Drug-Induced Parkinsonism: Too Many Cooks in the Kitchen.

Drug-induced parkinsonism (DIP) is a condition characterized by the development of parkinsonian symptoms as a result of medication use. It is often misdiagnosed and can be challenging to differentiate from Parkinson's disease (PD). In this case presentation, we describe the clinical course of a 64-year-old male who presented with parkinsonian symptoms while using atypical antipsychotics, which was originally misdiagnosed as PD. The case highlights the importance of recognizing the potential iatrogenic effects of medications with antidopaminergic properties, such as antipsychotics and antiepileptic drugs, which are common culprits in causing DIP. We discuss DIP management, long-term impacts, and differentiating DIP from PD through clinical findings and imaging, emphasizing the utility of the (123)I-ioflupane single-photon emission computerized tomography (SPECT) scan in aiding diagnosis. This case serves as a reminder to healthcare providers to remain vigilant in monitoring patients for adverse effects, polypharmacy, and harmful medication interactions.

Cyclone: open-source package for simulation and analysis of finite dynamical systems.

MOTIVATION: While there are software packages that analyze Boolean, ternary, or other multi-state models, none compute the complete state space of function-based models over any finite set. Results: We propose Cyclone, a simple light-weight software package which simulates the complete state space for a finite dynamical system over any finite set. AVAILABILITY AND IMPLEMENTATION: Source code is freely available at https://github.com/discretedynamics/cyclone under the Apache-2.0 license.

Disability-Specific Education in US Internal Medicine Primary Care Residency Programs: A Survey of Program Directors.

Phenomenon: The dearth of disability-specific education in United States medical schools and residency programs has perpetuated health care inequities experienced by people with disabilities. In this study, we surveyed internal medicine primary care residency program directors about the disability-specific education they offer their learners, their attitudes toward physicians' preparedness to care for people with disabilities, and their perceived challenges to offering more robust disability-specific education. Approach: We developed an on-line survey and forwarded it in 3 weekly emails during October of 2022 to 104 primary care residency program directors. We collected basic information about the residency programs and queried whether they were providing disability-specific education to their residents, which topics were being covered, and perceived barriers to offering additional disability-focused curricula. Data analyses included descriptive statistics, chi-squared, and independent samples t-tests. Findings: Forty-seven program directors responded (response rate 45.2%). The largest plurality of programs was in the Northeast, their average number of primary care residents was 15.6, most (67.4%) hosted primary care clinics in hospitals or academic centers, and 55.6% had affiliated divisions or departments of rehabilitation medicine. The majority of respondents felt that both internists and their own residents (88.3% and 77.8%, respectively) are inadequately educated in the care of people with disabilities, yet only 13 (28.9%) offered disability-focused curricula, and they tended to be narrow in scope. Only 8 of those 13 respondents (61.5%) reported that their disability curricula were required, rather than optional. Participants listed a number of barriers to implementing disability-focused education including a lack of advocacy for such work (65.2%), lack of time in the curriculum (63.0%), lack of expectation by educational governing boards that physicians understand disability-specific care considerations (60.9%), and lack of affiliated expertise in the care of people with disabilities (52.2%). Insights: While the program directors training future primary care physicians largely understand that physicians are inadequately prepared to offer equitable health care to individuals with disabilities, few of them are offering disability-specific education to their residents and most see significant barriers to doing so.

Death by Patient Portal.

In this narrative medicine essay, an internist suffering from portal communication burnout explored several solutions, none of which sat well with him, so he decided to write a letter to his patients explaining his fatigue and asking them to abide by some usage guidelines.

The Dearth of Disability Medical Education and a Partial Solution.

Issue: While over one-quarter of adult Americans have a disability, there is a paucity of disability-specific curricula in American medical schools and residency programs. Potential consequences of this educational dearth include persistent inaccessibility of health care facilities and delivery of inequitable health care to individuals with disabilities. Evidence: Several working groups have proposed disability-specific competencies for health professions education and means by which to integrate them into existing curricula. A limited number of medical schools and residency programs have formally introduced disability-specific materials into their curricula. To our knowledge, however, there are no generalist (internal medicine or family medicine) residency programs that offer specialized training in the clinical care of people with disabilities. Implications: Offering generalist physicians the opportunity to acquire the clinical and cognitive skills required to provide thorough and equitable health care to people with disabilities is critically important. There are too few physiatrists to see to their care needs. In this manuscript, we present a novel concentration in an Internal Medicine residency program in the care of individuals with a variety of disabilities. Our hope is that this work will initiate discussions among educational leaders about how to address the lack of graduate medical education-level training in disability care. We also hope it will afford program directors the opportunity to implement similar concentrations and tracks and will eventually produce a generation of generalists who are well-equipped to help care for people with disabilities.

An Assessment of Which Sociodemographic and Spinal Cord Injury-Specific Characteristics Influence Engagement With Experimental Therapies and Participation in Clinical Trials.

Background: Although a number of experimental therapies for spinal cord injury (SCI) have recently emerged, few authors have examined the goals of individuals with SCI considering experimental therapies, and none have determined whether sociodemographic and injury-specific characteristics influence that engagement. Objectives: To determine (a) the goals of individuals with SCI who are considering experimental therapies; (b) whether sociodemographic factors, injury-specific characteristics, and concerns over adverse events influence those goals and/or participation in experimental therapies and clinical trials; and (c) whether people with SCI feel they have adequate information about experimental therapies and clinical trials. Methods: An online survey that yielded 364 responses. Results: Most respondents (83.7%) had sought information about experimental therapies, and just under half (47.8%) had received one. The most frequently cited functional goals were improvement in bowel and bladder function and elimination of dysreflexia (60.4%). Several goals were influenced by age and level and completeness of injury, and most respondents (93.4%) wanted more information about experimental therapies. Just over one-third (34.6%) of respondents had participated in a clinical trial, and nearly all (96.9%) wanted more information about them. Having received experimental therapies and participated in clinical trials was positively correlated with seeking SCI-specific care from an SCI specialist rather than from a primary care physician. Most (83.9%) respondents would avoid or be reluctant to engage with a medical center if they were made aware of harm done to trial participants. Conclusion: This work suggests that there are unmet information needs among people with SCI, specifically pertaining to experimental therapies and clinical trials. It also reveals that improved access to SCI specialists may enhance access to novel treatments and research efforts. Being made aware of harm to trial participants may influence the decision of individuals with SCI to seek care at or enroll in trials at these clinical sites.

A pulse survey: assessment and management of bone loss in spinal cord injury.

STUDY DESIGN: An online survey OBJECTIVES: To describe current clinical practices regarding osteoporosis assessment and management in people with Spinal Cord Injury (SCI) and compare them to recommended diagnostic tests and interventions. SETTING: An international collaboration surveying professionals working in SCI Medicine. METHODS: Online cross-sectional survey regarding clinical practice trends in the assessment and treatment of osteoporosis in people with SCI. Assessment of whether discrete professional characteristics influenced practices and if those practices were consistent with recommendations from professional organizations. RESULTS: Eighty-two professionals working in SCI Medicine completed the survey. Respondents were equally likely to test for bone loss during the post-acute phase (between 4- and 18-months post injury) and after low impact fracture (41.46% and 42.68%, respectively) and more likely to test during the chronic phase (51.22%). The majority of respondents (n = 56, 70%) assessed bone density with DXA at the hip, and many (48.78%, n = 40) prescribed simultaneous mobilization, vitamin D and calcium to prevent bone loss in the acute, post-acute and chronic phases. A number of evaluations and interventions were inconsistent with best practice recommendations. CONCLUSIONS: Given that reported practices for detection and treatment of osteoporosis in SCI are inconsistent and not data-driven, there is need for dissemination and adoption of existing clinical practice guidelines.

COVID-19 and spinal cord injury and disease: results of an international survey as the pandemic progresses.

STUDY DESIGN: An online survey. OBJECTIVES: To follow-up with and re-query the international spinal cord community's response to the Coronavirus Disease 2019 (COVID-19) pandemic by revisiting questions posed in a previous survey and investigating new lines of inquiry. SETTING: An international collaboration of authors and participants. METHODS: Two identical surveys (one in English and one in Spanish) were distributed via the internet. Responses from both surveys were pooled and analyzed for demographic and response data. RESULTS: Three hundred and sixty-six respondents were gathered from multiple continents and regions. The majority (63.1%) were rehabilitation physicians and only 12.1% had patients with spinal cord injury/disease (SCI/D) that they knew had COVID-19. Participants reported that the COVID-19 pandemic had caused limited access to clinician and support services and worsening medical complications. Nearly 40% of inpatient clinicians reported that "some or all" of their facilities' beds were being used by medical and surgical patients, rather than by individuals requiring inpatient rehabilitation. Respondents reported a 25.1% increase in use of telemedicine during the pandemic (35% used it before; 60.1% during), though over 60% felt the technology incompletely met their patients' needs. CONCLUSION: The COVID-19 pandemic has negatively impacted the ability of individuals with SCI/D to obtain their "usual level of care." Moving forward into a potential "second wave" of COVID-19, patient advocacy and efforts to secure access to thorough and accessible care are essential.

A survey of internal and family medicine residents: Assessment of disability-specific education and knowledge.

BACKGROUND: The literature suggests that primary care physicians are inadequately educated in the care of people with disabilities. No study to date has evaluated whether internal medicine (IM) and family medicine (FM) residents have received disability-specific education or their level of comfort in caring for people with physical disabilities. OBJECTIVES: To assess IM and FM residents' receipt of disability-specific education during medical school and residency; to evaluate their self-reported comfort in managing secondary conditions associated with physical disabilities and in coordinating therapies and services for individuals with disabilities; to gauge their interest in receiving disability-specific education. METHODS: An on-line survey distributed to residents at a convenience sample of ten academic IM and FM residency programs in the northeastern United States. Participants (n = 176) were asked about their socio-demographic and training-specific characteristics and their self-assessed ability to manage secondary conditions associated with physical disabilities and coordinate care and services for individuals with disabilities. Chi Square tests were used to compare participant characteristics and outcomes. RESULTS: Few participants had received disability-specific education during medical school or residency (34.6% and 11.2%, respectively), and nearly all (96.0%) expressed interest in receiving more. Small minorities reported feeling comfortable managing common secondary conditions or in coordinating therapies and services for individuals with disabilities. CONCLUSION: Although one-fifth of adult Americans have a disability, few of our participating IM and FM residents had received disability-specific education or felt comfortable managing the care of people living with disabilities. Our results indicate a need to develop and disseminate disability-specific curricula.

A Primary Care Provider's Guide to Neurogenic Bowel Dysfunction in Spinal Cord Injury.

Spinal cord injury (SCI) affects the gastrointestinal (GI) tract in several ways, most notably by causing impairment of colonic motility and sphincter dysfunction. Altered GI function in the setting of neurological injury-also known as "neurogenic bowel dysfunction" (NBD) -strongly impacts the quality of life (QOL) of individuals living with SCI. Characterizing the severity of NBD, its impact on an individual's QOL, and which interventions have been successful or ineffective is integral to the routine care of people living with SCI. Treatment of NBD is generally multimodal and includes attention to diet, pharmacologic and mechanical stimulation, and possibly surgery. This article discusses the pathophysiology of NBD and specific approaches to its management.

A Provider's Guide to Vascular Disease, Dyslipidemia, and Glycemic Dysregulation in Chronic Spinal Cord Injury.

Individuals with chronic spinal cord injury (SCI) are predisposed to accelerated atherogenesis, dyslipidemia, and glycemic dysregulation, although not enough is known about the etiologies or clinical consequences of these secondary effects of paralysis. While guidelines for the detection and treatment of cardiometabolic disease in SCI have recently been published, there has been a historical paucity of data-driven approaches to these conditions. This article will describe what is and not known about the cardiovascular disease and glycemic dysregulation that frequently attend SCI. It will conclude with a review of both guideline-driven and informal recommendations addressing the clinical care of people living with SCI.

How individuals with spinal cord injury in the United States access and assess information about experimental therapies and clinical trials: results of a clinical survey.

STUDY DESIGN: An internet-based survey. OBJECTIVES: To determine how individuals with spinal cord injury (SCI) access information about experimental therapies and clinical trials. To understand which factors influence receipt of and perceived trustworthiness of that information. SETTING: Two academic medical centers and an SCI organization. METHODS: Demographic information frequencies and percentages were calculated then analyzed using chi-square tests for independence. Fisher's exact test of independence was used to assess significance for contingency tables with categories containing expected counts below five. RESULTS: Three hundred sixty four persons with SCI participated in the survey. Most felt confident in their ability to evaluate SCI-specific information from a variety of sources, though SCI organizations and the medical literature were deemed the most reliable. Information from SCI specialists was deemed more credible than that from non-SCI specialists, but only 53.6% of participants had access to them. Nearly all (89.0%) respondents who had sought information about experimental therapies had found it online, while 51.4% of those who had participated in a clinical trial had been contacted by a research team. Only 8.4% of participants felt their medical teams offered them sufficient information about experimental therapies and clinical trials. Wealthier and more educated respondents were more knowledgeable about health-related resources on the internet. Nearly all participants (96.9%) expressed interest in learning more about trials related to SCI. CONCLUSIONS: There is an information deficit among people with SCI pertaining to experimental therapies and clinical trials. It is exacerbated by lack of income, education, and access to SCI specialists.

Dense networks that do not synchronize and sparse ones that do.

Consider any network of n identical Kuramoto oscillators in which each oscillator is coupled bidirectionally with unit strength to at least µ(n-1) other oscillators. Then, there is a critical value of µ above which the system is guaranteed to converge to the in-phase synchronous state for almost all initial conditions. The precise value of µ remains unknown. In 2018, Ling, Xu, and Bandeira proved that if each oscillator is coupled to at least 79.29% of all the others, global synchrony is ensured. In 2019, Lu and Steinerberger improved this bound to 78.89%. Here, we find clues that the critical connectivity may be exactly 75%. Our methods yield a slight improvement on the best known lower bound on the critical connectivity from 68.18% to 68.28%. We also consider the opposite end of the connectivity spectrum, where the networks are sparse rather than dense. In this regime, we ask how few edges one needs to add to a ring of n oscillators to turn it into a globally synchronizing network. We prove a partial result: all the twisted states in a ring of size n=2m can be destabilized by adding just O(nlog2⁡n) edges. To finish the proof, one needs to rule out all other candidate attractors. We have done this for n≤8 but the problem remains open for larger n. Thus, even for systems as simple as Kuramoto oscillators, much remains to be learned about dense networks that do not globally synchronize and sparse ones that do.

How do healthcare providers manage depression in people with spinal cord injury?

STUDY DESIGN: An online survey. OBJECTIVES: To describe how healthcare providers manage depression after spinal cord damage (SCD) and to identify factors that predict use of recommended depression management practices. SETTING: An international cohort of respondents who provide clinical care to individuals with SCD. METHODS: An online survey was distributed to clinicians caring for individuals with SCD. The 20-question survey inquired about participant demographic and professional information, their knowledge and beliefs about depression after SCD, their methods of treating depression in SCD, and perceived barriers to treatment of depression. RESULTS: One hundred eleven individuals took this survey. Participants estimated on average that 48.7% of their patients with SCD have depression, and nearly two-thirds (62.2%) reported using their own clinical judgment to identify the condition. Respondents cited barriers to depression treatment including patient denial of depression (47.7%), stigmas attached to depression (41.4%), and lack of availability and high cost of counseling (45.9% and 35.1%, respectively) and antidepressant medications (5.4% and 10.8%, respectively). The belief that one is well trained to handle depressive symptoms predicted increased frequency of screening for depression and implementation of recommended treatments for depression. CONCLUSIONS: Respondents to this survey under-utilize valid screening measures and likely over-estimate the prevalence of depression in SCD. They cited a number of barriers to treatment for depression. Our results underscore the need for improved mental health education among SCD providers and the use of valid depression screening measures to help focus limited mental health services and treatments on those who need them.

A Primary Care Provider's Guide to Autonomic Dysfunction Following Spinal Cord Injury.

Spinal cord injury (SCI) disrupts the crucial "crosstalk" between the spinal autonomic nervous system and supraspinal control centers. Therefore, SCI may result not only in motor paralysis but also in potentially life-threatening impairments of many autonomic functions including, but not limited to, blood pressure regulation. Despite the detrimental consequences of autonomic dysregulation, management and recovery of autonomic functions after SCI is greatly underexplored. Although impaired autonomic function may impact several organ systems, this overview will focus primarily on disruptions of cardiovascular and thermoregulation and will offer suggestions for management of these secondary effects of SCI.

An arterial insufficiency ulcer in an individual with cervical spinal cord injury and hypotension.

INTRODUCTION: Arterial ulcers develop as a complication of tissue hypoperfusion, ordinarily from atherosclerotic disease, but sometimes due to other medical conditions or trauma. While people with spinal cord injury (SCI) may be predisposed to resting hypotension, and, hence, to inadequate peripheral circulation, there are no reports of arterial ulcers as a secondary effect of SCI. CASE PRESENTATION: A 54-year-old woman with long standing cervical SCI presented with a nonhealing lateral malleolar ulcer that was complicated by osteomyelitis and unresponsive to biweekly debridement. On examination, she was hypotensive with cool extremities and non-palpable pedal pulses but had no evidence of atherosclerotic disease, cardio-metabolic derangement, or vasculopathy. We treated her with Midodrine with improvement in her peripheral circulation then referred her for surgical intervention. DISCUSSION: To our knowledge, this is the first reported case of an arterial ulcer in a person living with SCI that was most likely caused by resting hypotension. It is possible that individuals with SCI-particularly those with higher-level injuries-are at risk for this condition. Clinicians must be alert to arterial ulcers as a potential complication of SCI with concomitant hypotension.

COVID-19 and spinal cord injury and disease: results of an international survey.

STUDY DESIGN: An online survey. OBJECTIVES: To query the international spinal cord medicine community's engagement with and response to the novel coronavirus (COVID-19) pandemic and to assess pandemic-specific information needs and patient concerns. SETTING: An international collaboration of authors and participants. METHODS: Two near-identical surveys (one English and one Spanish language) were distributed via the internet. Responses from those questions shared between the surveys were pooled then analyzed; four questions' responses (those not shared) were analyzed separately. RESULTS: A total of 783 responses were submitted from six continents. Few participants (5.8%) had tested their outpatients with SCI/D for COVID-19; only 4.4% reported having a patient with SCI/D with the virus. Of respondents who worked at an inpatient facility, 53.3% reported that only individuals with symptoms were being screened and 29.9% said that no screening was occurring. Participants relayed several concerns offered by their patients with SCI/D, including vulnerability to infection (76.9%) and fragility of caretaker supply (42%), and those living in countries with guaranteed health care were more likely to report widespread availability of COVID-19 testing than were those living in countries without universal care, χ2 (3, N = 625) = 46.259, p < 0.001. CONCLUSION: There is substantial variability in the rehabilitation medicine community in COVID-19 screening practices and availability of screening kits. People living with SCI/D are expressing legitimate and real concerns about their vulnerability to COVID-19. More and rapid work is needed to address these concerns and to standardize best-practice protocols throughout the rehabilitation community.

Guideline for the identification and management of cardiometabolic risk after spinal cord injury: a case of unsubstantiated recommendations.

The 2018 Guideline for the Identification and Management of Cardiometabolic Risk after Spinal Cord Injury (SCI) represented the first concerted effort to address a cluster of derangements and diseases that are claiming the lives of individuals living with injuries. Its contributors and authors scoured the literature, weighed the validity, importance, and clinical relevance of what data they found, and collaborated in an effort to meaningfully improve the health and lives of people with SCI. However, we are concerned that several of the guideline's central recommendations-particularly around screening for and detection of glycemic dysregulation and dyslipidemia-have been offered prematurely. In several instances, the authors cite data from studies of people without SCI and, in our opinion, inappropriately apply those findings to support their SCI-specific suggestions. In other instances, they recommend that we employ tests whose usefulness and clinical relevance have yet to be demonstrated among people living with injuries. In short, we fear that the authors have developed clinical guidelines that are inadequately supported by data. This guideline is an extraordinary show of collaboration, and is an important first step toward understanding and treating a number of secondary cardiometabolic effects of SCI. The lack of data underpinning several of its central recommendations-making them, in our opinion, unadoptable-underscores the inadequacy of research in this area and provides a roadmap for future investigative efforts.

Communication with general practitioners: a survey of spinal cord injury physicians' perspectives.

Study design: An online questionnaire. Objectives: To gauge spinal cord injury (SCI) specialists' assessment of their communications with general practitioners (GPs). To determine whether economic or health-care system-related factors enhance or inhibit such communication. Setting: A collaboration of co-authors from a health-care system. Methods: An online survey interrogating a number of aspects of communication between SCI specialists and GPs was developed, distributed, and made available for 4 months. Responses were analyzed for the entire cohort then according to descriptions of participants' home nations' economies and the type of health-care delivery systems in which they work. Results: A total of 88 responses were submitted. The majority (64%) were from nations with developed economies, a plurality (47.1%) were from countries that offer universal health coverage, and half used a combination of paper and electronic health records. A majority of respondents (61.8%) reported routinely communicating with their patients' GPs, but most (53.4%) rated those communications as only "fair". The most commonly listed barriers to communication with GPs were lack of time (46.3%) and a perceived lack of receptivity by GPs (26.9%). Nearly all respondents (91.6%) believed that the care they provide would be enhanced by improved communication with GPs. Participants who used electronic means of communication were more likely to communicate with GPs and to describe those interactions as "positive". Conclusions: Although there are a number of barriers to communication between SCI specialists and GPs, most SCI specialists are eager for such inter-physician communication and believe it would enhance their care they deliver.