1195Brain-predicted age difference is associated with cognitive processing and delayed recall in later life

Background

Brain age is a novel neuroimaging-based marker of ageing that uses machine learning to predict a person’s biological brain age. A higher brain age relative to chronological age (i.e., brain-predicted age difference [brain-PAD]) is considered a sign of accelerated ageing. We examined whether brain-PAD is associated with cognition and the change in cognitive function over time.

Methods

This study involved 531 cognitively healthy community-dwelling older adults (70+ years). Using a previously trained algorithm, brain age was estimated using T1-weighted structural magnetic resonance images acquired at baseline. Psychomotor speed, delayed recall, verbal fluency and global cognition were assessed at baseline, years 1 and 3.

Results

At baseline, a significant negative association was observed between brain-PAD and psychomotor speed (r=-0.14, p = 0.001), delayed recall (r=-0.09, p = 0.04), and the three-year change in delayed recall (r=-0.15, p = 0.02), which persisted after adjusting for covariates.

Conclusions

These findings indicate that accelerated brain ageing in cognitively unimpaired older people is associated with worse psychomotor speed, and delayed recall. This study also provides new evidence that accelerated brain ageing is a risk factor for progressive memory decline. Future research would benefit from further prospective analyses of associations between brain-PAD and cognitive function in community dwelling older adults.

Key messages

Brain age is a neuroimaging-based marker of biological ageing. A higher estimate of brain age relative to chronological age (i.e., accelerated ageing) is associated with worse psychomotor speed and memory, and memory decline.

Family reported outcomes, an unmet need in the management of a patient's disease: appraisal of the literature

BACKGROUND

A person's chronic health condition or disability can have a huge impact on the quality of life (QoL) of the whole family, but this important impact is often ignored. This literature review aims to understand the impact of patients' disease on family members across all medical specialities, and appraise existing generic and disease-specific family quality of life (QoL) measures.

METHODS

The databases Medline, EMBASE, CINHAL, ASSIA, PsycINFO and Scopus were searched for original articles in English measuring the impact of health conditions on patients' family members/partner using a valid instrument.

RESULTS

Of 114 articles screened, 86 met the inclusion criteria. They explored the impact of a relative's disease on 14,661 family members, mostly 'parents' or 'mothers', using 50 different instruments across 18 specialities including neurology, oncology and dermatology, in 33 countries including the USA, China and Australia. These studies revealed a huge impact of patients' illness on family members. An appraisal of family QoL instruments identified 48 instruments, 42 disease/speciality specific and six generic measures. Five of the six generics are aimed at carers of children, people with disability or restricted to chronic disease. The only generic instrument that measures the impact of any condition on family members across all specialities is the Family Reported Outcome Measure (FROM-16). Although most instruments demonstrated good reliability and validity, only 11 reported responsiveness and only one reported the minimal clinically important difference.

CONCLUSIONS

Family members' QoL is greatly impacted by a relative's condition. To support family members, there is a need for a generic tool that offers flexibility and brevity for use in clinical settings across all areas of medicine. FROM-16 could be the tool of choice, provided its robustness is demonstrated with further validation of its psychometric properties.

Characterization of American teduglutide consumers from 2015 to 2020: A large database study

INTRODUCTION

Teduglutide, a glucagon-like peptide-2 analog, is a novel therapy for intestinal failure that reduces need for parenteral support, especially in patients without a functional terminal ileum or colon. It can also predispose patients to accelerated progression of gastrointestinal (GI) malignancy and fluid overload. We demographically and clinically characterized American patients prescribed teduglutide.

METHODS

The Explorys database is an aggregate of deidentified patient data from dozens of US healthcare systems. We used SNOMED classification to identify patients prescribed teduglutide from 2015 to 2019. Through the browse cohort feature we determined the demographics, postsurgical anatomy, comorbidities, and indication for teduglutide use among these patients.

RESULTS

Of approximately 72 million patients, 170 were prescribed teduglutide. A large majority were female (70.6%). Most common etiologies of short-bowel syndrome were intestinal obstruction (52.9%) and Crohn's disease (41.2%). Common postsurgical anatomy included total colectomy (41.2%) and ileostomy. Common incident symptoms included abdominal pain (41.2%) and nausea (23.5%). Thirty (17.6%) patients were prescribed teduglutide despite comorbid heart failure, and 5.9% despite prior GI malignancy. A total of 11.8% of patients had a history of benign GI neoplasms before starting teduglutide. A total of 5.9% of patients had posttreatment formation of colon polyps.

CONCLUSION

In a large American database, the teduglutide prescription is rare. Only a minority have postsurgical anatomy associated with the most robust response to teduglutide. Serious adverse events appear rare, but a substantial number of patients are at risk for adverse effects because of the presence of comorbid heart failure or GI neoplasm.

A Comparative Evaluation of Sealing Ability of Five Different Materials for Furcation Perforation Repair Using UV-Spectrophotometric Analysis: An In-Vitro Study

This in-vitro study was done to compare the sealing ability of Mineral trioxide aggregate (MTA), Biodentine, a mixture of MTA and Glass ionomer cement (GIC) in 2:1 and 1:1 ratio and MTA CEM, as furcation repair material using a dye extraction leakage model in the department of Conservative Dentistry and Endodontics from January 2020 to December 2020. Eighty five extracted molars with divergent and well formed roots were selected for study and were randomly divided according to the material used for perforation repair. Group A: MTA, Group B: Biodentine, Group C: MTA mixed with GIC in 2:1 ratio. Group D: MTA mixed with GIC in 1:1 ratio. Group E: MTA CEM and 2 control groups. All samples were subjected to orthograde and retrograde methylene blue dye challenge followed by dye extraction with 70 weight % nitric acid. Samples were then analyzed using Ultra violet (UV) Visible Spectrophotometer at 550nm wavelength. The data were subjected to statistical analysis One Way ANOVA (level of significance <0.05) and post-hoc tukey test. MTA, Biodentine, Mixture of MTA and GIC in 2:1 ratio and MTA CEM showed significant less dye absorbance than MTA and GIC in 1:1 ratio. Within the limitation of the study, the newer mixture of MTA and GIC in 2:1 ratio showed promising sealing ability and was comparable to MTA, Biodentine and MTA CEM.

When infection mimics cauda equina syndrome: a cautionary tale

A 63-year-old man presented to the emergency department with low back pain, perineal and genital numbness, together with bilateral lower limb paraesthesia and urinary retention. He was admitted under the orthopaedic service for investigation of suspected cauda equina syndrome. Magnetic resonance imaging of his spine did not reveal any evidence of cauda equina compression. Magnetic resonance imaging of his brain demonstrated nonspecific multiple hyperintensities in the right frontotemporal and left temporo-occipital regions. Computed tomography of his chest, abdomen, and pelvis did not identify any evidence of malignancy. Cerebrospinal fluid from a lumbar puncture showed a high leucocyte count (predominantly lymphocytes). Viral cerebrospinal fluid polymerase chain reaction was positive for varicella zoster virus. A diagnosis of varicella zoster virus myeloradiculitis (Elsberg syndrome) was established and the patient was treated with intravenous aciclovir. Unfortunately, the patient succumbed to a devastating intracerebral haemorrhage during his inpatient stay, probably due to vasculopathy from the underlying varicella zoster virus infection. This case describes a rare infectious mimic of cauda equina syndrome. Elsberg syndrome is an infectious syndrome characterised by bilateral lumbosacral myeloradiculitis, with varicella zoster virus being a well-recognised aetiological agent. We discuss the relevant literature in detail and identify the key, cautionary lessons learned from this case.

A Cohort Study of Anticholinergic Medication Burden and Incident Dementia and Stroke in Older Adults

BACKGROUND

Anticholinergic medications may increase risk of dementia and stroke, but prospective studies in healthy older people are lacking.

OBJECTIVE

Compare risk of incident dementia and stroke by anticholinergic burden among initially healthy older people.

DESIGN

Prospective cohort study.

SETTING

Primary care (Australia and USA).

PARTICIPANTS

19,114 community-dwelling participants recruited for the ASPREE trial, aged 70+ years (65+ if US minorities) without major cardiovascular disease, dementia diagnosis, or Modified Mini-Mental State Examination score below 78/100.

MEASUREMENTS

Baseline anticholinergic exposure was calculated using the Anticholinergic Cognitive Burden (ACB) score. Dementia was adjudicated using Diagnostic and Statistical Manual of Mental Disorders volume IV criteria, and stroke using the World Health Organization definition.

RESULTS

At baseline, 15,000 participants (79%) had an ACB score of zero, 2930 (15%) a score of 1-2, and 1184 (6%) a score of ≥ 3 (indicating higher burden). After a median follow-up of 4.7 years and adjusting for baseline covariates, a baseline ACB score of ≥ 3 was associated with increased risk of ischemic stroke (adjusted HR 1.58, 95% CI 1.06, 2.35), or dementia (adjusted HR 1.36, 95% CI 1.01, 1.82), especially of mixed etiology (adjusted HR 1.53, 95% CI 1.06, 2.21). Results were similar for those exposed to moderate/highly anticholinergic medications.

LIMITATIONS

Residual confounding and reverse causality are possible. Assessment of dose or duration was not possible.

CONCLUSIONS

High anticholinergic burden in initially healthy older people was associated with increased risk of incident dementia and ischemic stroke. A vascular effect may underlie this association. These findings highlight the importance of minimizing anticholinergic exposure in healthy older people.

496 The Use of Virtual Trauma Clinics (VTC) In the Assessment of Acute Hand Trauma; A Service Evaluation

As a UK tertiary referral centre for hand trauma the current COVID outbreak has led to the reconfiguration of trauma services. We evaluate the impact of our newly introduced VTC on our hand trauma service, comparing a cohort of patients who were managed pre-COVID, with our current revised pathway.

We carried out a service evaluation of all those patients processed by the VTC over 14 days in April 2020 (n = 184). We collected prospective data on timing of referral to assessment and surgery. This data was compared to a matched period in April 2019 (n = 162).

Post VTC there has been a significant reduction in time to clerking and time to surgery (p = &lt; 0.001), with 98.1% being clerked within 1 day of referral. Post VTC 12.9% of patients were discharged directly from VTC, all other patients had definitive treatment in a single trip.

VTC has shown a clear benefit to patients with definitive management provided in a single trip in all cases. Whilst we have been able to clerk patients earlier any improvement in time to surgery depends on theatre staffing and availability, which differed in the two cohorts and certainly will as we move forward into normal services.

533 The Use of Virtual Reality Simulation to Facilitate Surgical Ward-Based Learning in Medical Students During the Covid-19 Pandemic

Introduction

The Covid-19 pandemic quickly resulted in the removal of all non-essential personnel from surgical wards. It also resulted in suspending medical student placements which are heavily relied upon to provide the students with necessary “hands-on” experience. Virtual Reality (VR) simulation was employed in order to ensure that the students had a comparable experience.

Method

VR simulations were used to simulate the ward environments and the students were able to gain valuable experience with common scenarios encountered on surgical wards. Each student was allocated a 1-hour time slot per session with a debriefing session after each. The digital immersive environment allowed students to build upon their didactic preparation and previously acquired knowledge base.

Results

Feedback was given at the end of each simulation by the simulation facilitator. Using the technical proficiency that they had acquired in the first scenario; the students went on to employ these skills directly in their next scenarios thereby capitalising on the repetition of core skills to maximize their learning.

Conclusions

In this instance, VR was successfully used to enhance both knowledge acquisition and experience. Feedback from the participating students was overwhelmingly positive with many suggesting that they were more comfortable learning in a simulated environment.

Real-world bone turnover marker use: impact on treatment decisions and fracture

The use of bone turnover marker (BTM) testing for patients with osteoporosis in the USA has not been well characterized. This retrospective US-based real-world data study found BTM testing has some association with treatment decision-making and lower fracture risk in patients with presumed osteoporosis, supporting its use in clinical practice.

INTRODUCTION

The purpose of this study was to characterize bone turnover marker (BTM) testing patterns and estimate their clinical utility in treatment decision-making and fragility fracture risk in patients with osteoporosis using a retrospective claims database.

METHODS

Data from patients aged ≥ 50 years with newly diagnosed osteoporosis enrolled in the Truven MarketScan^® Commercial Claims and Encounters and Medicare Supplemental and Co-ordination of Benefits databases from January 2008 to June 2018 were included. Osteoporosis was ascertained by explicit claims, fragility fracture events associated with osteoporosis, or prescribed anti-resorptive or anabolic therapy. BTM-tested patients were 1:1 propensity score matched to those untested following diagnosis. Generalized estimating equation models were performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for testing versus no testing on both treatment decision-making and fragility fracture.

RESULTS

Of the 457,829 patients with osteoporosis, 6075 were identified with ≥ 1 BTM test following diagnosis; of these patients, 1345 had a unique treatment decision made ≤ 30 days from BTM testing. The percentage of patients receiving BTM tests increased significantly each year (average annual % change: + 8.1%; 95% CI: 5.6-9.0; p = 0.01). Patients tested were significantly more likely to have a treatment decision (OR: 1.14; 95% CI: 1.13-1.15), and testing was associated with lower odds of fracture versus those untested (OR: 0.87; 95% CI: 0.85-0.88).

CONCLUSION

In this large, heterogeneous population of patients with presumed osteoporosis, BTM testing was associated with treatment decision-making, likely leading to fragility fracture reduction following use.