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neralized Estimating Equation approach for analyses of audiometric data may be preferable to the single-ear methods.
The aim of the study was to identify the effects of combined motor imagery and action observation therapy on vascular cognitive impairment.

Thirty vascular cognitive impairment patients were randomly assigned into three groups. Cognitive training group was given conventional cognitive training, motor imagery + action observation group was treated with motor imagery and action observation therapy, and mixed therapy group was given conventional cognitive training and motor imagery + action observation therapy, for 8 wks continuously. The Montreal Cognitive Assessment Scale, Rivermead Behavioral Memory Test, and event-related potential were used to evaluate the cognitive function at baseline, 4- and 8-wk posttreatment, and 1-mo follow-up.

There were significant time × group interactions in Montreal Cognitive Assessment Scale (F6,4.20 = 8.38, P < 0.001), event-related potential latent period (F6,294.24 = 5.10, P < 0.001), event-related potential amplitude (F6,1.68 = 23.08, P < 0.001), and Rivermead Behavioral Memory Test (F6,312.61 = 5.42, P < 0.001). Intragroup comparisons showed that Montreal Cognitive Assessment Scale and Rivermead Behavioral Memory Test scores and event-related potential amplitude increased significantly (P < 0.05), and event-related potential latency decreased significantly (P < 0.05) in all groups. Intergroup comparisons showed that the changes of all outcomes in mixed therapy group were greater than those in cognitive training and motor imagery + action observation group (P < 0.05) after treatment.

These results suggest that the combination of cognitive training with motor imagery and action observation therapy is an effective treatment on cognitive function in people with vascular cognitive impairment.
These results suggest that the combination of cognitive training with motor imagery and action observation therapy is an effective treatment on cognitive function in people with vascular cognitive impairment.
Less is known how dysphagia affects older patients without neurologic diseases and whether the symptoms of dysphagia have any association with impaired central control of swallowing. This study investigated the state of the corticobulbar tract, the surrogate marker for the central control of swallowing, in older dysphagic patients without any neurologic diseases, using diffusion tensor tractography.

This retrospective observational study was conducted at a tertiary university hospital including 10 patients 60 yrs or older with oropharyngeal dysphagia without neurological disease and 11 age- and sex-matched control participants. The corticobulbar tract was reconstructed, and the fractional anisotropy and tract volume were measured using diffusion tensor tractography.

The corticobulbar tracts of the dysphagia group were narrowed and not reconstructed by their configurations and had lower fractional anisotropy and tract volume values when compared with those of control group. Significant asymmetry between the left and the right corticobulbar tract hemispheres was found in the dysphagia group, whereas no asymmetry was found in the control group.

A deteriorated corticobulbar tract could be associated with the development of dysphagia in older adults without neurological diseases. Our findings might help establish more appropriate treatment strategies, such as targeted neuromodulation therapies in the future.
A deteriorated corticobulbar tract could be associated with the development of dysphagia in older adults without neurological diseases. Our findings might help establish more appropriate treatment strategies, such as targeted neuromodulation therapies in the future.
To describe the demographic characteristics of patients who used telemedicine and office visits in Physical Medicine and Rehabilitation (PM&R) during the COVID-19 pandemic and to quantify differences in clinical utilization between groups. Clinical utilization was defined as emergency department, urgent care, and hospital visits.

Retrospective cohort study of 1,096 patients who used telemedicine and 1,171 patients who used office visits from April to June 2020 in outpatient PM&R at UPMC for musculoskeletal-related complaints.

The telemedicine groups contained proportionally more people of color and higher comorbidities than the office visit groups. Patients who were seen in the telemedicine groups were more likely to be prescribed opioids than the office visit group. There were no differences in clinical utilizations between the telemedicine and office visit groups.

The higher use of telemedicine in patients of color suggests a need for studying long-term outcomes to evaluate differences in care standards. We also identified that there is an urgent need to understand how telemedicine affects opioid prescribing practices. Lastly, future studies are needed to understand why there were no differences in clinical utilization between the telemedicine and office visit groups.
The higher use of telemedicine in patients of color suggests a need for studying long-term outcomes to evaluate differences in care standards. We also identified that there is an urgent need to understand how telemedicine affects opioid prescribing practices. Lastly, future studies are needed to understand why there were no differences in clinical utilization between the telemedicine and office visit groups.
This case study presents a 31-yr-old male weightlifter without known neuromuscular disease who presented with 5 wks of atraumatic, constant fasciculations of his right teres major muscle without recent injury. Electromyography identified fasciculation potentials within the teres major and pronator teres, suggesting an acute C6 radiculopathy, although a cervical magnetic resonance imaging demonstrated no significant neuroforaminal stenosis. Trigger point injections and multiple medications failed to stop the fasciculations. Under electromyography and ultrasound guidance, he was focally injected with botulinum toxin to the teres major 10 wks from initial onset with subsequent complete resolution of the symptoms and no side effects.
This case study presents a 31-yr-old male weightlifter without known neuromuscular disease who presented with 5 wks of atraumatic, constant fasciculations of his right teres major muscle without recent injury. Electromyography identified fasciculation potentials within the teres major and pronator teres, suggesting an acute C6 radiculopathy, although a cervical magnetic resonance imaging demonstrated no significant neuroforaminal stenosis. Trigger point injections and multiple medications failed to stop the fasciculations. Under electromyography and ultrasound guidance, he was focally injected with botulinum toxin to the teres major 10 wks from initial onset with subsequent complete resolution of the symptoms and no side effects.
Missed appointments negatively affect patients, providers, and health systems. This study aimed to (1) quantify the percentage of missed appointments across 14 pediatric subspecialties in a tertiary-care children's hospital and (2) identify patient characteristics associated with missed appointments in those subspecialties.

We extracted patient characteristics from 267,151 outpatient appointments, between January 1, 2013, and December 31, 2018, across 14 subspecialty clinics. read more Medical complexity was categorized using the Pediatric Medical Complexity Algorithm. The primary outcome was appointment nonattendance. Cancellations, imaging/laboratory visits, patients older than 18 years, and duplicate visits were excluded. Characteristics associated with nonattendance were analyzed with chi-square tests and included in the multivariable model if p < .1. Missing data were addressed using random forest imputation, and assuming data were "missing at random." Variables were considered statistically significant if p < .05.

Of the 128,117 scheduled appointments analyzed, 23,204 (18.1%) were missed. In the multivariable model, clinical nutrition had the greatest subspecialty odds of missed appointments, whereas cardiology had the lowest. Patient characteristics most strongly associated with missed appointments were public insurance, history of >2 missed appointments, appointment lead time, lesser medical complexity, Black race/ethnicity, and fewer medications.

Clinical characteristics including lesser medical complexity and fewer medications are associated with missed appointments in pediatric subspecialties.
Clinical characteristics including lesser medical complexity and fewer medications are associated with missed appointments in pediatric subspecialties.We report a case of a 72-year-old woman who experienced postictal episodes of trismus lasting several minutes on 6 occasions during a series of 18 episodes of electroconvulsive therapy (ECT). There was no clear relationship between the development of trismus and any medications used during the treatments. The patient had no adverse outcomes or discomfort, but the development of trismus can put patients at significant risk.The first ethicists of the 1970s paved the way for the three most familiar models of clinical ethics consultation (1) a single consultant, (2) a member of a hospital ethics committee, and (3) a member of a subcommittee of a hospital ethics committee. Within the single consultant model there are (A) the lone ethicist (a member of hospital staff, working alone when consulting) and (B) the independent ethicist (a freelance, external consultant, working alone). This article discusses the structure and opportunities offered by the freelance, independent ethicist model, and provides guidance for those who employ freelance, independent ethicists, as well as guidance for ethicists who are considering adopting this practice model.A hub and spoke model offers an effective and efficient approach to providing informed guidance to those who need it. The National Center for Ethics in Health Care (NCEHC) at the Veterans Health Administration, Department of Veterans Affairs, is the largest known hub and spoke healthcare ethics delivery model. In this article, we describe ways NCEHC's hub and spoke configuration succeeded during the COVID-19 pandemic, as well as limitations of the model and possible improvements to inform adoption at other healthcare systems.Respect for autonomy is a key concept in contemporary bioethics and in ethics at the end of life in particular. An individualistic interpretation of autonomy may not incorporate the aspects of consideration that patients may have for their wider construct of personhood, which includes their love and consideration for their families. This anonymous case describes the intricacies of a patient's decision making at the end of life, the choices she made, and how her decisions changed as her situation evolved. The tension this produced within the medical team is unpacked using a lens of compassionate care in the intensive care unit.In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum's criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients' preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs.
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