S pastic paresis is a complex condition associated with damage to the upper motor neurons, typically caused by cerebral palsy, multiple sclerosis, stroke or trauma. Despite substantial impact on patients' independence and burden on caregivers, there is a lack of consensus on optimal management of this condition and the patient journey remains unclear. A group of physicians, experienced in spasticity management, recently convened with the objective of analysing the patient journey from a care pathway perspective in different geographical regions and under different conditions from acute phase to long-term/chronic disease status. The experts reviewed results from recent patient and healthcare practitioner surveys on the subject and assessed how current patient pathways could be improved, using their own experiences to highlight the issues related to management deficiencies in their individual countries. The group divided the patient journey into steps, considering the evidence from the point of view of healthcare practitioners, patients, caregivers and funders/payors. This paper is a response to the lack of consensus on the optimal management of spastic paresis, and acts as a call to action to develop a consistent care pathway that could be applied across a broad range of illnesses, using an interdisciplinary approach. KeywordsSpastic paresis, patient rehabilitation, patient journey, patient care, care pathway Disclosure: David Bowers has participated in an advisory board for Ipsen and has been a trainer for Allergan and Medtronic. Klemens Fheodoroff has received unrestricted research grants from Ipsen and Merz, and honoraria for instructional courses from Ipsen, Allergan and Merz. Patricia Khan has participated in advisory boards for Ipsen, and has received honoraria for instructional courses from Ipsen and Allergan. Julian P Harriss has received research funding into current practice in spasticity management (the SPACE study, supported by Merz Pharma) and expenses for participation in expert panels (Ipsen). Khashayar Dashtipour has received compensation/honoraria for services as a consultant or an advisory committee member or speaker from Allergan, Inc., Ipsen Biopharmaceuticals, Inc., Lundbeck Inc., Merz Pharmaceuticals, Teva Pharmaceutical Industries Ltd., UCB Inc., Impax Pharmaceutical and US World Meds. Laxman Bahroo has received personal compensation from Teva Neuroscience, UCB pharma, Impax, Allergan, Ipsen, US World Meds, AbbVie, Lundbeck and Acadia for consulting, serving on a scienti c advisory board or speaking activities, and research support from Ipsen and Teva Neuroscience. Michael Lee has participated in an advisory board for Ipsen. Denis Zakharov has received personal compensation from Ipsen and Merz for consulting, serving on a scienti c advisory board or speaking activities. Jovita Balcaitiene is an employee of Ipsen Pharma. Virgilio Evidente has received research support from Ipsen and honoraria for consulting and/or speaking from Ipsen, Merz, Solstice, US WorldMeds, Lundbeck, UCB, Xenoport, Te...

The established processes for ensuring safe outpatient surveillance of patients with known heart valve disease (HVD), echocardiography for patients referred with new murmurs and timely delivery of surgical or transcatheter treatment for patients with severe disease have all been significantly impacted by the novel coronavirus pandemic. This has created a large backlog of work and upstaging of disease with consequent increases in risk and cost of treatment and potential for worse long-term outcomes. As countries emerge from lockdown but with COVID-19 endemic in society, precautions remain that restrict ‘normal’ practice. In this article, we propose a methodology for restructuring services for patients with HVD and provide recommendations pertaining to frequency of follow-up and use of echocardiography at present. It will be almost impossible to practice exactly as we did prior to the pandemic; thus, it is essential to prioritise patients with the greatest clinical need, such as those with symptomatic severe HVD. Local procedural waiting times will need to be considered, in addition to usual clinical characteristics in determining whether patients requiring intervention would be better suited having surgical or transcatheter treatment. We present guidance on the identification of stable patients with HVD that could have follow-up deferred safely and suggest certain patients that could be discharged from follow-up if waiting lists are triaged with appropriate clinical input. Finally, we propose that novel models of working enforced by the pandemic—such as increased use of virtual clinics—should be further developed and evaluated.

Botulinum toxin type A (BoNT-A) is an effective treatment for post-stroke spasticity; however, some patients cannot access treatment until ≥1 year post-stroke. This Brazilian post-marketing study (NCT02390206) assessed the achievement of person-centered goals in patients with chronic post-stroke spasticity after a BoNT-A injection. Patients had a last documented stroke ≥1 year before study entry and post-stroke upper limb (UL) spasticity, with or without lower limb (LL) spasticity. Patients received BoNT-A injections at baseline (visit 1) and visit 2 (3–6 months). Primary endpoint was responder rate (achievement of primary goal from Goal Attainment Scaling (GAS)) at visit 2. Overall, 204 patients underwent GAS evaluation at visit 2, mean (SD) age was 56.4 (13.2) years and 90.7% had LL spasticity. Median (range) time between first stroke and onset of spasticity was 3.6 (0−349) months, onset of spasticity and first injection was 22.7 (0−350) months and waiting time for a rehabilitation appointment was 9.0 (1−96) months. At visit 2, 61.3% (95% CI: 54.4, 67.7) of patients were responders, which was similar for UL and LL primary goals (57.8% [95% CI: 49.9, 65.3] vs. 64.1% [95% CI: 48.4, 77.3]). This study provides evidence to support the effectiveness of BoNT-A treatment for chronic post-stroke spasticity.

Esta investigação caracteriza os usuários vítimas de acidentes de moto atendidos em um centro de reabilitação de referência estadual do sul do Brasil. É parte de pesquisa voltada ao trauma raquimedular - TRM. Estudo descritivo e quantitativo. Foram investigadas em 207 prontuários: procedência, idade, sexo, data e causa da lesão. Constatou-se que as vítimas de acidentes motociclísticos são homens (81.09%) jovens, dos quais, 10% menores de 18 anos. Metade dos usuários tiveram lesões extremamente ou muito graves – TRM, traumatismo crânio encefálico e amputação de membros inferiores. O coeficiente de mortalidade por acidentes motociclísticos no Brasil e em Santa Catarina cresceu 250% no período de 2000 a 2009, enquanto o crescimento populacional foi de 16%. Os acidentes motociclísticos constituem-se grave problema de saúde pública pelo número cada vez maior de pessoas atingidas e gravidade das lesões. Urge estabelecer políticas públicas – educação, segurança pública e saúde, objetivando inverter esta tendência.

encephalopathy; typically, cefepime-induced neurotoxicity occurs within a week after initiation of the agent. Conclusion: As increasingly medically complex patients on multiple antibiotic regimens are cared for in the acute inpatient rehabilitation setting, physiatrists require a heightened awareness for potential adverse effects from medications. Cefepime-induced encephalopathy should be suspected in the presence of acute mental status changes, even if the treatment duration exceeds a week. A 54-year-old male patient with history of resected glioma brain tumors recently hospitalized due to increased falls, decline in cognition, and transient bladder incontinence. Workup revealed glioma recurrence with ventriculomegaly from obstruction of the posterior right choroidal fissure. A ventriculoperitoneal (VP) shunt was placed to treat hydrocephalus yielding improvement in symptoms. On day three of rehabilitation admission, the patient experienced worsening sitting balance with waxing and waning ataxia, bladder incontinence, and confusion. Workup was unremarkable for infection, electrolyte imbalance, or medication toxicity. Repeat head CT demonstrated stable ventricle size. The patient's neurosurgery team made adjustments to the patient's VP shunt settings for known hydrocephalus which resulted in improvement of symptoms. Shunt adjustment was made two additional times due to return and worsening of hydrocephalus symptoms, now including bowel incontinence. MRI of the spine was requested in addition to the intracranial evaluation. MRI of the lumbar spine revealed leptomeningeal spread of glioma involving the entire spinal cord. Program Description: Academic university hospital and Private Inpatient rehabilitation hospital. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: The patient's functional goals were adjusted to include spinal cord injury rehabilitation. The patient did well within this new rehabilitation framework. Discussion: This is the first reported case, to our knowledge, of leptomeningeal carcinomatosis presenting with symptoms nearly indistinguishable from peri-operative VP shunt malfunction, leading to high potential for misdiagnosis. Conclusion: We present a case of a patient with a primary brain tumor that caused obstructive hydrocephalus and was treated with a VP shunt. It is important to maintain a high index of suspicion that includes the entirety of the CNS in this patient population, despite symptoms that seem to localize to intracranial lesions and devices.