Development of a New Care Pathway for Depression and Anxiety in Adult-Onset Isolated Dystonia

Background

Recently, we identified barriers and facilitators to the screening and treatment of depressive and anxiety symptoms in adult-onset isolated dystonia (AOID). These symptoms are common, functionally impairing, and often underdetected and undertreated.

Objectives

To develop a care pathway for mood symptoms in AOID.

Methods

We used a multistep modified Delphi approach to seek consensus among healthcare professionals with experience of AOID on the screening, diagnosis, and treatment of mood symptoms. A combination of face-to-face meetings and online surveys was performed from 2019 to 2020. We created the survey and then reviewed with stakeholders before 2 rounds of Delphi surveys, all of which was finally reviewed in a consensus meeting. A purposive sample of 41 expert stakeholders from 4 Canadian provinces, including neurologists, nurses, psychiatrists, psychologists, and family physicians, was identified by the research team.

Results

The Delphi process led to consensus on 12 statements that operationalized a pathway of care to screen for and manage depression and anxiety in people with AOID. Key actions of the pathway included yearly screening with self-rated instruments, multidisciplinary involvement in management involving local networks of providers coordinated by movement disorders neurologists, and access to educational resources. The Delphi panel indicated the 2 core steps as the documentation of the most recent screening outcome and the documentation of a management plan for patients who were positive at the last screening.

Conclusions

This new care pathway represents a potentially useful intervention that can be used to build an integrated model of care for AOID.

The prevalence of anxiety in adult-onset isolated dystonia: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Clinically relevant anxiety and anxiety disorders are commonly associated with adult-onset isolated dystonia, contributing substantially to quality-of-life impairment in patients with this movement disorder. However, the prevalence of anxiety symptoms and disorders in adult-onset isolated dystonia remains unclear. We aimed to conduct a systematic review and meta-analysis of the prevalence of anxiety symptoms/disorders in adult-onset isolated dystonia.

METHODS

Studies reporting the prevalence of anxiety disorders determined through diagnostic interviews or from clinically relevant anxiety symptoms detected with rating scales were identified in three databases (MEDLINE, EMBASE and PsycINFO). The gray literature was also examined to detect studies not captured through the search strategy.

RESULTS

The search strategy yielded 6535 citations; 34 studies met the inclusion criteria. The overall prevalence of clinically relevant anxiety symptoms and anxiety disorders for cervical dystonia was 40% (95% confidence interval [CI] 20% to 60%); for studies examining cranial dystonia it was 25% (95% CI 21% to 30%); for studies exploring mixed populations of adult-onset isolated dystonia it was 33.3% (95% CI 22% to 43%), 26% (95% CI 12% to 40%) for laryngeal dystonia, and 32% (95% CI 21% to 43%) for upper limb dystonia. Social phobia was the most prevalent anxiety disorder across the different forms of adult-onset isolated dystonia. Between-study statistical heterogeneity was high for most prevalence estimates.

CONCLUSIONS

Clinically relevant anxiety and anxiety disorders are common across all forms of adult-onset isolated dystonia. New research avenues should explore and plan the development of pathways of care targeting these important non-motor features.

Motor features in Parkinson's disease with normal olfactory function

BACKGROUND

Normosmic Parkinson's disease (PD) might be a unique clinical phenotype with a more benign course when compared with hyposmic PD.

OBJECTIVE

The objective of this study was to evaluate motor features and the acute levodopa response according to olfactory function.

METHODS

A total of 169 de novo PD patients that underwent olfactory testing and acute levodopa challenge for clinical prediction of sustained long-term dopaminergic response were evaluated.

RESULTS

The overall frequency of normosmia was 33%. Normosmic PD patients scored nonsignificantly different to hyposmic/anosmic patients on motor scale and on degree of improvement with levodopa. Motor scores at follow-up were comparable among groups.

CONCLUSIONS

Normal olfactory function is common in early PD and was not associated with a different motor phenotype when compared with PD patients with olfactory dysfunction. © 2016 International Parkinson and Movement Disorder Society.

Antipyretic effects of dipyrone versus ibuprofen versus acetaminophen in children: results of a multinational, randomized, modified double-blind study

This study compared the antipyretic effectiveness of acetaminophen, ibuprofen, and dipyrone in young children with fever. The results were based on a modified double-blind, randomized, multinational trial that evaluated 628 febrile children, aged 6 months to 6 years. All three drugs lowered temperature in the 555 patients completing the study. Temperature normalization rates in the ibuprofen and dipyrone groups (78% and 82%, respectively) were significantly higher than the acetaminophen group (68%, P = 0.004). After 4 to 6 hours, mean temperature in the dipyrone group was significantly lower than the other groups, demonstrating longer temperature normalization with dipyrone. All three drugs showed comparable tolerability profiles.

[Thrombocytopenic purpura after hepatitis B vaccine]

OBJECTIVE: To demonstrate a case of idiopathic thrombocytopenic purpura after hepatitis B vaccine and drive attention to this possible relation when other causes have been excluded.METHODS: Description of a case of a patient who was 1 month and 16 days old and presented petechiae and ecchymoses one week before she entered the Emergency Room of the Hospital das Clínicas da Universidade de São Paulo. Other causes beyond Hepatitis B vaccine, received one month before the hemorrhagic state, were ruled out with the history and laboratory exams. A review of the literature about PTI revealed case reports of the disease connected with Hepatitis B vaccine administration.RESULTS: The vaccine was considered the probable cause. The child was treated with intravenous immunoglobulin, improving from thrombocytopenia after three days, and remaining without symptoms during one month of follow up.CONCLUSION: The thrombocytopenic purpura after hepatitis B vaccine is a rare event whose causal relation is hard to prove. The diagnosis is based on the exclusion of other possible causes, but in this case, the hypothesis may be considered since new cases are being reported in the literature.

[Epidemiologic aspects of Haemophilus influenzae type b infection]

This paper reviews the role of Haemophilus influenzae type b (Hib) as one of the most important pathogens causing invasive infectious diseases, especially in the first 2 years of life. In developing countries H. influenzae is responsible for 30% of all pneumonia cases with positive cultures and for 20% to 60% of all bacterial meningitis cases. In this study we compared Brazilian and international epidemiologic data obtained from several bibliographic databases (MEDLINE, 1966 to 1995; LILACS, 1982 to 1995; Thesis Databank, 1980 to 1995; and Dissertation Abstracts, 1988 to 1994). The incidence of Hib infection in Brazil was analyzed for individual states and for different ages, including within the first year of life. Meningitis cases were used as an incidence marker because of the difficulty in identifying the causative organism in such other infections as pneumonia, osteomyelitis, epiglottitis, cellulitis, and endocarditis. Our analysis showed that the nationwide Brazilian data masked the regional incidence and lethality of H. influenzae. For example, in 1991 the national incidence was 18.4 per 100,000 children under 1 year of age. In the same period, the Federal District had an incidence of 175 per 100,000 among children between 4 and 6 months of age. Similarly, the North of Brazil had a 35% case fatality rate in 1987, whereas the rate was 22% for Brazil as a whole. This study raises issues concerning the relevant epidemiologic factors associated with Hib infection and the costs and benefits of prophylaxis and vaccination in the age groups most at risk.

[Necrotizing tracheobronchitis in an infant]

OBJECTIVE

To alert the pediatric emergency physician about an unusual cause of airways obstruction in children undergoing mechanical ventilation.

METHODS

We report a case of necrotizing tracheobronchitis (NTB) in an 8-month-old boy and discuss the pathophysiology, diagnosis and treatment of this disease.

RESULTS

This child presented a good outcome that was related to prompt diagnosis and treatment with bronchoscopic removal of necrotic tissue.

CONCLUSIONS

The pediatric emergency physician must consider NTB in every children undergoing mechanical ventilation who presents acute episodes of airways obstruction, hypercarbia, lack of chest movement and pulmonary hyperinflation, even out of the perinatal period. This characteristic clinical presentation, when recognized, is an indication for emergency tracheobronchoscopy.

Respiratory syncytial virus infection in infants is associated with predominant Th-2-like response

Viral infections have been associated with cellular immune responses and production of Th-1 cytokines. Respiratory syncytial virus (RSV), however, induces virus-specific IgE, which might be a consequence of a Th-2-like activation. To test this hypothesis we quantified interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) in the supernatant of peripheral blood mononuclear cells cultured for 24 and 48 h in the presence or absence of phytohemaglutinin and pokeweed mitogen and the lymphocyte phenotypes to analyze subsets and their activation markers, from 15 hospitalized infants during an acute lower respiratory infection caused by RSV and 17 healthy control infants from 1 to 15 mo of age. Compared with the control infants, those infected with RSV had an increase in the number of B-cells (p < 0.02) and decreases in both CD8+ T-cells (p < 0.01) and activated CD8+/CD25+ suppressor/ cytotoxic T-cells (p < 0.007). In RSV-infected infants, IFN-gamma production was subtotally suppressed, whereas IL-4 production was decreased to a lesser degree, giving significantly (p < 0.001) increased IL-4/IFN-gamma ratio compared with that in the control infants. These findings suggest a predominant Th-z-like response in RSV-infected infants, which could explain some aspects of the immunopathogenesis of RSV infection and the RSV-specific and nonspecific IgE antibody responses observed.

Primary community-acquired pneumonia by Escherichia coli. Case report and review of the literature

A two year old girl with chronic neurologic convulsive disease was admitted with a six day history of pneumonia and, despite treatment, died on hospital day 3. The X-ray revealed right upper lobar pneumonia. The results of pleural effusion and blood cultures drawn on admission yielded a non-typable Escherichia coli. No other source of infection was identified. The authors discuss the clinical and pathophysiological aspects of Escherichia coli pneumonia.

[Septicaemia caused by Klebsiella pneumoniae--a review of 28 cases]

Twenty-eight children with septicaemia and positive blood cultures for Klebsiella pneumoniae were retrospectively studied and compared with 190 children with sepsis caused by other organisms, identified or not in blood cultures. Septicaemia due to Klebsiella pneumoniae occurred more frequently in children older than 2 years of age, especially those who had an underlying disease and, therefore, were malnourished or had an impaired immune defense system that had required invasive procedures and previous hospitalization. Although the case fatality rate was high in both groups, Klebsiella pneumoniae did not contribute to elevate the relative risk of death. In this study, Klebsiella pneumoniae isolates were highly sensitive to colistin (92.9%) and cefoxitin (82.1%), but poorly sensitive to third generation cephalosporin and imipenen.

[Rotavirus, adenovirus, astrovirus, calicivirus and small round virus particles in feces of children with and without acute diarrhea, from 1987 to 1988, in the greater São Paulo]

Between 1987 and 1988, 193 faecal specimens from children, with or without diarrhea, were submitted to enzyme immunoassay, polyacrylamide-gel electrophoresis and electronmicroscopy tests for virus detection. The positivity for Rotavirus, Adenovirus, Astrovirus, Calicivirus and Small Round Virus Particles (SRVP) was 11.3%, 3.1%, 2.1%, 1.0% and 4.1%, respectively, for the 97 children with acute diarrhea. Of the 96 children without diarrhea, 4.2% were positive for Rotavirus, 1.0% for Calicivirus and 7.3% for SRVP. Of 15 positive specimens for Rotavirus, 14 showed electrophoretic patterns proper to group A and 1 specimen of group C Rotavirus. The analysis of electrophorotypes demonstrated great heterogeneity of electrophoretic patterns and predominance of subgroup 2, "long". The association of virus, bacteria and parasites was present both in children with or without acute diarrhea.

[Cryptosporidium parasitism in children with acute diarrhea]

During the period from August 1987 to July 1990, 241 fecal samples collected from 1 to 48 months old children with acute diarrhea and examined in the Child's Institute of Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo, were submitted to parasitological tests in the Enteroparasitosis Section of the Instituto Adolfo Lutz. Fourty two (17.43%) fecal samples showed Cryptosporidium sp. oocysts by carbol-fucsin stain. Parasitism by Cryptosporidium sp. was more frequent during the period comprised from March to May, in the studied three years. The authors discussed the Cryptosporidium sp. in association with other agents.

[Etiology of lower respiratory infections in hospitalized infants]

As a contribution to knowledge about the etiology of lower respiratory tract infections (LRI) in infants, 235 patients aged one year or less admitted to a children's hospital at northern metropolitan area of Santiago, Chile along years 1987 throughout 1989 with radiologically confirmed diagnosis were studied. Infants were eligible only if their symptoms lasted for not more than five days and their hospital stay was less than two days. Controls consisted on 74 healthy infants. A search for presumptive etiology was done by means of usual bacteriological procedures (pharyngeal swabs and blood cultures), plus latex test for type b Haemophilus influenzae (Hib) and Streptococcus pneumoniae (SP) in concentrated urine specimens; indirect immunofluorescence (IF) for specific Chlamydia trachomatis (CT) IgM; serological tests, isolation and IF in pharyngeal aspirates for syncytial respiratory virus (SRV), influenza, parainfluenzae and adenoviruses were also used. Evidence of viral infection was detected from 135/235 (57.5%) of cases and 21/74 (28.3%) controls, SRV being the most common. From 18/119 and 2/119 studied patients Hib and SP antigens were respectively detected, but urinary antigens were also present in 6/24 controls, raising questions about this test's specificity. IF titers of 1:32 or higher for CT were found in 5/80 patients, all younger than 5 months. It was possible to perform the whole set of available methods in 80 patients, in 70% of which some evidence of a known etiologic agent was found. Serology alone gave etiological clues in only 30% of these cases and usual microbiological cultures of throat swabs and blood from none of them. No combinations of age, fever, respiratory rate, apnea, bronchial obstructive syndrome, white blood cell counts over 15,000 or of band forms over 500 per cu mm, erythrocyte sedimentation rates, reactive C protein and x-ray findings allowed differential diagnosis between presumptive bacterial or viral etiology, except in one case of an infant presenting with pleural effusion and positive antigenuria for Hib.

[Etiology of acute infections of the lower respiratory tract in hospitalized infants: bacterial antigens]

Demonstration of bacterial antigens in biological fluids has been used for early detection of bacterial infections. Recent evidence suggests that higher detection rates of these antigens can be obtained from concentrated urine than from serum samples of patients. Evidence of bacterial infection by antigen detection was looked for from 50 fold concentrated urine samples by means of an ultrafilter system (Minicom) and latex agglutination for Haemophilus influenzae B (HiB) and Streptococcus pneumoniae (Sp) in three groups of patients. Group A (Positive controls), included 7 patients whose blood culture were positive for HiB (n = 5) and Sp (n = 2). Group B (Healthy controls) involved 16 children without clinical and laboratory signs of infection, coming from ambulatory well baby clinics and surgical wards, and group C was formed by 77 patients with negative blood cultures but with clinical and X ray evidence of lower respiratory tract infection. The corresponding antigen was demonstrated in urine samples from all group A patients. Three group B subjects gave positive results for HiB antigen. HiB antigen was detected from 10 and Sp antigen from 2 group C patients. These results suggest that the search for bacterial antigens in urine would be useful for etiological diagnosis and management of patients with bacterial pneumoniae. There is no definite explanation for the finding of HiB antigen in urine from apparently healthy children but the possibility of previous or actual asymptomatic infections must be taken into account.