest patients. Therefore, to prevent disability and decreased QoL, evaluating the progression of upper limb dysfunction in HD is important to offer the best possible therapeutic interventions.

SPOON: an observational, cross-sectional study of perceptions and expectations of adults with generalised myasthenia gravis in France

OBJECTIVES

To capture patient perceptions about living with myasthenia gravis (MG) with respect to aspirations and ways to improve treatment.

DESIGN

Online patient survey.

SETTING

Patients recruited by MG patient associations or at MG reference treatment centres.

PARTICIPANTS

Adults with physician-diagnosed generalised MG, living in France for ≥12 months, who had received ≥1 MG treatment were eligible. 291 patients opened the questionnaire, 255 were eligible and 246 completed the survey (age range 41-67 years; 187 women and 59 men).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary: free-text response to the question 'Living with your disease, what would you like to do that you currently find difficult or impossible to do?' Secondary: free-text response to the question 'What improvements do you think could be made to treatments for MG?' Themes from replies to these questions were analysed using grounded theory and cluster analysis.

RESULTS

For the disease aspirations question, 617 citations were provided by 238 participants, which were grouped into 45 dimensions and six high-level domains (physical activity, activities of daily living, psychological burden, social activities, work/school and other). The most frequently cited dimensions were sport (82 citations), greater mobility (56 citations), being less tired (46 citations) and greater endurance (37 citations). Younger age, female gender, recent diagnosis and poorer quality of life were associated with citing more themes. For the treatment amelioration question, 263 citations were provided by 195 participants, which were grouped into 60 dimensions and three high-level domains (medication characteristics, safety and care paradigm). The most cited treatment-related dimensions were fewer side effects (40 citations), fewer daily medication intakes (21 citations) and fewer digestive side effects (20 citations).

CONCLUSIONS

These findings could help healthcare professionals to understand and better address patients' aspirations about living with MG, notably concerning the importance of physical activity, and their expectations for improved treatments.

A digital intervention for cognitive deficits following COVID-19: a randomized clinical trial

Post-COVID-19 cognitive deficits are common, persistent, and disabling. Evidence on effective treatments is limited. The goal of this study was to investigate the efficacy of a digital intervention to reduce cognitive and functional deficits in adults with persistent post-COVID-19 cognitive dysfunction. We used the remotely-delivered intervention in a randomized clinical trial conducted from July 13, 2021 to April 26, 2023. We hypothesized that participants in the intervention group would improve in measures of cognition and daily functioning. Participants were adults with cognitive deficits persisting >4 weeks following acute COVID-19 illness. Of 183 participants screened, 110 were enrolled; 98 participants (78.6% female; mean age = 48.1) completed at least one study visit. Participants were randomized 1:1 to the intervention (AKL-T01) or waitlist control. AKL-T01 is a digital therapeutic using a videogame interface to target attention and executive control. The intervention was delivered remotely for 6 weeks. The primary outcome was change in performance on a sustained attention measure (Digit Symbol Matching Task). The difference in the primary outcome between the intervention (n = 49) and controls (n = 49) was not statistically significant (F [3,261] = 0.12, p = 0.95). Secondary cognitive outcomes of task-switching (F[3,262] = 2.78, p = 0.04) and processing speed (F[3,267] = 4.57, p = 0.004) improved in the intervention relative to control. Secondary measures of functioning also improved in the intervention relative to control, including disability (F[1,82] = 4.02, p = 0.05) and quality of life (F[3,271] = 2.66, p = 0.05). Exploratory analyses showed a greater reduction in total fatigue (F[1,85] = 4.51, p = 0.04), cognitive fatigue (F[1,85] = 7.20, p = 0.009), and anxiety (F[1,87] = 7.42, p = 0.008) in the intervention relative to control. Despite the lack of improvement in sustained attention, select post-COVID-19 cognitive deficits may be ameliorated by targeted cognitive training with AKL-T01, with associated improvements in quality of life and fatigue. If replicated, the scalable nature of this digital intervention may help address substantial need for accessible, effective treatments among individuals with long COVID.

Sleep fragmentation despite intact rest-activity patterns in premanifest Huntington's disease: An actigraphy study

OBJECTIVE

Sleep research in Huntington's disease (HD) has primarily focused on manifest HD, with significantly less attention given to premanifest HD (Pre-HD). Therefore, we investigated sleep and rest-activity patterns in people with Pre-HD versus healthy controls (HC).

METHODS

We conducted a cross-sectional study including 36 Pre-HD and 48 HC participants. Pre-HD participants were stratified into three groups according to their proximity to estimated diagnosis, using a cytosine-adenine-guanine (CAG) and current age-based predictive model: NEAR (<9 years to diagnosis), MID (9-15 years to diagnosis) and FAR (>15 years to diagnosis). Sleep and rest-activity patterns were assessed using wrist-worn actigraphy, a sleep diary, and sleep questionnaires.

RESULTS

NEAR and MID groups experienced higher fragmentation index than HC and FAR groups. NEAR and MID groups also exhibited greater WASO than the FAR group. NEAR and MID groups showed lower intra-daily variability (IV) than HC and FAR groups, with the NEAR group also being more active in the most active 10 h (M10). Groups did not differ on subjective sleep measures, inter-daily stability (IS), sleep regularity index, relative amplitude, or amount of activity in the least active 5 h (L5). Considering all Pre-HD participants, fewer years to diagnosis, higher CAG-age-product (CAP) scores (a measure of cumulative exposure to the HD-causing gene mutation) and larger CAG repeat lengths correlated with higher WASO, fragmentation index, L5, IS, and lower sleep efficiency and IV. Higher CAP score correlated with higher M10.

CONCLUSIONS

Despite intact rest-activity patterns and similar subjective sleep quality to HC, greater sleep fragmentation is a prominent and early feature in Pre-HD. Therefore, reducing sleep fragmentation may be a potential target for sleep intervention in HD. Longitudinal studies using larger samples are needed to assess sleep across the disease spectrum and its impact on clinical outcomes, like cognition.

Respiratory Strength Training Versus Respiratory Relaxation Training in the Rehabilitation of Physical Impairment, Function, and Return to Participation After Stroke: Protocol for a Randomized Controlled Trial

BACKGROUND

Persistent disability in chronic stroke survivors is often attributed to arm or leg weakness; however, respiratory muscle weakness also impedes poststroke rehabilitation, reduces quality of life, and increases the risk of health complications. Respiratory complications are common after stroke and place patients at risk for both prolonged functional disability and mortality. In addition, stroke survivors face ongoing cardiovascular disease that places them at risk for recurrent stroke.

OBJECTIVE

The study aims to compare the effects of 2 respiratory training programs, paired with individualized flexibility, strengthening, and cardiovascular exercise programs, on physiologic, activity, and societal participation outcomes in chronic stroke survivors.

METHODS

This study will be a randomized controlled trial. Participants are 80 community-dwelling adults with chronic stroke. In conjunction with a 24-session (3 times/week for 8 weeks), American Heart Association-informed, whole-body exercise program, participants will be randomized to receive either respiratory strength training or respiratory relaxation training. Study intervention will be directed by a physical therapist and take place in a community fitness center. Outcome assessments will occur in a clinical research center. The primary outcome measure is maximal respiratory pressure. Secondary outcome measures include airway clearance, walking endurance, spatial-temporal gait characteristics, community walking, functional strength and fatigue, depression, and societal participation measures. Longer-term societal participation is a complex domain that may be influenced by other factors beyond physical function. Participants' health status will be monitored for 1 year following the intervention for falls, respiratory illness, and hospitalizations. Additional subanalyses will evaluate the effect of smoke exposure on short- and long-term outcomes. Outcome assessors are blinded to group assignments. Respiratory relaxation training is an active comparator, but no pure control group is included.

RESULTS

This study was funded in March 2020 with enrollment commencing in November 2020. Completion of enrollment is projected for May 2025 with a study projected end date of April 2026. Published results are anticipated in Fall 2026.

CONCLUSIONS

Results from this study will improve our understanding of the additive benefits of respiratory exercises on short- and long-term physiologic, functional, and societal gains for these individuals. These data will be instructive to meet a current unmet rehabilitative need to promote patient-centered care and contribute to decreasing morbidity and mortality in chronic stroke survivors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05819333; https://clinicaltrials.gov/study/NCT05819333.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59749.

Four New Patient-Reported Outcome Measures Examining Health-Seeking Behavior in Persons With Type 2 Diabetes Mellitus (REDD-CAT): Instrument Development Study

BACKGROUND

The management of type 2 diabetes mellitus (T2DM) includes mastery of complex care activities, self-management skills, and routine health care encounters to optimize glucose control and achieve good health. Given the lifelong course of T2DM, patients are faced with navigating complex medical and disease-specific information. This health-seeking behavior is a driver of health disparities and is associated with hospitalization and readmission. Given that health-seeking behavior is a potentially intervenable social determinant of health, a better understanding of how people navigate these complex systems is warranted.

OBJECTIVE

To address this need, we aimed to develop new patient-reported outcome (PRO) measures that evaluate health-seeking behavior in persons with T2DM. These new PROs were designed to be included in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system, which includes several other PROs that capture the importance of social determinants of health.

METHODS

Overall, 225 participants with T2DM completed 56 self-report items that examined health-seeking behaviors. Classical Test Theory and Item Response Theory were used for measurement development. Exploratory factor analysis (EFA; criterion ratio of eigenvalue 1 to eigenvalue 2 being >4; variance for eigenvalue 1 ≥40%) and confirmatory factor analysis (CFA; criterion 1-factor CFA loading <.50; 1-factor CFA residual correlation >.20; comparative fit index ≥0.90; Tucker-Lewis index ≥0.90; root mean square error of approximation <0.15) were used to determine unidimensional sets of items. Items with sparse responses, low-adjusted total score correlations, nonmonotonicity, low factor loading, and high residual correlations of high error modification indices were candidates for exclusion. A constrained graded response model was used to examine item misfit, and differential item functioning was examined to identify item bias. Cronbach α was used to examine internal consistency reliability for the new PROs (criterion ≥0.70), and floor and ceiling effects were examined (criterion ≤20%).

RESULTS

Four unidimensional sets of items were supported by EFA (all EFA eigenvalue ratios >4; variance for eigenvalue 1=41.4%-67.3%) and CFA (fit statistics all exceeded criterion values). This included (1) "Health-Seeking Behavior: PCP-Specific" (6 items); (2) "Health-Seeking Behavior: General Beliefs" (13 items); (3) "Health-Seeking Behavior: Family or Friends-Specific" (5 items); and (4) "Health-Seeking Behavior: Internet-Specific" (4 items). All items were devoid of differential item functioning for age, sex, education, or socioeconomic status factors. "Health-Seeking Behavior: General Beliefs" was developed to include both a computer adaptive test and a 6-item short form version; all other PROs were developed as static short forms. The psychometric reliability of these new PROs was supported; internal consistency ranged from acceptable to excellent (Cronbach α=.78-.91), and measures were free of significant floor or ceiling effects (floor effects range: 0%-8.9%; ceiling effects range: 0%-8.4%).

CONCLUSIONS

The new REDD-CAT Health-Seeking Behavior PROs provide reliable assessments of health-seeking behaviors among those with T2DM.

Apathy and Functional Status in Early-Stage Huntington's Disease

OBJECTIVE

Apathy is common in Huntington's disease (HD) and difficult to treat. Multiple recent calls have been made to increase understanding of apathy across the spectrum of HD severity. Functional status is an important outcome in HD trials; however, no consensus currently exists regarding the impact of apathy on functional status in HD. The authors aimed to identify correlates of apathy and effects on functional status in a primarily early-stage HD sample.

METHODS

This study included secondary analyses of data from a study of neuropsychiatric symptoms in a clinical HD sample. Spearman correlation analyses were used to assess the relationships between apathy (with the Frontal Systems Behavior Scale-Apathy [FrSBe-Apathy] subscore), clinical variables, and patient-reported outcomes. To assess the association of apathy with functional status, two multiple regression analyses were performed, with a different functional status measure (Adult Functional Adaptive Behavior [AFAB] scale or Total Functional Capacity [TFC] scale) as the dependent variable in each analysis.

RESULTS

Statistically significant correlates of apathy included the Quality of Life in Neurological Disorders (Neuro-QoL) Satisfaction With Social Roles and Activities and Neuro-QoL Positive Affect and Well-Being scores (N=70 patients). Univariate correlation analyses also revealed statistically significant associations of FrSBe-Apathy scores with both functional status measures. In the multiple regression analyses, apathy significantly contributed to variability in functional status as measured by both the AFAB (N=49 patients) and TFC (N=56 patients) scales.

CONCLUSIONS

These results underscore the need to address apathy as a target for improving functional status, social satisfaction, and well-being in HD, even for individuals with early-stage HD.

Persistent symptoms after COVID-19: an Australian stratified random health survey on long COVID

OBJECTIVE

To determine the impact of persistent symptoms after coronavirus disease 2019 (COVID-19) in an Australian population.

DESIGN, SETTING, PARTICIPANTS

We conducted a statewide health survey of a stratified random sample of adults who had had a confirmed acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19-positive group) and their close contacts (control group). The sample was drawn from Victoria's COVID-19 database between January 2020 and October 2022. Data were collected from 12 688 survey respondents between September 2022 and April 2023 (11 174 in the COVID-19-positive group and 1514 in the control group).

MAIN OUTCOME MEASURES

Persistent new symptoms, recovery, and daily function using validated questionnaires for fatigue, neurocognitive symptoms, anxiety, depression and quality of life.

RESULTS

At a mean of 12.6 months after infection, 4560 respondents in the COVID-19-positive group (39.1%; 95% CI, 37.9-40.3%) reported at least one persistent new symptom, compared with 216 respondents in the control group (20.8%; 95% CI, 18.5-23.1%). A total of 1656 respondents (14.2%; 95% CI, 13.4-15.0%) were classified as having clinical long COVID using the criteria of at least one persistent new symptom and less than 80% recovery three months after the infection. Of the respondents with clinical long COVID, 535 (3.2%; 95% CI, 2.6-3.8%) reported at least moderate problems with usual activities at 12 months after their infection. The proportion of respondents with clinical long COVID was lower for those with more recent infections. The risk factors for clinical long COVID were female sex, age 40-49 years, infection severity, chronic illness, and past anxiety or depression. Factors associated with a decreased risk of having clinical long COVID included infection when the Omicron strain was dominant and infection when the Delta strain was dominant, as compared with when the ancestral strain of the virus was dominant.

CONCLUSION

Persistent symptoms after COVID-19 are common, though with a lower incidence following infection from less virulent strains. Although long COVID can be largely managed in primary care, a minority of people who have persistent symptoms and impaired function may require specialist care pathways, the effectiveness of which should be a focus of future research.

The Impact of Functionality and Psychological Outcome on Social Engagement 3-months after Intracerebral Hemorrhage

BACKGROUND

Although it is well-known that intracerebral hemorrhage (ICH) is associated with physical and psychological morbidity, there is scant data on factors influencing social engagement after ICH. Understanding the relationship between functionality, psychological outcome and social engagement post-bleed may facilitate identification of patients at high risk for social isolation after ICH.

METHODS

Patients ≥18-years-old with non-traumatic ICH from January 2015-March 2023 were identified from the Neurological Emergencies Outcomes at NYU (NEON) registry. Data on discharge functionality were collected from the medical record. 3-months post-bleed, patients/their legally-authorized representatives (LARs) were contacted to complete Neuro-QoL social engagement, anxiety, depression, and sleep inventories. Patients were stratified by ability to participate in social roles and activities (good=T-score>50, poor=T-score≤50) and satisfaction with social roles and activities (high=T-score>50 and low=T-score≤50). Univariate comparisons were performed to evaluate the relationship between post-bleed social engagement and both functionality and psychological outcome using Pearson's chi-square, Fisher's Exact test, and Mann-Whitney U tests. Multivariate logistic regression was subsequently performed using variables that were significant on univariate analysis (p<0.05).

RESULTS

The social engagement inventories were completed for 55 patients with ICH; 29 (53 %) by the patient alone, 14 (25 %) by a LAR alone, and 12 (22 %) by both patient and LAR. 15 patients (27 %) had good ability to participate in social roles and activities and 10 patients (18 %) had high satisfaction with social roles and activities. Social engagement was associated with both functionality and psychological outcome on univariate analysis, but on multivariate analysis, it was only related to functionality; post-bleed ability to participate in social roles and activities was associated with discharge home, discharge GCS score, discharge mRS score, and discharge NIHSS score (p<0.05) and post-bleed satisfaction with social roles and activities was related to discharge mRS score and discharge NIHSS score (p<0.05).

CONCLUSION

In patients with nontraumatic ICH, social engagement post-bleed was related to discharge functionality, even when controlling for depression, anxiety, and sleep disturbance.

Career duration and later-life health conditions among former professional American-style football players

OBJECTIVES

Career duration is often used as a metric of neurotrauma exposure in studies of elite athletes. However, as a proxy metric, career length may not accurately represent causal factors, and associations with health outcomes may be susceptible to selection effects. To date, relationships between professional American-style football (ASF) career length and postcareer health remain incompletely characterised.

METHODS

We conducted a survey-based cross-sectional cohort study of former professional ASF players. Flexible regression methods measured associations between self-reported career duration and four self-reported health conditions: pain, arthritis, mood and cognitive symptoms. We also measured associations between career duration and four self-reported ASF exposures: prior concussion signs and symptoms (CSS), performance enhancing drugs, intracareer surgeries and average snaps per game. Models were adjusted for age and race.

RESULTS

Among 4189 former players (52±14 years of age, 39% black, 34% lineman position), the average career length was 6.7±3.9 professional seasons (range=1-20+). We observed inverted U-shaped relationships between career duration and outcomes (all p<0.001), indicating that adverse health effects were more common among men with intermediate career durations than those with shorter or longer careers. Similar findings were observed for play-related exposures (eg, CSS and snaps).

CONCLUSIONS

Relationships between ASF career duration and subsequent health status are non-linear. Attenuation of the associations among longer career players may reflect selection effects and suggest career length may serve as a poor proxy for true causal factors. Findings highlight the need for cautious use of career duration as a proxy exposure metric in studies of former athletes.

Sensor-Acquired Reachable Workspace (RWS) Correlates with Activities of Daily Living (ADL) Function in Stroke as Measured by Functional Independence Measure (FIM) Self-Care

Optimal upper extremity motor control and range of motion are necessary to achieve even the basic activities of daily living (ADL) function. Stroke, with resulting hemiparesis, can significantly and negatively impact an individual's ADL function. Functional Independence Measure (FIM) self-care score can provide an assessment of what aspects and to what degree ADL functions are impaired. FIM self-care assessment can also track changes in ADL function during stroke recovery and rehabilitation. Recently, the sensor-acquired 3D motion analysis of stroke patients' upper extremity has shown promise as a potential alternative to assess ADL function. This observational study evaluates whether the sensor-acquired upper extremity reachable workspace (RWS) measure correlates with clinician-evaluated FIM self-care score in stroke patients. Seventeen patients with stroke were enrolled in the study. FIM self-care, NeuroQoL upper extremity, and reachable workspace outcome measures (relative surface area, RSA) were collected upon rehabilitation hospital admission, at discharge, and at the 3-month visit. Pearson and Spearman's rank correlation coefficients as well as multiple linear regression analyses were used to determine the relationships between FIM self-care, NeuroQoL, and reachable workspace RSAs. Moderately strong correlation between total reachable workspace RSA and total FIM self-care score at discharge and at 3 months were noted (r = 0.619, r = 0.661, p < 0.05), and similarly strong correlation was also noted with the upper extremity NeuroQoL total score (r = 0.690, r = 0.815, p < 0.05). Multiple linear regression analyses revealed a change in average bilateral total RSA of 0.1 unit from admission to the 3-month follow-up correlated with a respective change in the FIM self-care score of 2.011 points (95%CI: 0.663-3.360). Longitudinal improvement in ADL function during stroke rehabilitation and recovery process is correlated with improvement in reachable workspace.

Neurologic Quality of Life Outcomes in Patients with Normal Pressure Hydrocephalus After Ventriculoperitoneal Shunt Placement: A Prospective Assessment of Cognition, Mobility, and Social Participation

BACKGROUND

Idiopathic normal pressure hydrocephalus (iNPH) typically presents with gait disturbances, cognitive decline, and urinary incontinence. Symptomatic improvement generally occurs following shunt placement, but limited evidence exists on the quality of life (QOL) metrics in iNPH. Therefore, we conducted a prospective study of the effect of shunt placement on QOL in iNPH patients, using Quality of Life in Neurologic Disorders (Neuro-QOL) metrics.

METHODS

Eligible patients underwent shunt placement after evidence of symptomatic improvement following temporary cerebrospinal fluid diversion via inpatient lumbar drain trial. Patients were administered short- and long-form Neuro-QOL assessments prior to shunt placement and at 6-month and 1-year postoperative timepoints to evaluate lower extremity mobility, cognitive function, and social roles and activities participation. Changes in QOL measures were analyzed using a repeated-measures linear mixed effects model.

RESULTS

There were 48 patients with a mean age of 75.4 ± 6.3 years. Average short-form mobility scores improved by 3.9 points (14.6%) at 6-month follow-up and by 6.2 points (23.2%) at 1-year follow-up compared with preoperative baseline (P = 0.027 and P = 0.0002, respectively). Short-form cognition scores increased by 5.2 points (22.4%) at 6 months and 10.9 points (47.0%) at 1 year postoperatively (P = 0.007 and P < 0.0001, respectively). On long-form assessment, social roles and activity participation scores improved by 29.3 points (23.4%) at 6 months and 31.6 points (25.2%) at 1 year after surgery compared to baseline (P = 0.028 and P = 0.02, respectively).

CONCLUSIONS

Our findings demonstrate that shunt placement leads to improved QOL in iNPH patients across multiple domains. Significant improvements in mobility, cognition, and social roles and activity participation are realized within the first 6 months and are sustained on 1-year follow-up.

Anxiety Symptoms and Disease Severity in Parkinson Disease

ABSTRACT

BACKGROUND: Anxiety is prevalent in Parkinson disease (PD), negatively affecting quality of life for patients and their families. Targeted anxiety interventions are needed that account for variables such as disease severity; however, there is insufficient evidence regarding the trajectory of anxiety along the disease course. OBJECTIVE: The aim of this study was to investigate the association between disease severity and anxiety symptoms in a PD sample. METHODS: This descriptive study used secondary data analyses of data from a web-based survey study of individuals with PD in the United States. Participants were 21 years or older, had access to the Internet, and were given a diagnosis of PD (N = 72). We performed multiple regression analyses to assess the relationship between patient-reported disease severity and anxiety symptoms. RESULTS: There was a statistically significant association between disease severity and anxiety symptoms in people with PD, after controlling for all 5 explanatory variables (sex, age, wearing off, disease severity, and disease duration) ( P < .001). Age and wearing off PD medication also had statistically significant, although smaller, effects on anxiety symptoms ( P < .05). CONCLUSION: Disease severity was related to increased anxiety symptoms among individuals with PD. Anxiety intervention research is needed, and future studies should account for variations in disease severity and medication effects in both intervention and study design.

Age of First Exposure Does Not Relate to Post-Career Health in Former Professional American-Style Football Players

OBJECTIVE

Prior studies examining small samples of symptomatic former professional football players suggest that earlier age of first exposure (AFE) to American football is associated with adverse later life health outcomes. This study examined a larger, more representative sample of former professional American football players to assess associations between AFE before age 12 (AFE < 12) and clinical outcomes compared with those who started at age 12 or older (AFE 12 +).

METHODS

Former professional American football players who completed a questionnaire were dichotomized into AFE < 12 and AFE 12 + . AFE groups were compared on outcomes including symptoms of depression and anxiety, perceived cognitive difficulties, neurobehavioral dysregulation, and self-reported health conditions (e.g., headaches, sleep apnea, hypertension, chronic pain, memory loss, dementia/Alzheimer's disease, and others).

RESULTS

Among 4189 former professional football players (aged 52 ± 14 years, 39% self-reported as Black), univariable associations with negligible effect sizes were seen with AFE < 12, depressive symptoms (p = 0.03; η2 = 0.001), and anxiety-related symptoms (p = 0.02; η2 = 0.001) only. Multivariable models adjusting for age, race, body mass index, playing position, number of professional seasons, and past concussion burden revealed no significant relationships between AFE < 12 and any outcome. Linear and non-linear models examining AFE as a continuous variable showed similar null results.

CONCLUSIONS

In a large cohort of former professional American-style football players, AFE was not independently associated with adverse later life outcomes. These findings are inconsistent with smaller studies of former professional football players. Studies examining AFE in professional football players may have limited utility and generalizability regarding policy implications for youth sports.

Motor and Non-Motor Factors of Concern About Falling and Fear of Falling in Multiple Sclerosis

BACKGROUND AND PURPOSE

Despite the frequency of concern about falling (CAF) and fear of falling (FOF) in multiple sclerosis (MS), there remains a lack of clarity between FOF and CAF, though persons with MS have indicated that CAF and FOF are distinct constructs. Our team previously developed and validated a new questionnaire, the Concern and Fear of Falling Evaluation (CAFFE), to assess these concepts. This study aimed to examine CAF and FOF prevalence, and determine relationships among CAF, FOF, and self-reported motor, cognitive, and psychological function in MS relapsing (RRMS) and progressive (PMS) subtypes.

METHODS

In a single online survey, participants with MS completed questions about CAF and FOF, demographic information, the CAFFE, and self-report measures of motor, cognitive, and psychological function.

RESULTS

A total of 912 individuals completed the survey. Persons with PMS reported greater CAF (80.1%) and FOF (59.1%) than those with RRMS (57.0% and 41.6%, respectively). Persons with PMS endorsing FOF (yes/no) reported greater FOF on the CAFFE, greater avoidance behavior, greater walking impairment, and poorer motor function than people with RRMS ( P < 0.001). Self-reported motor function, walking impairment, and avoidance behavior were highly correlated to the CAFFE across the overall sample ( P < 0.001).

DISCUSSIONS AND CONCLUSIONS

These findings underscore the disparity between CAF and FOF, emphasize the importance of evaluating CAF and FOF in MS subtypes separately, and highlight both motor and non-motor factors contributing to CAF and FOF. Future work should focus on interventions that incorporate motor, cognitive, and psychological components to address CAF and FOF.

VIDEO ABSTRACT

for more insights from the authors Supplemental Digital Content available at http://links.lww.com/JNPT/A481 .

Optimizing Detection and Prediction of Cognitive Function in Multiple Sclerosis With Ambulatory Cognitive Tests: Protocol for the Longitudinal Observational CogDetect-MS Study

BACKGROUND

Cognitive dysfunction is a common problem in multiple sclerosis (MS). Progress toward understanding and treating cognitive dysfunction is thwarted by the limitations of traditional cognitive tests, which demonstrate poor sensitivity and ecological validity. Ambulatory methods of assessing cognitive function in the lived environment may improve the detection of subtle changes in cognitive function and the identification of predictors of cognitive changes and downstream effects of cognitive change on other functional domains.

OBJECTIVE

This paper describes the study design and protocol for the Optimizing Detection and Prediction of Cognitive Function in Multiple Sclerosis (CogDetect-MS) study, a 2-year longitudinal observational study designed to examine short- and long-term changes in cognition, predictors of cognitive change, and effects of cognitive change on social and physical function in MS.

METHODS

Participants-ambulatory adults with medically documented MS-are assessed over the course of 2 years on an annual basis (3 assessments: T1, T2, and T3). A comprehensive survey battery, in-laboratory cognitive and physical performance tests, and 14 days of ambulatory data collection are completed at each annual assessment. The 14-day ambulatory data collection includes continuous wrist-worn accelerometry (to measure daytime activity and sleep); ecological momentary assessments (real-time self-report) of somatic symptoms, mood, and contextual factors; and 2 brief, validated cognitive tests, administered by smartphone app 4 times per day. Our aim was to recruit 250 participants. To ensure standard test protocol administration, all examiners passed a rigorous examiner certification process. Planned analyses include (1) nonparametric 2-tailed t tests to compare in-person to ambulatory cognitive test scores; (2) mixed effects models to examine cognitive changes over time; (3) mixed effects multilevel models to evaluate whether ambulatory measures of physical activity, sleep, fatigue, pain, mood, and stress predict changes in objective or subjective measures of cognitive functioning; and (4) mixed effects multilevel models to examine whether ambulatory measures of cognitive functioning predict social and physical functioning over short (within-day) and long (over years) time frames.

RESULTS

The study was funded in August 2021 and approved by the University of Michigan Medical Institutional Review Board on January 27, 2022. A total of 274 adults with MS (first participant enrolled on May 12, 2022) have been recruited and provided T1 data. Follow-up data collection will continue through March 2026.

CONCLUSIONS

Results from the CogDetect-MS study will shed new light on the temporal dynamics of cognitive function, somatic and mood symptoms, sleep, physical activity, and physical and social function. These insights have the potential to improve our understanding of changes in cognitive function in MS and enable us to generate new interventions to maintain or improve cognitive function in those with MS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05252195; https://clinicaltrials.gov/study/NCT05252195.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59876.

Cognitive behavioral interventions for depression and anxiety in adults with neurological disorders: a systematic review and meta-analysis

We examined the efficacy of cognitive and behavioral interventions for improving symptoms of depression and anxiety in adults with neurological disorders. A pre-registered systematic search of Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, Embase, and Neurobite was performed from inception to May 2024. Randomized controlled trials (RCTs) which examined the efficacy of cognitive and behavioral interventions in treating depression and/or anxiety among adults with neurological disorders were included. Estimates were pooled using a random-effects meta-analysis. Subgroup analyses and meta-regression were performed on categorical and continuous moderators, respectively. Main outcomes were pre- and post-intervention depression and anxiety symptom scores, as reported using standardized measures. Fifty-four RCTs involving 5372 participants with 11 neurological disorders (including multiple sclerosis, epilepsy, stroke) were included. The overall effect of interventions yielded significant improvements in both depression (57 arms, Hedges' g = 0.45, 95% confidence interval [CI] 0.35-0.54) and anxiety symptoms (29 arms, g = 0.38, 95% CI 0.29-0.48), compared to controls. Efficacy was greater in studies which employed a minimum baseline symptom severity inclusion criterion for both outcomes, and greater in trials using inactive controls for depression only. There was also evidence of differential efficacy of interventions across the neurological disorder types and the outcome measure used. Risk of bias, intervention delivery mode, intervention tailoring for neurological disorders, sample size, and study year did not moderate effects. Cognitive and behavioral interventions yield small-to-moderate improvements in symptoms of both depression and anxiety in adults with a range of neurological disorders.

Perceived Chronic Traumatic Encephalopathy and Suicidality in Former Professional Football Players

Importance

Participation in American-style football (ASF) has been linked to chronic traumatic encephalopathy neuropathological change (CTE-NC), a specific neuropathologic finding that can only be established at autopsy. Despite being a postmortem diagnosis, living former ASF players may perceive themselves to have CTE-NC. At present, the proportion and clinical correlates of living former professional ASF athletes with perceived CTE who report suicidality are unknown.

Objective

To determine the proportion, clinical correlates, and suicidality of living former professional ASF players with perceived CTE.

Design, Setting, and Participants

A cross-sectional study within the Football Players Health Study at Harvard University was conducted from 2017 to 2020. Using electronic and paper surveys, this population-based study included former ASF players who contracted with a professional league from 1960 to 2020 and volunteered to fill out a baseline survey. Data for this study were analyzed from June 2023 through March 2024.

Exposures

Data included demographics, football-related exposures (eg, position, career duration), and current health problems (anxiety, attention-deficit/hyperactivity disorder, depression, diabetes, emotional and behavioral dyscontrol symptoms, headache, hyperlipidemia, hypertension, low testosterone level, pain, sleep apnea, and subjective cognitive function).

Main Outcomes and Measures

The proportion of participants reporting perceived CTE. Univariable and multivariable models were used to determine clinical and suicidality correlates of perceived CTE.

Results

Among 4180 former professional ASF players who volunteered to fill out a baseline survey, 1980 (47.4%) provided follow-up data (mean [SD] age, 57.7 [13.9] years). A total of 681 participants (34.4%) reported perceived CTE. Subjective cognitive difficulties, low testosterone level, headache, concussion signs and symptoms accrued during playing years, depressive/emotional and behavioral dyscontrol symptoms, pain, and younger age were significantly associated with perceived CTE. Suicidality was reported by 171 of 681 participants with perceived CTE (25.4%) and 64 of 1299 without perceived CTE (5.0%). After adjusting for established suicidality predictors (eg, depression), men with perceived CTE remained twice as likely to report suicidality (odds ratio, 2.06; 95% CI, 1.36-3.12; P < .001).

Conclusions and Relevance

This study found that approximately one-third of living former professional ASF players reported perceived CTE. Men with perceived CTE had an increased prevalence of suicidality and were more likely to have health problems associated with cognitive impairment compared with men without perceived CTE. Perceived CTE represents a novel risk factor for suicidality and, if present, should motivate the diagnostic assessment and treatment of medical and behavioral conditions that may be misattributed to CTE-NC.

Pomalidomide for Epistaxis in Hereditary Hemorrhagic Telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is characterized by extensive telangiectasias and arteriovenous malformations. The primary clinical manifestation is epistaxis that results in iron-deficiency anemia and reduced health-related quality of life.

METHODS

We conducted a randomized, placebo-controlled trial to evaluate the safety and efficacy of pomalidomide for the treatment of HHT. We randomly assigned patients, in a 2:1 ratio, to receive pomalidomide at a dose of 4 mg daily or matching placebo for 24 weeks. The primary outcome was the change from baseline through week 24 in the Epistaxis Severity Score (a validated bleeding score in HHT; range, 0 to 10, with higher scores indicating worse bleeding). A reduction of 0.71 points or more is considered clinically significant. A key secondary outcome was the HHT-specific quality-of-life score (range, 0 to 16, with higher scores indicating more limitations).

RESULTS

The trial was closed to enrollment in June 2023 after a planned interim analysis met a prespecified threshold for efficacy. A total of 144 patients underwent randomization; 95 patients were assigned to receive pomalidomide and 49 to receive placebo. The baseline mean (±SD) Epistaxis Severity Score was 5.0±1.5, a finding consistent with moderate-to-severe epistaxis. At 24 weeks, the mean difference between the pomalidomide group and the placebo group in the change from baseline in the Epistaxis Severity Score was -0.94 points (95% confidence interval [CI], -1.57 to -0.31; P = 0.004). The mean difference in the changes in the HHT-specific quality-of-life score between the groups was -1.4 points (95% CI, -2.6 to -0.3). Adverse events that were more common in the pomalidomide group than in the placebo group included neutropenia, constipation, and rash.

CONCLUSIONS

Among patients with HHT, pomalidomide treatment resulted in a significant, clinically relevant reduction in epistaxis severity. No unexpected safety signals were identified. (Funded by the National Heart, Lung, and Blood Institute; PATH-HHT Clinicaltrials.gov number, NCT03910244).