Validation of the Hebrew Version of the Unified Dyskinesia Rating Scale

BACKGROUND

The Unified Dyskinesia Rating Scale (UDysRS) is a well-established tool for producing comprehensive assessments of severity and disability associated with dyskinesia in patients with Parkinson's disease (PD). The scale was originally developed in English, and a broad international effort has been undertaken to develop and validate versions in additional languages. Our aim was to validate the Hebrew version of the UDysRS.

METHODS

We translated the UDysRS into Hebrew, back-translated it into English, and carried out cognitive pretesting. We then administered the scale to non-demented native Hebrew-speaking patients who fulfilled the Brain Bank diagnostic criteria for probable PD (n = 250). Data were compared to the Reference Standard data used for validating UDysRS translations.

RESULTS

The different portions of the Hebrew UDysRS showed high internal consistency (α ≥ 0.92). A confirmatory factor analysis in which we compared the Hebrew UDysRS to the Reference Standard version produced a comparative fit index (CFI) of 0.98, exceeding the threshold criterion of CFI > 0.9 indicating factor validity. A secondary exploratory factor analysis provided further support to the consistency between the factor structures of the Hebrew and Reference Standard versions of the UDysRS.

CONCLUSION

The UDysRS Hebrew version shows strong clinimetric properties and fulfills the criteria for designation as an official International Parkinson and Movement Disorder Society-approved translation for use in clinical and research settings.

Relationship between Homocysteine and Muscle Strength Decline: The Baltimore Longitudinal Study of Aging

Background

Decreased muscle strength is strongly associated with future mobility limitations in older adults. Homocysteine is a risk factor for vascular disease and may exacerbate muscle strength decline. The present study aimed to examine the association between homocysteine levels and muscle strength in adults aged 50 years or older.

Methods

Data were from 1,101 participants of The Baltimore Longitudinal Study of Aging between December 2004 and March 2015. Muscle strength was measured using grip strength. Mixed effects linear regression was used to estimate the association between homocysteine and muscle strength in men and women, separately.

Results

Total mean follow-up time was 4.7 ± 3.1 years, range from 0 to 10.1 years. Baseline mean grip strength was 39.9 kg for men and 25.5 kg for women. Grip strength declined over the follow-up time for both men and women. Among women, there was a significant inverse relationship between homocysteine and grip strength, where grip strength declined as a function of increasing homocysteine over time (β = -0.05, p = .031). Among men, an increase of 1 μmol/L in homocysteine was associated with -0.10 kg decrease in grip strength, though not significantly.

Conclusions

In this study of healthy older adults aged 50 years or older, higher homocysteine was related to lower muscle strength in women. This is the first study to characterize the relationship over a long follow-up period. Future research should focus on assessing homocysteine as a marker of physical function decline and translating the relationship into clinical and public health practice.

Regular Exercise, Quality of Life, and Mobility in Parkinson's Disease: A Longitudinal Analysis of National Parkinson Foundation Quality Improvement Initiative Data

BACKGROUND

Research-based exercise interventions improve health-related quality of life (HRQL) and mobility in people with Parkinson's disease (PD).

OBJECTIVE

To examine whether exercise habits were associated with changes in HRQL and mobility over two years.

METHODS

We identified a cohort of National Parkinson Foundation Quality Improvement Initiative (NPF-QII) participants with three visits. HRQL and mobility were measured with the Parkinson's Disease Questionnaire (PDQ-39) and Timed Up and Go (TUG). We compared self-reported regular exercisers (≥2.5 hours/week) with people who did not exercise 2.5 hours/week. Then we quantified changes in HRQL and mobility associated with 30-minute increases in exercise, across PD severity, using mixed effects regression models.

RESULTS

Participants with three observational study visits (n = 3408) were younger, with milder PD, than participants with fewer visits. After 2 years, consistent exercisers and people who started to exercise regularly after their baseline visit had smaller declines in HRQL and mobility than non-exercisers (p < 0.05). Non-exercisers worsened by 1.37 points on the PDQ-39 and a 0.47 seconds on the TUG per year. Increasing exercise by 30 minutes/week was associated with slower declines in HRQL (-0.16 points) and mobility (-0.04 sec). The benefit of exercise on HRQL was greater in advanced PD (-0.41 points) than mild PD (-0.14 points; p < 0.02).

CONCLUSIONS

Consistently exercising and starting regular exercise after baseline were associated with small but significant positive effects on HRQL and mobility changes over two years. The greater association of exercise with HRQL in advanced PD supports improving encouragement and facilitation of exercise in advanced PD.

Validation of the Hebrew version of the Movement Disorder Society-Unified Parkinson's Disease Rating Scale

BACKGROUND

The Movement Disorders Society (MDS) published the English new Unified Parkinson's Disease Rating Scale (MDS-UPDRS) as the official benchmark scale for Parkinson's disease (PD) in 2008. We aimed to validate the Hebrew version of the MDS-UPDRS, explore its dimensionality and compare it to the original English one.

METHODS

The MDS-UPDRS questionnaire was translated to Hebrew and was tested on 389 patients with PD, treated at the Movement Disorders Unit at Tel-Aviv Medical Center. The MDS-UPDRS is made up of four sections. The higher the score, the worst the clinical situation of the patient is. Confirmatory and explanatory factor analysis were applied to determine if the factor structure of the English version could be confirmed in the Hebrew version.

RESULTS

The Hebrew version of the MDS-UPDRS showed satisfactory clinimetric properties. The internal consistency of the Hebrew-version was satisfactory, with Cronbach's alpha values 0.79, 0.90, 0.93, 0.80, for parts 1 to 4 respectively. In the confirmatory factor analysis, all four parts had high (greater than 0.90) comparative fit index (CFI) in comparison to the original English MDS-UPDRS with high factor structure (0.96, 0.99, 0.94, 1.00, respectively), thus confirming the pre-specified English factor structure. Explanatory factor analysis yielded that the Hebrew responses differed from the English one within an acceptable range: in isolated item differences in factor structure and in the findings of few items having cross loading on multiple factors.

CONCLUSIONS

The Hebrew version of the MDS-UPDRS meets the requirements to be designated as the Official Hebrew Version of the MDS-UPDRS.

Vitamin B12 and Homocysteine Associations with Gait Speed in Older Adults: The Baltimore Longitudinal Study of Aging

OBJECTIVES

This study aimed to assess the independent associations of serum levels of vitamin B12 and plasma concentrations of homocysteine with gait speed decline.

DESIGN, SETTING, PARTICIPANTS

This study utilized longitudinal analysis of participants 50 years or older from The Baltimore Longitudinal Study of Aging, N=774.

MEASUREMENTS

Gait speed (m/s) was assessed using the 6-meter usual pace test. Vitamin B12 and homocysteine concentrations were collected using standard clinical protocols. Linear mixed effects regression was stratified by baseline age category (50-69, 70-79, and ≥80 years old).

RESULTS

Mean follow-up time for the total study sample was 5.4 ± 2.0 years. No association between vitamin B12 and gait speed decline over the follow-up time for any age group was found. Elevated homocysteine concentrations were associated with decline in gait speed after adjustment for covariates (50-69: β= -0.005, p=.057; 70-79: β= -0.013, p<.001, ≥80: β= -0.007, p=.054).

CONCLUSION

Homocysteine and vitamin B12 are inversely related, yet only homocysteine was associated with gait speed decline in this population of healthy older adults. Given these results, future research should be directed towards investigating the relationship in populations with greater variation in vitamin B12 concentrations and other mechanisms influencing homocysteine concentrations.

Predictors of intensive care unit length of stay and intracranial pressure in severe traumatic brain injury

OBJECTIVE

The aim of this study was to explore the relationship of intracranial pressure (ICP) with intensive care unit (ICU) length of stay in a large cohort of severe traumatic brain injury patients and identify factors associating with prolonged ICU course.

METHODS

This was a single-center database review of de-identified research data that had been prospectively collected; setting: neurosurgical ICU, Ben Taub General Hospital, Houston, TX.

RESULTS

In a cohort of 438 severe traumatic brain injury (TBI) patients, 149 (34%) had a motor Glasgow Coma Scale score of 1 to 3 on admission and 284 (65%) had 4 to 5. Intracranial pressure during the ICU course was 19.8±11.2 mm Hg. Favorable outcome was obtained in 148 (34%), and unfavorable, in 211 (48%) patients with a mortality of 28%. ICU length of stay (LOS) was 19.4±13.9 days. Joint modeling of ICP and ICU LOS was undertaken, adjusted for the International Mission for Prognosis and Analysis of Clinical Trials in TBI admission prognostic indicators. A higher ICP was not significantly associated with longer ICU LOS (P=.4). However, presence of a mass lesion on admission head computed tomography was strongly correlated with a prolonged ICU LOS (P=.0007). Diffuse injuries with basal cistern compression or midline shift were marginally associated with a longer ICU LOS (P=.053).

CONCLUSIONS

ICP, as monitored and managed according to BTF guidelines, is not associated with ICU length of stay. Patients with severe TBI and a mass lesion on admission head computed tomography were found to have prolonged ICU LOS independently of other indicators of injury severity and intracranial pressure course.

Effect of creatine monohydrate on clinical progression in patients with Parkinson disease: a randomized clinical trial

IMPORTANCE

There are no treatments available to slow or prevent the progression of Parkinson disease, despite its global prevalence and significant health care burden. The National Institute of Neurological Disorders and Stroke Exploratory Trials in Parkinson Disease program was established to promote discovery of potential therapies.

OBJECTIVE

To determine whether creatine monohydrate was more effective than placebo in slowing long-term clinical decline in participants with Parkinson disease.

DESIGN, SETTING, AND PATIENTS

The Long-term Study 1, a multicenter, double-blind, parallel-group, placebo-controlled, 1:1 randomized efficacy trial. Participants were recruited from 45 investigative sites in the United States and Canada and included 1741 men and women with early (within 5 years of diagnosis) and treated (receiving dopaminergic therapy) Parkinson disease. Participants were enrolled from March 2007 to May 2010 and followed up until September 2013.

INTERVENTIONS

Participants were randomized to placebo or creatine (10 g/d) monohydrate for a minimum of 5 years (maximum follow-up, 8 years).

MAIN OUTCOMES AND MEASURES

The primary outcome measure was a difference in clinical decline from baseline to 5-year follow-up, compared between the 2 treatment groups using a global statistical test. Clinical status was defined by 5 outcome measures: Modified Rankin Scale, Symbol Digit Modalities Test, PDQ-39 Summary Index, Schwab and England Activities of Daily Living scale, and ambulatory capacity. All outcomes were coded such that higher scores indicated worse outcomes and were analyzed by a global statistical test. Higher summed ranks (range, 5-4775) indicate worse outcomes.

RESULTS

The trial was terminated early for futility based on results of a planned interim analysis of participants enrolled at least 5 years prior to the date of the analysis (n = 955). The median follow-up time was 4 years. Of the 955 participants, the mean of the summed ranks for placebo was 2360 (95% CI, 2249-2470) and for creatine was 2414 (95% CI, 2304-2524). The global statistical test yielded t1865.8 = -0.75 (2-sided P = .45). There were no detectable differences (P < .01 to partially adjust for multiple comparisons) in adverse and serious adverse events by body system.

CONCLUSIONS AND RELEVANCE

Among patients with early and treated Parkinson disease, treatment with creatine monohydrate for at least 5 years, compared with placebo did not improve clinical outcomes. These findings do not support the use of creatine monohydrate in patients with Parkinson disease.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00449865.

Rankin scale as a potential measure of global disability in early Parkinson's disease

We conducted an exploratory analysis of the utility of the modified Rankin Scale (mRS) as a global measure of disability in early Parkinson's diesase (PD) using the baseline data from a large cohort of PD patients enrolled in a longitudinal study of creatine. The mRS is scored 0-6 with lower scores reflecting less disability. For the analysis the mRS score was dichotomized at <2 versus ≥2. We explored the association of the mRS with multiple measures of PD-related impairments, including the Unified Parkinson Disease Rating Scale (UPDRS); cognitive function characterized by the Symbol Digit Modalities--verbal, and Scales for Outcomes in Parkinson's disease--cognition (SCOPA-COG); quality of life (Parkinson's disease questionnaire [PDQ-39]) and EuroQOL; Beck Depression Inventory II (BDI); and Total Functional Capacity (TFC). We also investigated the interaction between variables. One thousand seven hundred forty-one patients were included in the analysis of which 374 had a mRS score of 2 or above. In the univariate model, all interested measures except SCOPA-COG (p=0.23) had significant association with mRS (p<0.001) after controlling for confounders. In the multivariate model, UPDRS Part II and III (activities of daily living and motor), BDI, TFC and PDQ-39 were significant (p<0.05). The mRS has a significant association with the wide spectrum of measures of impairment and quality of life in early PD and shows good potential to be a global measure of disability in early PD. The sensitivity of the mRS to change and performance of the scale in more advanced PD will have to be established longitudinally.

A pilot study using nurse education as an intervention to increase skin self-examination for melanoma

BACKGROUND

A pilot study of an intervention using nurse education for skin self-examination (SSE) was conducted in order to determine specific factors that would be important for the design of a larger intervention.

METHODS

Seventy-five subjects completed a pretest, a posttest, a thorough skin examination by a dermatologist, and an educational session by a nurse.

RESULTS

Results showed that the subjects increased the frequency of SSE to a predetermined optimal frequency of once every one to two months. Increases in optimal SSE were associated with increases in knowledge about melanoma (p = 0.006).

CONCLUSIONS

Before intensive campaigns are launched to improve SSE, models incorporating theories of behavioral change should be tested.

No improvement in survival from melanoma diagnosed from 1973 to 1984

BACKGROUND

While the incidence and mortality of melanoma has increased dramatically during the last few decades, survival rates, based on the case-fatality ratio, have apparently improved. Efforts at early detection have probably been effective in the discovery of lesions at a curable stage. However, the effects of lead-time bias need to be accounted for in order to understand the contribution of early detection to the increased incidence. This can best be done by appropriately controlling for depth of the tumour or a surrogate of depth, at diagnosis.

METHODS

A survival analysis was conducted for 3197 Connecticut residents newly diagnosed with invasive melanoma between 1973 and 1984. Five prognostic variables were evaluated: sex, age at diagnosis, anatomical site, histological type, and year of diagnosis.

RESULTS

As expected, women and the young had better survival than men and the elderly. Melanomas located on the trunk had poorer prognosis than those on other sites. The survival experience by histological type was significantly different; lentigo maligna melanoma and superficial spreading melanoma had the best survival and nodular melanomas the poorest, while 'other' and unclassifiable melanomas had intermediate survival. When survival by period of diagnosis was controlled by other variables, which included surrogates for disease stage, there was no improvement in survival over time.

CONCLUSION

These data do not imply that early diagnosis and treatment are ineffective; rather, that within stages of disease, survival improvements did not occur during the period 1973-1984.