Purpose/Hypothesis: Falls in the older adult population are the leading cause of fatal and non-fatal injuries in America. Polypharmacy, the use of multiple medications, has been identified as a major risk factor for falls in older adults. A variety of medication screens exist that identify adverse effects of medications which can directly impact fall risk; however, current screening measures have limitations. The Quantitative Drug Index (QDI) is a new, clinically anchored index to quantify all potential adverse effects associated with drug-mediated fall risk. The purpose of this study was to validate the QDI as a fall risk screening tool. Number of Subjects: 138 adults were recruited from local senior centers and screened. Inclusion criteria: community-dwelling, age 60 to 89 years, and currently prescribed at least one medication. Exclusion criteria: progressive neurological disorders, unstable medical conditions, cognitive impairment, severe depression or anxiety, severe lower extremity impairment that would impact mobility, and severe vision impairment. Materials and Methods: Mobility and balance outcome measures related to fall risk included: 30-second chair stand test, 10-meter walk test, Timed Up and Go (TUG) and Dynamic Gait Index (DGI). Self-report measures of fall risk included fall history, Fall Risk Questionnaire (FRQ) and Activity-specific Balance Confidence scale (ABC). The QDI was derived from each participant's medications. Participants were classified as either fallers or nonfallers based on self-report history of falls within the past year. Nonparametric Spearman’s Rho correlations were used to determine relationships between faller status and measures of fall risk. A receiver operating characteristic (ROC) curve analysis determined cutoff scores for outcome measures related to faller status. Results: A fair to moderate relationship between the QDI and several physical performance and self-report measures was identified: FRQ (r=0.363), ABC (r=-0.401), DGI (r=-0.360). However, little to no relationship was found between faller status and QDI score (r=0.221). The ROC analysis determined the area under the curve for QDI was 0.63 with a cutoff score of 2.5 yielding sensitivity of 78% and specificity of 47%. Conclusions: The development of the QDI was an interdisciplinary effort between pharmacists and physical therapists to screen for fall risk in older individuals. The QDI offers a better way to quantify the adverse effects of drugs on mobility compared with simple drug counts. The QDI alone does not identify individuals at fall risk; however, the QDI is significantly correlated to several measures of fall risk, including FRQ, ABC, and DGI. The ROC Curve Analysis identified a cutoff score for fall risk for the QDI which was found to have similar sensitivity and specificity to the TUG. Clinical Relevance: The QDI could be incorporated into electronic medical records to identify patients who may be at fall risk and would be appropriate for further balance and mobility evaluation.

Objectives:Following the loss of vestibular function, some patients functionally improve and are minimally bothered by their loss of peripheral function while others remain more symptomatic and are unable to return to their activities of daily living. To date, the mechanisms for functional improvement remain poorly understood. The purpose of the present study was to examine the association between corrective saccades and measures of handicap, dynamic visual acuity, gait, and falls. Design:A retrospective chart review was performed to identify patients who were diagnosed with unilateral or bilateral vestibular hypofunction and who also completed a baseline vestibular rehabilitation evaluation. A total of 82 patients with unilateral vestibular hypofunction and 17 patients with bilateral vestibular hypofunction were identified. The video head impulse test results for each patient were grouped based on the type of presenting saccades. Specifically, the saccade grouping included the following: (1) covert, (2) overt, or (3) a combination of both types of saccades. Results:The results show that covert saccades are associated with better performance on measures of dynamic visual acuity, gait, and balance in patients with unilateral vestibular hypofunction. Patients exhibiting overt saccades or combination of both covert and overt saccades were more often found to have an abnormal gait speed and be characterized as being at risk for falls using the Dynamic Gait Index. We observed no differences in physical function for those patients with bilateral vestibular hypofunction as a function of saccade grouping. Conclusions:When comparing saccade groups (covert, overt, or combination of both), patients with unilateral vestibular hypofunction and covert saccades demonstrated better performance on standard baseline physical therapy measures of dynamic visual acuity and gait and balance. We did not observe any significant associations between saccade group and physical function in patients with bilateral vestibular hypofunction; however, additional studies are needed with adequate sample sizes. Our findings may suggest that corrective saccade latency in patients with unilateral vestibular hypofunction is related to measures of physical function. The extent to which saccade latency has the potential to be a useful target for vestibular rehabilitation is still to be determined and may be promising target to improve functional outcomes.

Purpose/Hypothesis: Mal de Debarquement Syndrome (MdDS) is a rare condition in which those afflicted perceive a chronic rocking or swaying sensation, often relieved when in motion and symptomatic when still. Etiology is uncertain; therefore, treatment options are limited. While there is reported success with medication, optokinetic stimulation or transcutaneous magnetic stimulation, there is no single treatment that works for all patients. This retrospective chart review investigated rehabilitation outcomes following sensorimotor, multi-axis, rotational (SMART) training to address MdDS symptoms. Number of Subjects: Forty-nine Materials and Methods: Forty-nine patients participated in 10-20 sessions of SMART training, with integrated use of a visual targeting system and physical therapy. Between sessions, patients were instructed to perform mindfulness breathing, relaxation and grounding techniques. Pre- and post-training Dizziness Handicap Inventory (DHI), 4-item Dynamic Gait Index (DGI), and computerized posturography including Sensory Organization Test (SOT) were assessed. Subjective change following rehabilitation was tracked at discharge, 5 weeks, 3 months, 6 months and 1 year post-training. Results: Mean age (SD) of patients was 52.9 (12.6) years with the majority (n=47) being female. Mean time from onset of symptoms (SD) was 50.8 (87.8) months suggesting chronic symptoms. At discharge, 42 of 49 patients reported improvements, with nearly half (n=24, 48.9%) of all patients reporting marked or moderate improvement in symptoms; whereas, 14 (28.6%) reported minimal improvement in symptoms. Based on paired t-tests, all outcome measures – DHI, MdDS severity Visual Analog Scale (VAS), Motion VAS, 4-item DGI, and SOT - improved significantly (p < 0.001) from initial evaluation to discharge. Several personal factors were associated with rehabilitation outcomes based on bivariate correlations. With some variation, patients sustaining improvements at 1 week post-discharge, generally continued to sustain at 5 weeks, 3 months, 6 months and 1 year. Conclusions: SMART training plus physical therapy resulted in improved performance outcomes and in significant reduction or resolution in MdDS symptoms. This study provides early evidence that this method of training has promising potential to aid in the management or recovery of MdDS. Clinical Relevance: MdDS is disorder with no specific cure. Treatment is limited. SMART training may serve as an effective outcome to reduce or resolve symptoms associated with MdDS.

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No description available.

<p>  </p> <p><strong>Background:</strong> Older adults have a higher prevalence of pain compared to other age groups and are more likely to become long-term opioid users. The clinical benefits of long-term opioid therapy (LTOT) are not clearly known, however, LTOT has been found to increase the risk of all-cause mortality, opioid overdose, constipation, fractures, and myocardial infarction. </p> <p><br></p> <p><strong>Objective: </strong>The study was conducted to estimate the incidence of LTOT and risk factors associated with LTOT in older adults aged 65 years and older.</p> <p><br></p> <p><strong>Methods:</strong> This was a retrospective cohort study based on Medicare claims data obtained from Research Data Assistance Center (ResDAC). Opioid naïve older adults filling an opioid prescription between 2014 and 2016 were included. The outcome was LTOT which was defined as an opioid use episode lasting longer than 90 days and having more than 60 cumulative days of supply. The independent variables (risk factors) were patient characteristics (demographics, comorbidities, substance use disorders), characteristics of initial/index opioid dispensed (opioid type, duration of action of opioid, opioid dose, number of days’ supply, concomitant medications), and pain conditions. Multivariable logistic regression was performed to assess the association between the risk factors and LTOT. To address statistical interactions among variables, secondary analyses were conducted after stratifying the dataset by pain conditions.</p> <p><br></p> <p><strong>Results:</strong> Among 162,287 opioid naive patients, 10,296 (6.3%) transitioned to LTOT. Demographic characteristics associated with LTOT were age greater than 85 years (adjusted odds ratios [AOR]: 1.1, 95% confidence interval [CI]:1.03-1.18) and being black (AOR: 1.11, 95% CI: 1.01-1.22). Risk factors related to substance use disorders included drug use disorder (AOR: 1.59, 95% CI: 1.30-1.95), alcohol use disorder (AOR: 1.26, 95% CI: 1.06-1.49), tobacco use disorder (AOR: 1.33, 95% CI: 1.21-1.45), and a history of opioid use disorder (OUD) (AOR: 1.63, 95% CI: 1.34-1.98). Patients with more than 5 comorbidities had 1.56 times higher odds (95% CI: 1.46-1.66) of LTOT compared to patients with 0-2 comorbidities. Characteristics of initial/index opioid associated with LTOT were dispensing long-acting opioids (AOR: 1.73, 95% CI: 1.22-2.46), concomitant use of benzodiazepines (AOR: 1.19, 95% CI: 1.11-1.28), gabapentinoids (AOR: 1.59, 95% CI: 1.49-1.69), and non-steroidal anti-inflammatory drugs (NSAIDs) (AOR: 1.23, 95% CI: 1.16-1.30). Starting therapy with tramadol increased the odds of LTOT compared to hydrocodone in patients with osteoarthritis and joint pain (AOR: 1.22, 95% CI: 1.06-1.41) as well as abdominal and bowel pain (AOR: 1.53, 95% CI: 1.05- 2.22). However, starting therapy with oxycodone decreased the odds of LTOT in patients with osteoarthritis and joint pain (AOR: 0.69, 95% CI: 0.53-0.90). For all pain conditions, initial opioid supply of ≥30 days led to 10-16 times higher odds of LTOT compared to days’ supply of 1-3 days.</p> <p><br></p> <p><strong>Conclusions:</strong> Higher age, black race, comorbidities, substance use disorders, and history of OUD are the patient-related risk factors of LTOT in older adults. Moreover, specific patterns of initial/index opioid prescription/dispensing such as greater number of days’ supply, dispensing long-acting opioids, and concomitant use of benzodiazepines, gabapentinoids, and NSAIDs increase the odds of LTOT. Prescribers should take these factors into consideration when prescribing opioids to older adults.</p>

No description available.

Background Type 2 diabetes is a common chronic disease with a two-fold increased risk for cardiovascular morbidity and mortality and has an increasing prevalence worldwide. This thesis is based on a study conducted in primary health care in Östergötland and Jönköping, Sweden. The aim of the thesis was to evaluate new risk markers to identify patients with high risk of developing cardiovascular disease in middle-aged men and women with type 2 diabetes. Methods Data from the cohort study CArdiovascular Risk in type 2 DIabetes – a Prospective study in Primary care (CARDIPP) was used. In paper III data were also used from CARDIPP-Revisited where all participants in the CARDIPP study were invited four years after the baseline investigation for a re-investigation. In paper IV data were used from CAREFUL which is a control group of 185 subjects without diabetes. The investigation included a standard medical history including data on diabetes duration and on-going medication. Anthropometric data were recorded and both office and ambulatory blood pressure were measured. The patients filled out a detailed questionnaire and physical activity was measured by using waist-mounted pedometers. Pedometer-determined physical activity was classified in four groups: Group 1: &lt;5000 steps/day (‘sedentary’); Group 2: 5000-7499 steps/day (‘low active’); Group 3: 7500-9999 steps/day (‘somewhat active’); Group 4: and ≥10 000 steps/day (‘active’). Blood samples were drawn for routine analyses and also frozen for later analyses. The investigations at the departments of physiology included echocardiography, measurements of the carotid intima-media thickness, applanation tonometry and measurements of  sagittal abdominal diameter. Results Paper 1: Patients with a non-dipping systolic blood pressure pattern showed higher left ventricular mass index and pulse wave velocity (PWV) compared with patients with ≥10% decline in nocturnal systolic blood pressure. Patients with &lt;10% decline in nocturnal systolic blood pressure had higher BMI and sagittal abdominal diameter, lower GFR and higher albumin:creatinine ratio and also higher levels of NT-proBNP than patients with a dipping pattern of the nocturnal blood pressure. Paper 2: The number of steps/day were inversely significantly associated with BMI, waist circumference and sagittal abdominal diameter, levels of CRP, levels of interleukin-6 and PWV. Paper 3: At the 4-year follow-up the change in PWV (ΔPWV) from baseline was calculated. The group with the lowest steps/day had a significantly higher increase in ΔPWV compared with the group with the highest steps/day. The associations between baseline steps/day and ΔPWV remained after further adjustment in a multivariate linear regression statistically significant (p=0.005). 23% of the variation in the study could be explained by our model. Every 1000 extra steps at baseline reduced the change in ΔPWV by 0.103 m/s between baseline and follow-up. Paper 4: Low vitamin D levels were associated with significantly increased risk for premature mortality in men with type 2 diabetes. High levels of parathyroid hormone were associated with significantly increased risk for premature mortality in women with type 2 diabetes. These relationships were still statistically significant also when two other well-established risk markers for mortality, PWV and carotid intima-media thickness, were added to the analyses. Conclusions Ambulatory blood pressure recording can by addressing the issue of diurnal blood pressure variation, explore early cardiovascular organ damage and microvascular complications that goes beyond effects of standardised office blood pressure measurements. Pedometer-determined physical activity may serve as a surrogate marker for inflammation and subclinical organ damage in patients with type 2 diabetes. There is novel support for the durable vascular protective role of a high level of daily physical activity, which is independent of BMI and systolic blood pressure. The use of pedometers is feasible in clinical practice and provides objective information not only about physical activity but also the future risk for subclinical organ damage in middle-aged people with type 2 diabetes. Our results indicate that low vitamin D levels in men or high parathyroid hormone levels in women give independent prognostic information of an increased risk for total mortality.

Orientador: Sebastião Jorge Chammé / Banca: Romeu Gomes / Banca: Wilson Jacob Filho / Banca: Viviane Souza Galvão / Banca: Kester Carrara / Resumo: Propusemos como objeto deste estudo, a formação do médico e a sensibilização para lidar com a pessoa idosa, que envolveu a análise dos olhares de estudantes de Medicina e pacientes idosos dentro da proposta de aprendizagem baseada em problemas e do currículo da Faculdade de Medicina de Marília-FAMEMA. Objetivos: Analisar a percepção de estudantes de Medicina da Aprendizagem Baseada em Problemas - ABP do currículo da FAMEMA como espaço de formação de médicos sensibilizados para a atenção das pessoas idosas;analisar as representações de estudantes e idosos acerca do que é ser um médico sensibilizado para a questão do envelhecimento. Métodos: Foram coletados dados de um questionário aplicado aos estudantes de medicina ao final da 4ª. série, e entrevistas realizadas com pacientes idosos e estudantes ao final da 6ª. série, e empregamos a análise temática para a inferência dos dados com a utilização de duas categorias de análise do estudo: "o estudante e a aprendizagem sobre o idoso", e "o idoso e o médico para a pessoa idosa". Resultados e discussão: Os olhares dos estudantes sobre a sua aprendizagem ao final da 4ª. e da 6ª. séries são complementares e, coincidentes, encontram-se: a abrangência e adequação da 'Unidade 17 - Envelhecimento' e sua contribuição no desenvolvimento pessoal, de desempenhos e competências para aprender a aprender, saber pensar, resgatar a perda do humano em nossas vidas, e saber cuidar; a doença é mais representada no currículo do Curso de Medicina que o doente, existindo 'ilhas curriculares' com uma atuação mais condizente com a atenção às necessidades dos pacientes; a 'disease' prepondera em muito sobre a 'illness'; teoria e prática permanecem pouco integradas; nada substitui a prática e o contato direto com a realidade, os problemas de papel, por melhor que... (Resumo completo, clicar acesso eletrônico abaixo). / Abstract: This study attempts to observe physicians' education process and how to humanize students with the elder's care by looking at the actual observation made by students and elderly themselves. This is considered within the context of a Problem-Based Learning (PBL) MD program at the Faculty of Medicine of Marilia (FAMEMA) Objectives: To analyze students' perceptions of problem based learning-PBL as it is used at FAMEMA's and how it functions as a space for training of doctors needing to be sensitive to the elder's care; and to analyze students and elderly people impressions of what is to be a doctor sensitive to the aging process. Methods: We collected data through a questionnaire applied to medical students finishing their 4th year of medical education. In-depth interviews with elderly people and with students at the end of 6th year were developed. Thematic analysis was used for data inference, focusing on two types of aspects in this study: "the student and learning about the elderly" and "the elder and the doctor caring for the aged". Results and discussion: Students at the end of 4th and 6th years are coincident in relation to: quality and pertinence of Unit 17 Unit - "Aging". They also match in terms of the Unit's contribution to personal development, acquisition of skills and competences "to learn how to learn", to reason, to rescue the human aspect of our lives, and to know how to provide care of the elderly. Disease is over represented in relation to the actual patient. Hence, there are "curricular islands" better suited to the care of these patients' needs. Still, prevails the pathological-medical model over the one that looks at illness, as a person's ailment. Practice and theory remain poorly integrated. Nothing can substitute practice and direct contact with the real world. Paper problems, regardless of how well they have been... (Complete abstract, click electronic address below). / Doutor

INTRODUÇÃO: Tem-se afirmado que a via de acesso minimamente invasiva na artroplastia total de joelho (ATJ) por não agredir o músculo quadríceps femoral permite reabilitação mais precoce. A fim de verificar a influência da preservação do aparelho extensor no ato cirúrgico, avaliou-se a força da musculatura extensora e flexora do joelho em pacientes submetidos à ATJ por duas vias de acesso diferentes. MÉTODOS: Este estudo comparou, no período de janeiro de 2005 a julho de 2006, os valores de torque máximo e de trabalho total obtidos por dinamometria isocinética aos seis meses de pós-operatório. Foram avaliados 12 indivíduos submetidos à ATJ por via de acesso minimamente invasiva e 8 indivíduos submetidos à ATJ por via de acesso transquadricipital. RESULTADOS: A análise estatística dos valores de torque máximo e de trabalho total absolutos e corrigidos pelo peso corporal não demonstrou diferença entre os dois grupos. CONCLUSÃO: Não há diferença de força da musculatura extensora e flexora do joelho aos seis meses de cirurgia. / INTRODUCTION: It has been stated that for total knee arthroplasty (TKA), the minimally invasive approach permits earlier rehabilitation because it is not prejudicial for the femoral quadriceps muscle. To verify the influence of preserving the extensor apparatus during surgery, strength of the knee extension and flexion muscles was evaluated in patients submitted to TKA with different approaches. METHODS: The values of maximum torque and total work obtained by isokinetic dynamometry six months after surgery were compared for the MIS group of 12 individuals submitted to TKA by the minimally invasive surgical approach and the Control group of eight others submitted to TKA by the transquadricipital approach, between January 2005 and July 2006. RESULTS: Statistical analysis of the absolute values of maximum torque and total work corrected by body weights did not show a difference between the two groups. CONCLUSION: There was no difference in the extension and flexion strength of the knee muscles six months after surgery.