Validation of the Arabic Rowland Universal Dementia Assessment Scale (A-RUDAS) in elderly with mild and moderate dementia

OBJECTIVES

Validated screening tests for dementia in Arabic are lacking. Given the low levels of education among elderly in the Middle East and North Africa region, the commonly used screening instrument, the Mini Mental State Examination, is not best suited. Alternatively, the Rowland Universal Dementia Assessment Scale (RUDAS) was especially designed to minimize the effects of cultural learning and education. The aim of this study was to validate the RUDAS in the Arabic language (A-RUDAS), evaluate its ability to screen for mild and moderate dementia, and assess the effect of education, sex, age, depression, and recruitment site on its performance.

METHODS

A-RUDAS was administered to 232 elderly aged ≥65 years recruited from the communities, community-based primary care clinics, and hospital-based specialist clinics. Of these, 136 had normal cognition, and 96 had dementia. Clinicians diagnosed dementia according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria. Interviewers, blind to the cognitive status of participants, administered A-RUDAS. The psychometric properties of A-RUDAS were examined for three cutoffs.

RESULTS

At the cutoff of ≤22, A-RUDAS exhibited good sensitivity (83%) and specificity (85%) with an area under the receiver operating characteristic curve of 83.95%. Adjusting for age, sex, education, depression, and recruitment site, A-RUDAS score demonstrated a high level of accuracy in screening for mild and moderate dementia against DSM-IV diagnosis.

CONCLUSION

The A-RUDAS is proposed for dementia screening in clinical practice and in research in Arabic-speaking populations with an optimal cutoff of ≤22.

ID: 19: ELIGIBILITY FOR PCSK9 TREATMENT IN 734 HYPERCHOLESTEROLEMIC PATIENTS REFERRED TO A REGIONAL CHOLESTEROL TREATMENT CENTER WITH LDL CHOLESTEROL ≥70 MG/DL DESPITE MAXIMAL TOLERATED CHOLESTEROL LOWERING THERAPY

Background

LDL cholesterol (LDLC) lowering has been revolutionized by PCSK9 inhibitors, Alirocumab (Praluent) and Evolocumab (Repatha), which have approved indications as an adjunct to diet-maximally tolerated cholesterol lowering therapy in heterozygous (HeFH) or homozygous (HoFH) familial hypercholesterolemia, and/or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient despite maximal tolerated therapy.

Methods

We applied FDA approved and commercial insurance eligibility criteria for PCSK9 inhibitor use in 734 patients serially referred over 3 years who then received ≥2 months maximally tolerated LDLC lowering diet-drug therapy with follow up LDLC ≥70 mg/dl, as well as in 37 patients approved by commercial insurance for PCSK9 inhibitors. We obtained estimates of the percentage of patients with HeFH and/or CVD who meet FDA and commercial insurance eligibility for PCSK9 inhibitors using LDLC goal-based guidelines.

Results

Of the 734 patients with LDLC ≥70 mg/dl after ≥2 months maximally tolerated LDLC lowering therapy, 220 (30%) had HeFH and/or CVD events with LDLC >100 mg/dl, meeting both FDA and commercial insurance criteria for PCSK9 inhibitor therapy. Sixty-six (9%) patients were statin intolerant, without HeFH or CVD events. Of the 37 patients whose PCSK9 inhibitor therapy was approved for coverage by medical insurance carriers, 34 (92%) had LDLC>100 mg/dl after ≥2 months on maximally tolerated LDLC lowering therapy. Sixteen (43%) of these 37 patients had HeFH without CVD (LDLC on maximally tolerated conventional treatment 181±48 mg/dl), 11 (30%) had CVD without HeFH (LDLC on maximally tolerated conventional treatment 122±22 mg/dl), and 8 (22%) had both HeFH and CVD (LDLC on maximally tolerated conventional treatment 204±56 mg/dl).

Conclusion

Of the 734 patients referred for high LDLC treatment, with LDLC ≥70 mg/dl after ≥2 months on maximally tolerated therapy, 220 (30%) had HeFH and/or CVD with LDLC >100 mg/dl, meeting both FDA and insurance criteria for PCSK9 inhibitor therapy. If 30% of patients with high LDLC and HeFH-CVD are eligible for PCSK9 inhibitors, then specialty pharmaceutical pricing models (∼$14,300/year) will collide with an estimated 16–21 million HeFH-CVD patients. Although the costs for PCSK9 inhibitors given to an estimated 16 to 21 million patients are extraordinary ($228–300 billion), we speculate that, when weighed against direct and indirect costs of CVD, on balance, the cost to society might be either none, or that society would, in fact, save money by an anticipated 50% reduction of CVD events with PCSK9 inhibitors. Whether the health care savings arising from the anticipated reduction of CVD on the PCSK9 inhibitors justify the broad population use of these agents remains to be determined.

ID: 20: HOSPITALIZATION FOR PULMONARY EMBOLISM ASSOCIATED WITH ANTECEDENT TESTOSTERONE OR ESTROGEN THERAPY IN PATIENTS FOUND TO HAVE FAMILIAL THROMBOPHILIA

Background

In patients hospitalized over a 4 year period for pulmonary embolism (PE), and subsequently found to have familial-acquired thrombophilia, we assessed relationships of thrombophilia with testosterone (TT) and estrogen therapy (ET) anteceding PE.

Methods

From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to document TT or ET anteceding PE in patients subsequently found to have familial or acquired thrombophilia.

Results

Preceding hospitalization for PE, of the 154 men and 193 women, 8 men (5% of men) used TT, 24 women (12% of women) used ET (16 birth control pills, 6 hormone replacement therapy, 2 progesterone). Median age in the 8 men was 56 and for the 24 women 38. After excluding 45 women with cancer preceding PE, 24 of 148 (16%) women with PE had used ET, and after excluding 33 men with cancer, 8/121 men (7%) used TT. Of these 8 men, 6 used TT gels, 50 mg/day, and 2 had intra muscular TT 50 mg/week.

Of the 8 men, 5 (63%) smoked, 2 had a history of thrombotic events, and 2 had type 2 diabetes. The median number of months from the initiation of TT to development of PE was 7 months.

Coagulation evaluations were done in 6 of the 8 men. All 6 had ≥1 thrombophilia; 1 heterozygous for the G20210A prothrombin gene (PTG) mutation, 1 with high factor VIII, 3 with high homocysteine (1 of whom had MTHFR C677T homozygosity), 2 with low protein C, 2 with low protein S, and 2 with low free protein S. Two of 8 men had Klinefelter's syndrome.

Of the 24 women, 2 were diabetic, 1 had a history of thrombosis, and 7 (29%) smoked. The median time between initiation of ET and the PE was 18 months.

In 18 out of the 24 women, coagulation evaluations were performed. 15 had ≥1 thrombophilia; 4 were factor V Leiden heterozygotes, 1 PTG heterozygote, 2 high Factor VIII, 1 high Factor XI, 2 with the lupus anticoagulant, 3 low protein S, 2 low Free S, 3 low antithrombin III, 3 high anticardiolipin antibodies.

Conclusion

After excluding antecedent cancer, 24/148 women (16%) had ET before PE, and TT was taken by 8/121 (7%) men. PE is an important complication of TT in men and ET in women, in part reflecting an interaction between familial and acquired thrombophilia and exogenous hormone use.

ID: 73: ATHEROTHROMBOSIS, THROMBOPHILIA, AND RELENTLESS PROGRESSION OF CORONARY ARTERY DISEASE

Introduction

Atherothrombosis involves a complex pathway often initiated by ulceration of an atherosclerotic plaque with platelet aggregation and thrombus formation. In the concurrent presence of familial and acquired thrombophilia, coronary artery disease (CAD) is often accelerated despite conventional lipid lowering, anti-platelet, and vascular interventions (stents, angioplasty, bypass). In a cohort of 30 patients with premature CAD and atherothrombosis, often worsening despite maximal conventional medical-surgical intervention, our specific aim was to describe major concurrent thrombophilia as a treatable component of atherothrombosis.

Methods

In 30 patients with premature, severe, and progressive CAD and atherothrombosis, despite maximal lipid lowering, anti-platelet therapy, and direct intervention (stents, angioplasty, coronary artery bypass grafts), we assessed for the presence of familial and acquired thrombophilia, with comparison to 110 healthy normal controls without CAD, and to 110 patients without CVD but with previous venous thromboembolism (VTE).

Results

The 30 patients (21 men, 9 women) had severe CAD despite anti-platelet treatment, maximal lipid lowering therapy (mean±SD LDLC was 82±46, median 72 mg/dl), and direct arterial intervention. The patients' first cardiac event occurred at age 46±12, median 47 years, and current age was 59±12, median 59 years. Most patients had suffered from multiple myocardial infarctions (12 had multiple stents, 8 were post cardiac bypass), 8 had previous VTEs, 3 had TIAs and one had preeclampsia.

Compared with 110 healthy normal controls, the 30 patients with CAD-atherothrombosis were more likely to have high homocysteine (20% vs 5%, P=0.014), Factor Leiden Heterozygosity (23% vs 2, P=0.006), lupus anticoagulant (27% vs 2%, P=0.003), high anticardiolipin antibody IgM (17% vs 3%, P=0.005), high factor VIII (30% VS 7%, P=0.007), high Factor XI (25% vs 3%, P=0.003), low antigenic protein C (26% vs 6%, P=0.18) and low antigenic protein S (21% vs 2%, P=0.007). Of the 8 patients who had CABG, 2 had multiple early venous graft failure (25%) compared to the historical one year graft failure of 10–15%. Thrombophilia did not differ across the atherothrombosis/CAD and VTE groups, except that the lupus anticoagulant was more common in the CAD-atherothrombosis patients than in the VTE patients (27% VS 4%, P=0.002).

Conclusion

In the presence of premature-aggressive CAD, despite maximal lipid lowering, anti-platelet therapy, and angioplasty-stent-bypass interventions, it is clinically valuable to assess for anticoagulant-treatable thrombophilia, which interacts with the atherosclerosis with resultant atherothrombosis. The patterns of thrombophilia in atherothrombotic patients do not differ from those in VTE without CAD, except for the lupus anticoagulant.

ID: 86: SAFETY OF 50,000-100,000 UNITS OF VITAMIN D3 PER WEEK IN VITAMIN D DEFICIENT, HYPERCHOLESTEROLEMIC PATIENTS, WITH STATIN INTOLERANCE

Background

In ∼85–90% of statin intolerant patients, vitamin D deficiency (serum 25 (OH) D <32 ng/ml) is a reversible cause of statin intolerance, usually requiring 50,000 to 100,000 units of vitamin D/week continuously to normalize serum vitamin D, and thus successfully allow reinstitution of statins which previously could not be tolerated because of myalgia-myositis.

Specific Aim

In 274 statin intolerant patients, all with low entry serum vitamin D (<32 ng/ml, median 21 ng/ml), we assessed safety and efficacy of vitamin D supplementation (50,000–100,000 units/week) over treatment periods of 3 months (n=274), 3 and 6 months (n=161), 3, 6, and 9 months (n=58), and 3, 6, 9, and 12 months (n=22).

Results

In the 385 patients with 3 month follow-up, taking mean 61,000 and median 50,000 IU of vitamin D3/week, median serum vitamin D rose from 20 to 42 ng/ml (p<0.0001); vitamin D became high (>100 ng/ml) but not toxic-high (>150 ng/ml) in 4 patients (1.0%) (101, 102, 106, 138 ng/ml). Median serum calcium was unchanged from entry (9.6 mg/dl) to 9.6 at 3 months. On vitamin D supplementation, the trend of change in serum calcium from normal-to-high or from high-to-normal did not significantly differ (McNemar S=1.0, p=0.32), and there was no significant trend in change of the calculated glomerular filtration rate (eGFR) from entry to follow-up (McNemar S=2.6, p=0.11).

In the 161 patients with 3 and 6 month follow-up, taking mean 67,000 and median 50,000 IU of vitamin D3/week, median entry serum vitamin D rose from 21 to 42 to 44 ng/ml (p<0.0001), serum vitamin D was high (>100 but <150 ng/ml) in 2 patients at 3 months (1.2%, 101, 102 mg/ml) and in 3 (1.9%) at 6 months (101, 140, 140 ng/ml). Median serum calcium was unchanged from entry (9.7 mg/dl), at 3 and 6 months (9.7, 9.6 mg/dl, p>0.05). On vitamin D supplementation, the change in serum calcium from normal-to-high or high-to-normal was no significant trend (McNemar S=0.7, p=0.41), and no trend in change of eGFR (McNemar S=1.3, p=0.26).

In the 58 patients with 3, 6, and 9 month follow-up on mean and median 71,000 and 100,000 IU of D3/week, median entry vitamin D rose from 20 to 37, 41, and 44 ng/ml (p<0.0001), with 1 (1.7%, 102 ng/ml), 2 (3.5%, 140, 140 ng/ml), and 0 (0%) patients high. Median serum calcium was unchanged from entry, median 9.7, 9.8, 9.6, and 9.6 mg/dl. On vitamin D supplementation, the trend of change in serum calcium from normal-to-high or high-to-normal was not significant (McNemar S=1.8, p=0.18), and no trend in change of eGFR (McNemar S=2, p=0.16).

In the 22 patients with follow-up at 3, 6, 9, and 12 months on mean and median 70,000 and 75,000 IU of D3/week, median serum vitamin D rose from 20 to 37, to 41, to 44, and to 43 ng/ml (p<0.0001), with 1 (5%, 102 ng/ml) high, 2 (9%, 140, 140) high, 0 (0%) high, and 1 (5%, 126 ng/ml) high. Serum calcium was unchanged, median at entry 9.6, and then at 3, 6, 9, and 12 months 9.7, 9.7, 9.5, and 9.7 mg/ml. At entry serum calcium was normal in 21, none high, and one became high at 12 month follow-up. The trend of change in eGFR was insignificant, McNemar S=1.0, p=0.32.

When serum D rose above 100 ng/ml in the few cases, as above, it fell into the normal range within 2 weeks by reducing the vitamin D dose by 50%.

Conclusions

When 50,000–100,000 units of vitamin D/week are given to reverse statin intolerance in statin intolerant patients with low entry vitamin D (<32 ng/ml), it appears to be safe over up to 1 year follow-up, without toxic high serum vitamin D levels >150 ng/ml, and levels rarely >100 ng/ml, and without changes in serum calcium or eGFR.

A national survey of the provision of ultrasound surveillance for the detection of hepatocellular carcinoma

OBJECTIVE

Hepatocellular carcinoma (HCC), the sixth most common cancer worldwide and third most common cause of cancer related death, is closely associated with the presence of cirrhosis. Survival is determined by the stage of the cancer, with asymptomatic small tumours being more amenable to treatment. Early diagnosis is dependent on regular surveillance and the primary objective of this survey was to gain a better understanding of the baseline attitudes towards and provision of ultrasound surveillance (USS) HCC surveillance in the UK. In addition, information was obtained on the stages of cancer of the patients being referred to and discussed at regional multidisciplinary team meetings.

DESIGN

UK hepatologists, gastroenterologists and nurse specialists were sent a questionnaire survey regarding the provision of USS for detection of HCC in their respective hospitals.

RESULTS

Provision of surveillance was poor overall, with many hospitals lacking the necessary mechanisms to make abnormal results, if detected, known to referring clinicians. There was also a lack of standard data collection and in many hospitals basic information on the number of patients with cirrhosis and how many were developing HCC was not known. For the majority of new HCC cases was currently being made only at an incurable late stage (60%).

CONCLUSIONS

In the UK, the current provision of USS based HCC surveillance is poor and needs to be upgraded urgently.

ID: 15: ELIGIBILITY FOR PCSK9 THERAPY IN CHOLESTEROL CENTER PATIENTS WITH INITIAL LDL CHOLESTEROL ≥130 BUT <160 MG/DL

Background

By lowering LDL cholesterol (LDLC) ∼60% beyond statins, PCSK9s have the potential to profoundly improve primary and secondary prevention of atherosclerotic coronary artery (CAD), peripheral (PAD), and carotid artery disease.

Purpose

In 189 patients referred to a regional Cholesterol Center for diagnosis and treatment of hypercholesterolemia, who had initial LDL cholesterol (LDLC) ≥130 but <160 mg/dl, our specific aim was to determine how many would be eligible for PCSK9 therapy by extant preferred commercial insurance criteria.

Methods

Current preferred commercial insurance criterion for PCSK9 therapy consisted of ≥1 of the following 3 conditions:

Heterozygous familial hypercholesterolemia (previous LDLC >190 mg/dl and Tendon Xanthomas),

Atherosclerotic cerebral-cardio-peripheral vascular disease.

Failure to tolerate 2 or more statins.

Results

At entry, in the 189 patients, mean±SD and median LDLC were 144±9 mg/dl and 143 mg/dl respectively. Of the 189 patients (96 female and 93 male with median age 53) 16 (8%) were diagnosed as having heterozygous FH, with median LDLC of 139 mg/dl, and 32 (17%) had sustained a cerebral-cardio- peripheral vascular event with median LDLC on treatment of 146 mg/dl. Of the 189 patients, in 44 (23%) the maximum tolerated statin dose was zero (complete statin intolerant), with median LDLC of 145 mg/dl. Of the 44 statin intolerant patients, 18 (41%) had either HeFH or an atherosclerotic event, and 26 (59%) had neither positive. Altogether 73 of 189 (39% of patients with entry LDLC ≥130 but <160 were eligible for PCSK9 therapy from commercial carriers.

Conclusion

Of 189 patients referred to a regional Cholesterol diagnosis and treatment center with initial LDLC ≥130 but <160 mg/dl, 73 (39%) met current commercial insurance carrier preferred criteria for PCSK9 drug coverage.

A comparative cross-cultural study of the prevalence of late life depression in low and middle income countries

BACKGROUND

Current estimates of the prevalence of depression in later life mostly arise from studies carried out in Europe, North America and Asia. In this study we aimed to measure the prevalence of depression using a standardised method in a number of low and middle income countries (LMIC).

METHODS

A one-phase cross-sectional survey involving over 17,000 participants aged 65 years and over living in urban and rural catchment areas in 13 sites from 9 countries (Cuba, Dominican Republic, Puerto Rico, Mexico, Venezuela, Peru, China, India and Nigeria). Depression was assessed and compared using ICD-10 and EURO-D criteria.

RESULTS

Depression prevalence varied across sites according to diagnostic criteria. The lowest prevalence was observed for ICD-10 depressive episode (0.3 to 13.8%). When using the EURO-D depression scale, the prevalence was higher and ranged from 1.0% to 38.6%. The crude prevalence was particularly high in the Dominican Republic and in rural India. ICD-10 depression was also associated with increased age and being female.

LIMITATIONS

Generalisability of findings outside of catchment areas is difficult to assess.

CONCLUSIONS

Late life depression is burdensome, and common in LMIC. However its prevalence varies from culture to culture; its diagnosis poses a significant challenge and requires proper recognition of its expression.

Lifetime Prevalence and Factors Associated with Head Injury among Older People in Low and Middle Income Countries: A 10/66 Study

Introduction

Traumatic brain injury (TBI) is a growing public health problem around the world, yet there is little information on the prevalence of head injury in low and middle income countries (LMICs). We utilised data collected by the 10/66 research group to investigate the lifetime prevalence of head injury in defined sites in low and middle income countries, its risk factors and its relationship with disability.

Methods

We analysed data from one-phase cross-sectional surveys of all residents aged 65 years and older (n = 16430) distributed across twelve sites in eight low and middle income countries (China, Cuba, Dominican Republic, India, Venezuela, Mexico, Peru, and Puerto Rico). Self-reported cases of head injury with loss of consciousness were identified during the interview. A sensitivity analysis including data provided by informants of people with dementia was also used to estimate the impact of this information on the estimates. Prevalence ratios (PR) from Poisson regressions were used to identify associated risk factors.

Results

The standardised lifetime prevalence of TBI ranged from 0.3% in China to 14.6% in rural Mexico and Venezuela. Being male (PR: 1.6, 95% CI: 1.29–1.82), younger (PR: 0.95, 95% CI: 0.92–0.99), with lower education (PR 0.91, 95% CI: 0.86–0.96), and having fewer assets (PR 0.92, 95% CI: 0.88–0.96), was associated with a higher prevalence of TBI when pooling estimates across sites.

Discussion

Our analysis revealed that the prevalence of TBI in LMICs is similar to that of developed nations. Considering the growing impact of TBI on health resources in these countries, there is an urgent need for further research.

Subjective cognitive complaints across the adult life span: a 14-year analysis of trends and associations using the 1993, 2000 and 2007 English Psychiatric Morbidity Surveys

BACKGROUND

Cognitive complaints are common in all age groups but most often researched in old age. We aimed to investigate prevalences and time trends over 14 years of subjective memory complaints (SMC) and subjective concentration complaints (SCC) in adults and investigate associations with mood disorders and cognitive function.

METHOD

Data from three English national mental health surveys carried out in 1993, 2000 and 2007 were analysed. SMC and SCC were measured using the Clinical Interview Schedule-Revised and cognitive function using the modified Telephone Interview for Cognitive Status.

RESULTS

Both SMC and SCC increased up to middle age and then declined, followed by a second rise in the very oldest age groups. Age-specific prevalence of both increased across survey years but relationships with mental health and cognitive outcomes were relatively stable.

CONCLUSIONS

Cognitive complaints are most common in middle age and have become more prevalent over time.

Structural issues affecting creation of a community action and advocacy board

The most effective woman-initiated method to prevent HIV/sexually transmitted infections is the female condom (FC). Yet, FCs are often difficult to find and denigrated or ignored by community health and service providers. Evidence increasingly supports the need to develop and test theoretically driven, multilevel interventions using a community-empowerment framework to promote FCs in a sustained way. We conducted a study in a midsized northeastern US city (2009-2013) designed to create, mobilize and build capacity of a community group to develop and implement multilevel interventions to increase availability, accessibility and support for FCs in their city. The Community Action and Advocacy Board (CAAB) designed and piloted interventions concurrently targeting community, organizational and individual levels. Ethnographic observation of the CAAB training and intervention planning and pilot implementation sessions documented the process, preliminary successes, challenges and limitations of this model. The CAAB demonstrated ability to conceptualize, plan and initiate multilevel community change. However, challenges in group decision-making and limitations in members' availability or personal capacity constrained CAAB processes and intervention implementation. Lessons from this experience could inform similar efforts to mobilize, engage and build capacity of community coalitions to increase access to and support for FCs and other novel effective prevention options for at-risk women.

Human papillomavirus, p16, and epidermal growth factor receptor biomarkers and CT perfusion values in head and neck squamous cell carcinoma

BACKGROUND AND PURPOSE

Head and neck squamous cell carcinoma tumors positive for laboratory biomarkers hrHPV and p16 and negative for EGFR often respond better to nonsurgical organ-preservation therapy than hrHPV-negative, p16-negative, and EGFR overexpressing tumors. CTP has been shown to distinguish which locally advanced head and neck squamous cell carcinomas will respond to induction chemotherapy or chemoradiation. Our purpose was to determine whether a relationship exists between CTP measures and the expression of these laboratory biomarkers, because both appear to separate head and neck squamous cell carcinoma tumors into similar groups.

MATERIALS AND METHODS

We conducted an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective review of head and neck CTP in 25 patients with locally advanced head and neck squamous cell carcinoma who had signed informed consent. Eight women and 17 men, 41-80 years of age, constituted a pretreatment group of 18 patients and a palliative group of 7 patients. Tumor biopsy samples were analyzed for overexpression of hrHPV, p16, and EGFR. The hrHPV, p16, and EGFR status of the tumors was correlated with CTP parameters (MTT, BV, BF, CP) by using the Wilcoxon evaluation and Fischer exact test.

RESULTS

There were significantly lower CP values in pretreatment tumors overexpressing EGFR (P = .04). CP values ≤17.23 were significantly correlated with EGFR overexpression (P = .015). A trend toward higher CP values was present in hrHPV-positive and p16-overexpressing pretreatment tumors (P = .14).

CONCLUSIONS

A significant correlation exists between CTP measures and EGFR overexpression in head and neck squamous cell carcinomas, suggesting an association between certain imaging findings and molecular biomarkers. These results may be related to a tumor cell survival mechanism linking perfusion and biomarker expression.