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    <recommendedItem id="20100101_19_425"
                     title="AAN: Industrial Cleaner Again Tied to Parkinson Risk (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAN/tb/18338?impressionId=1265817575468"
                     
      TORONTO  --  The degreasing agent trichloroethylene (TCE) has been linked to increased rates of Parkinson&apos;s disease among industrial workers in yet another study, this time involving a large, well-studied group of World War II veterans.&lt;br&gt;
&lt;br&gt;Parkinson&apos;s disease developed in individuals with occupational exposure to TCE at more than five times the rate seen in those without such exposure (odds ratio 5.5, 95% CI 1.02 to 30), reported Samuel Goldman, MD, of the Parkinson&apos;s Institute in Sunnyvale, Calif.&lt;br&gt;
&lt;br&gt;Goldman described the research in a phone interview with &lt;em&gt;MedPage Today&lt;/em&gt;. It&apos;s scheduled for presentation here in April at the American Academy of Neurology&apos;s annual meeting.&lt;br&gt;
&lt;br&gt;A previous study in 2008 had fingered TCE as the most likely culprit behind a cluster of Parkinson&apos;s disease cases afflicting workers at a single industrial plant. (See &lt;a href=&quot;http://www.medpagetoday.com/Geriatrics/ParkinsonsDisease/7894&quot; mce_href=&quot;http://www.medpagetoday.com/Geriatrics/ParkinsonsDisease/7894&quot; target=&quot;_blank&quot;&gt;Trichloroethylene Implicated as Risk for Parkinsonism&lt;/a&gt;)&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Also, Goldman said, animal studies have found that TCE is selectively toxic to nigral dopaminergic neurons, the same type of nerve cell that progressively dies off in Parkinson&apos;s disease. He said the chemical&apos;s activity in rodent brains is very similar to that of MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), a dopaminergic neurotoxin commonly used to simulate Parkinson&apos;s disease in preclinical research.&lt;/p&gt;
&lt;p&gt;Goldman said the new study was the first population-based analysis to link TCE to the disease.&lt;/p&gt;
&lt;p&gt;It focused on 198 twin pairs in the National Academy of Sciences-National Research Council&apos;s World War II Twins Cohort, which comprises some 16,000 twin pairs overall.&lt;/p&gt;
&lt;p&gt;Members of the all-male cohort, who were born from 1917 to 1927 and served in the war, have been followed since the 1960s. Occupational histories for participants are available along with medical records from the VA healthcare system.&lt;/p&gt;
&lt;p&gt;In those pairs chosen for the current study, records showed that one twin had developed Parkinson&apos;s disease and the other had not. This design largely eliminates genetics as a confounding factor in the analysis.&lt;/p&gt;
&lt;p&gt;Goldman explained that occupational histories for each participant were reviewed by a blinded industrial hygienist and a preventive medicine physician to identify likely exposures to TCE and four other industrial chemicals: xylene, toluene, carbon tetrachloride, and tetrachloroethylene.&lt;/p&gt;
&lt;p&gt;As a single source of exposure, only TCE was significantly associated with development of Parkinson&apos;s disease, Goldman said.&lt;/p&gt;
&lt;p&gt;People working as aircraft mechanics, machinists, plumbers, and electricians likely had regular exposure to TCE, Goldman said. The chemical was commonly used as a &quot;spot&quot; cleaner to remove grease and oils from metal surfaces. It was also used for a time as a dry cleaning solvent, although tetrachloroethylene was more common for that purpose.&lt;/p&gt;
&lt;p&gt;Goldman said no increased risk was seen with xylene or toluene, but there were near-significant trends toward increased Parkinson&apos;s disease risk from carbon tetrachloride and tetrachloroethylene: &lt;ul&gt; &lt;li&gt;Carbon tetrachloride: OR 2.8 (95% CI 0.97 to 7.8)&lt;/li&gt; &lt;li&gt;Tetrachloroethylene: OR 9.0 (95% CI 0.78 to 103)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Twins exposed to either TCE or tetrachloroethylene were at significantly increased risk, with an odds ratio of 8.1 (95% CI 1.43 to 43) relative to individuals with no exposure to either chemical.&lt;/p&gt;
&lt;p&gt;Goldman said the analysis also examined whether duration of exposure was associated with increased risk. He said the results were in the same pattern as for the yes-no exposure analysis, but the findings were very uncertain because of the relatively small sample size.&lt;/p&gt;
&lt;p&gt;Occupational histories were available for only 99 of the 198 discordant twin pairs and some of the information was obtained by proxy rather than from the participant himself.&lt;/p&gt;
&lt;p&gt;Because of the wide confidence intervals even for the yes-no exposure analysis, the findings need confirmation in a larger study, he said, noting that the best approach would be a cohort study involving people with known, long-term exposure to TCE, compared with well-chosen controls.&lt;/p&gt;
&lt;p&gt;&quot;The study wouldn&apos;t have to be large,&quot; Goldman said. He estimated that 1,000 to 2,000 participants would be adequate to determine if the connection to Parkinson&apos;s disease is real.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Institute of Neurological Disorders and Stroke, the Valley Foundation, and the James and Sharron Clark Family Fund.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_470"
                     title="For-Profit Hospitals Most Likely to Overtreat Dementia Patients (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Geriatrics/Dementia/tb/18402?impressionId=1265817575468"
                     
      Tube-feeding patients with advanced dementia  --  a practice whose effectiveness has been questioned by two widely cited literature reviews  --  is most common in larger hospitals and those run for profit, researchers said.&lt;br&gt;
&lt;br&gt;The odds of a feeding-tube insertion in a hospitalized patient with advanced dementia were about 50% greater when the hospital was larger than 310 beds than in facilities with 100 beds or less, and it was 33% more common in for-profit versus government-owned facilities, reported Joan M. Teno, MD, of Brown University in Providence, R.I., and colleagues.&lt;br&gt;
&lt;br&gt;Hospitals that frequently admitted elderly patients in the last six months of life to their ICUs  --  signifying a pattern of aggressive end-of-life care  --  were also substantially more likely to use tube feeding, the researchers wrote in the Feb. 10 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;At some 12% of the 2,797 acute-care hospitals included in the analysis, which covered an eight-year period ending in 2007, feeding tubes were never used in patients with advanced dementia.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;In others, however, such patients were intubated for feeding at rates of up to 38.9 per 100 hospitalizations.&lt;/p&gt;
&lt;p&gt;Teno and colleagues suggested that many of these insertions reflect overtreatment. They cited previous research showing that tube feeding &quot;does not improve survival, prevent aspiration pneumonia, heal or prevent decubitus ulcers, or improve other clinical outcomes.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Feeding tube insertion in persons with advanced cognitive impairment demonstrates a disconnect with the existing evidence of their effectiveness,&quot; Teno and colleagues commented. &quot;Many experts have expressed concerns regarding the overuse of feeding tubes.&quot;&lt;/p&gt;
&lt;p&gt;They called for more research into the decision-making processes that produce such variations among hospitals and interventions to reduce unnecessary insertions and those that conflict with patients&apos; preferences.&lt;/p&gt;
&lt;p&gt;Teno and colleagues analyzed data on some 163,000 patients included in the U.S. Nursing Home Minimum Data Set whose records indicated an age greater than 65, advanced cognitive impairment, lack of prior tube feeding, and an acute-care hospitalization from 2000 to 2007.&lt;/p&gt;
&lt;p&gt;They also had data on the size and business structure of the hospitals to which patients were admitted.&lt;/p&gt;
&lt;p&gt;The researchers found the following adjusted odds ratios for hospital characteristics associated with feeding tube insertions: &lt;ul&gt; &lt;li&gt;Business model: 1.33 (95% CI 1.21 to 1.46) for for-profit versus government owned.&lt;/li&gt; &lt;li&gt;Size: 1.48 (95% CI 1.35 to 1.63) for more than 310 beds versus less than 101 beds.&lt;/li&gt; &lt;li&gt;ICU use in failing elderly patients: 2.60 (95% CI 2.20 to 3.06) for highest decile of ICU care in the last six months of life versus the lowest decile.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The adjustments included age, gender, race and ethnicity, medical history, degree of cognitive impairment, advanced care directives, and durable power of attorney.&lt;/p&gt;
&lt;p&gt;The differences were much greater before the adjustments. For example, the raw data showed a rate of 8.0 feeding tube insertions per 100 hospitalizations at large facilities compared with 4.3 per 100 in small hospitals.&lt;/p&gt;
&lt;p&gt;Similarly, hospitals with the most aggressive ICU use in elderly patients had an insertion rate of 10.1 per 100 hospitalizations, while those with the lowest ICU use in such patients had a mean rate of 2.9 per 100.&lt;/p&gt;
&lt;p&gt;Teno and colleagues also found that some other hospital factors  --  such as the ratio of specialists to general medicine physicians and the use of hospice services  --  did not significantly predict feeding tube use.&lt;/p&gt;
&lt;p&gt;On the other hand, indicators of advanced care planning were significantly associated with reduced feeding tube insertions, although perhaps not as much as would be expected.&lt;/p&gt;
&lt;p&gt;Expressed as adjusted odds ratios, the rate reductions were: &lt;ul&gt; &lt;li&gt;Living will: 0.75 (95% CI 0.70 to 0.79)&lt;/li&gt; &lt;li&gt;Durable power of attorney: 0.88 (95% CI 0.84 to 0.91)&lt;/li&gt; &lt;li&gt;DNR orders: 0.65 (95% CI 0.62 to 0.67)&lt;/li&gt; &lt;li&gt;Orders to forgo artificial hydration and nutrition: 0.73 (95% CI 0.67 to 0.80)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;&quot;These results raise more questions than answers,&quot; Teno and colleagues noted in calling for additional research into the reasons for the trends they identified.&lt;/p&gt;
&lt;p&gt;&quot;Future research to examine these reported variations should focus on decision making for feeding tube insertion in hospitalized nursing home residents with dementia. Additionally, the role that hospitals and nursing homes have in advance care planning is critically important,&quot; they wrote, noting that advanced care planning is often neglected in nursing homes.&lt;/p&gt;
&lt;p&gt;Teno and colleagues noted some limitations to the study, notably the reliance on administrative records for most data, as well as the lack of information on physician counseling and patient preferences beyond the orders recorded in the database.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Institute on Aging funded the study.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_206"
                     title="Treadmill Training Improves Walking in Parkinson&apos;s (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Neurology/ParkinsonsDisease/tb/18049?impressionId=1265817575468"
                     
      Treadmill training can improve the impaired walking associated with Parkinson&apos;s disease, researchers said.&lt;br&gt;
&lt;br&gt;The technique leads to improvements in gait speed, stride length, and walking distance, but not gait cadence, according to Jan Mehrholz, PhD, of the Klinik Bavaria in Kreischa, Germany, and colleagues.&lt;br&gt;
&lt;br&gt;However, it remains unclear how long such improvements last, the researchers noted in a &lt;em&gt;Cochrane Systematic Review&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Treadmill training has emerged recently as a &quot;promising investigational therapy&quot; aimed at patients with weakness on one side of the body and impaired gait, Mehrholz and colleagues wrote in their review.&lt;br&gt;
&lt;br&gt;To evaluate what&apos;s known about the subject, the researchers searched the literature and found eight randomized, controlled studies with a total of 203 participants.&lt;/p&gt;
&lt;p&gt;On average, patients were 61, with an average duration of disease in the studies ranging from one to eight years.&lt;/p&gt;
&lt;p&gt;When the studies were analyzed, the researchers found: 


&lt;table style=&quot;color: #151515; line-height: 16px; font: normal 14px Arial;&quot;&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;Seven studies  --  with153 participants all told  --  found that treadmill training improved gait speed. The pooled standardized mean difference was 0.50, which was significant at &lt;em&gt;P&lt;/em&gt;=0.003.&lt;/td&gt;&lt;/tr&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;Five studies, with a total of 95 participants, looked at stride length and found that treadmill training was beneficial. The pooled standardized mean difference was 0.50, which was significant at &lt;em&gt;P&lt;/em&gt;=0.05.&lt;/td&gt;&lt;/tr&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;Two studies, with 41 participants, found that treadmill training improved walking distance. The mean difference was 358 meters, which was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001.&lt;/td&gt;&lt;/tr&gt;
&lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;Finally, four studies (with 78 participants) found no significant mean difference in cadence.&lt;/td&gt;&lt;/tr&gt;
              &lt;/table&gt;

&lt;p&gt;The treadmill training was acceptable to patients, the researchers said, in that it did not increase the risk of patients dropping out of studies. Adverse events were not reported.&lt;/p&gt;
&lt;p&gt;The researchers noted that the study protocols varied markedly.&lt;/p&gt;
&lt;p&gt;The treadmill training lasted from one 30-minute session to eight weeks, although most studies used a four-, six- or eight-week period. Frequency varied from a single session to four times a week, the researchers said.&lt;/p&gt;
&lt;p&gt;The type of treadmill training also varied, with some investigators using body-weight supported treadmill training and others a speed-dependent approach.&lt;/p&gt;
&lt;p&gt;Primary outcomes also differed, Mehrholz and colleagues said.&lt;/p&gt;
&lt;p&gt;Because of those variations, they said, there is &quot;still a need for well-designed large-scale studies&quot; to look at the risk and benefits of treadmill training for Parkinson&apos;s patients.&lt;/p&gt;
&lt;p&gt;Specifically, they said, those studies should address open questions about how long the effect lasts and what should be the frequency and duration of training.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the Klinik Bavaria Kreischa, the Technical University Dresden, SRH Fachhochschule Gera, and the California State University Long Beach.&lt;/p&gt;&lt;p&gt;Mehrholz and another author were co-authors of one included trial but did not participate in its quality assessment and data extraction.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_9_162"
                     title="Link Added to Pesticide-Parkinson&apos;s Chain"
                     score="-0.005"
                     href="