Health Care Utilization in the Last Year of Life in Parkinson Disease and Other Neurodegenerative Movement Disorders.

Background and Objectives: Neurodegenerative movement disorders are rising in prevalence and are associated with high health care utilization. Generally, health care resources are disproportionately expended in the last year of life. Health care utilization by those with neurodegenerative movement disorders in the last year of life is not well-understood. The goal of this study was to assess the utilization of acute care in the last year of life among individuals with neurodegenerative movement disorders and determine whether outpatient neurology or palliative care affected acute care utilization and place of death. Methods: We conducted a retrospective cross-sectional study including health system administrative data in Alberta, Canada, from 2011 to 2017. Administrative data were used to determine place of death and quantify emergency department (ED) visits, hospitalizations, intensive care unit admissions, and outpatient generalist and specialist visits. Diagnoses were classified by 10th revision of the International Classification of Diseases codes. Stata 16v was used for statistical analyses. Results: Among 1439 individuals (60% male), Parkinson disease (n = 1226), progressive supranuclear palsy (n = 78), multiple system atrophy (n = 47), and Huntington disease (n = 58) were the most common diagnoses. The most frequent place of death was in hospital (45.9%), followed by long-term care (36.3%), home (7.9%), and residential hospice (4.0%). Most (64.2%) had >1 ED visit, and 14.4% had >3 emergency department visits. Fifty-five percent had >1 hospitalization, and 23.3% spent >30 days in hospital. Few (2.6%) were admitted to ICU. Only 37.2% and 8.8% accessed outpatient neurologist and specialist palliative care services, respectively. Multivariate logistic regression found the odds of dying at home was higher for those who received outpatient palliative consultation (OR, 2.49, 95% confidence interval [CI], 1.48-4.21, p < 0.001) and were with a longer duration of home care support (OR, 1.0007, 95% CI, 1.0004-1.0009, p < 0.001). Discussion: There are high rates of in-hospital death and acute care utilization in the year before death among those with neurodegenerative movement disorders. Most did not access specialist palliative or neurologic care in the last year of life. Outpatient palliative care and home care services were associated with increased odds of dying at home. Our results indicate the need for further research into the causes, costs, and potential modifiers to inform public health planning.

[Retrospective study of 48 cases of primary central nervous system lymphoma]. / Estudio retrospectivo de 48 casos de linfoma primario del sistema nervioso central.

Primary central nervous system lymphoma (PCNSL) is an infrequent form of non-Hodgkin lymphoma restricted to the CNS. More than 90% are type B and mainly affect patients aged 50-70 years. Immunodeficiency is the most important risk factor. The aim of our study was to evaluate the immune status, clinical presentation and findings in complementary studies of PCNSL patients. A retrospective analysis of 48 cases treated in our center between January 1992 and May 2015 was performed. Median age at diagnosis was 61 years (range 25-84); with male predominance (2.1:1). Forty one cases (85%) were immunocompetent patients. Brain MRI findings showed parenchymal involvement in 45 cases (94%), 43% with frontal lobe and 35% basal ganglia, 4% had meningeal involvement and 2% had ophthalmic involvement at diagnosis. Fifty-five percent had restricted signal on diffusion weighted imaging and contrast enhancement was found in 89%. Pyramidal syndrome was the main initial clinical manifestation (56%). There were abnormal findings in 62% of CSF samples, but in only 11.1% positive cytology results were detected. The most frequent type was diffuse large B-cell lymphoma (83%), being B-cell type the most common form between them (96%). In our series PCNSL was more frequent in immunocompetent elderly male subjects. At initial evaluation, clinical manifestations and MRI findings were variable. The initial suspicion of this entity would allow an early diagnosis, avoiding empirical treatments that may confuse or delay diagnosis.

Estudio restrospectivo de 48 casos de linfoma primario del sistema nervioso central / Retrospective study of 48 cases of primary central nervous system lymphoma

Los linfomas primarios del sistema nervioso central (LPSNC) son neoplasias infrecuentes confinadas al SNC. Más del 90% son de tipo B y afectan principalmente a pacientes entre 50-70 años. La inmunodeficiencia es el factor de riesgo más importante. El objetivo de nuestro trabajo fue evaluar las características demográficas, estado inmunológico y los hallazgos en los estudios complementarios de pacientes con LPSNC. Se realizó el análisis retrospectivo de 48 casos estudiados en nuestro centro desde enero 1992 a mayo 2015. La edad mediana de presentación fue 61 años (25-84); la relación hombre:mujer 2.1:1. El 85% (41 casos) fueron inmunocompetentes al momento del diagnóstico. El 94% (45 casos) tuvo compromiso parenquimatoso, 4% (2 casos) meníngeo y 2% (1 caso) ocular. El lóbulo más afectado fue el frontal (43%) y 35% tuvieron compromiso ganglio basal. En RM, el 89% mostró realce con contraste y 55% restricción en difusión. El síndrome piramidal fue la manifestación inicial más frecuente (56%). El LCR fue inflamatorio en el 72%, aunque solo 11.1% presentó examen citológico positivo. El tipo más frecuente de LPSNC fue no-Hodgkin B (96%) y el subtipo difuso de células grandes el más habitual (83%). En nuestra serie la ausencia de inmunocompromiso fue una característica frecuente y la presentación clínico-radiológica fue muy pleomórfica. La sospecha inicial permitiría arribar a un diagnóstico temprano, evitando tratamientos empíricos que puedan confundir o retrasar el diagnóstico.

Primary central nervous system lymphoma (PCNSL) is an infrequent form of non-Hodgkin lymphoma restricted to the CNS. More than 90% are type B and mainly affect patients aged 50-70 years. Immunodeficiency is the most important risk factor. The aim of our study was to evaluate the immune status, clinical presentation and findings in complementary studies of PCNSL patients. A retrospective analysis of 48 cases treated in our center between January 1992 and May 2015 was performed. Median age at diagnosis was 61 years (range 25-84); with male predominance (2.1:1). Forty one cases (85%) were immunocompetent patients. Brain MRI findings showed parenchymal involvement in 45 cases (94%), 43% with frontal lobe and 35% basal ganglia, 4% had meningeal involvement and 2% had ophthalmic involvement at diagnosis. Fifty-five percent had restricted signal on diffusion weighted imaging and contrast enhancement was found in 89%. Pyramidal syndrome was the main initial clinical manifestation (56%). There were abnormal findings in 62% of CSF samples, but in only 11.1% positive cytology results were detected. The most frequent type was diffuse large B-cell lymphoma (83%), being B-cell type the most common form between them (96%). In our series PCNSL was more frequent in immunocompetent elderly male subjects. At initial evaluation, clinical manifestations and MRI findings were variable. The initial suspicion of this entity would allow an early diagnosis, avoiding empirical treatments that may confuse or delay diagnosis.

Botulinum Toxin Use in Refractory Pain and Other Symptoms in Parkinsonism.

BACKGROUND: Parkinson's disease (PD) and other parkinsonian syndromes are chronic, progressive neurodegenerative diseases. With advancing disease, both motor and non-motor symptoms represent a considerable burden and symptom relief and quality of life improvement become the main goal of treatment. Botulinum toxins (BTX) are an effective treatment modality for many neurological conditions. METHODS: To understand the potential usefulness of BTX in this population, we performed a retrospective chart review of all patients with a clinical diagnosis of idiopathic PD and atypical parkinsonism who received treatment with BTX injections in our center from 1995 to 2014 for a variety of symptoms. Response to BTX was assessed using a subjective Clinical Global Impression. RESULTS: Records of 160 patients were reviewed. Probable idiopathic PD was the diagnosis in 117 patients (73.1%). The main indication for BTX treatment was pain (50.6% of cases). Other indications were the treatment of functional impairment resulting from dystonia (26.25%), sialorrhea (18.75%), freezing of gait, and camptocormia. Considering pain as indication, 81% of all patients with PD reported benefits after the first BTX injections. This benefit was maintained after the last recorded visit without significant difference in outcome compared with the first injection (p=0.067). Similar results were observed in patients with atypical parkinsonism. CONCLUSIONS: Our results confirm the safety and efficacy of different uses of BTX in the symptomatic treatment of patients with parkinsonism even in advanced stages of the disease, and suggest BTX treatment could have a safe and useful role in the treatment of pain in this population.

Melatonin treatment counteracts the hyperthermic effect of lipopolysaccharide injection in the Syrian hamster.

The present study examined the acute response in body temperature to lipopolysaccharide (LPS) injection to Syrian hamsters at two time intervals during the light-dark cycle. Its modification by melatonin (MT) administration in the drinking water was also assessed. Hamsters were intraperitoneally (i.p.) implanted with a transmitter to measure core body temperature. MT was administered from day 8 post-surgery until the end of experiment. On day 16 after surgery, LPS or saline was injected i.p. at the beginning of the light phase (ZT 0) or of the scotophase (ZT 14). At ZT 0, LPS increased core body temperature, an effect that persisted for at least 5h and that was blunted by MT administration. At ZT 14, the hyperthermic effect of LPS was absent. Rather, at ZT 14 the animals showed increases in core body temperature following saline or LPS during the first 2h after injection only, which were significantly less intense in LPS-treated animals. MT administration blunted this difference. Five days after injection, hamsters that had received LPS at ZT 0 showed an increase in the mesor of core body temperature rhythm as compared to saline. This effect was suppressed by MT administration. The results demonstrate that MT prevents body temperature increase after LPS at ZT 0.