Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Hot spot identification method based on Andrews curves: an application on the COVID-19 crisis effects on caregiver distress in neurocognitive disorder

Identifying and locating areas - hot spots - that present high concentration of observations in a high-dimensional data set is crucial in many data processing and analysis methods and techniques, since observations that belong to the same hot spot share information and behave in a similar way. A useful tool towards that aim is the reduction of the data dimensionality and the graphical representation of them. In the present paper, a new method to identify and locate hot spots is proposed, based on the Andrews curves. Simulations results demonstrate the performance of the proposed method, which is also applied to a high-dimensional data set, regarding caregiver distress related to symptoms of people with neurocognitive disorder and to the mental effects of the recent outbreak of the COVID-19 pandemic.

The Relationship Between Grey Matter Volume and Clinical and Functional Outcomes in People at Clinical High Risk for Psychosis

Objective

To examine the association between baseline alterations in grey matter volume (GMV) and clinical and functional outcomes in people at clinical high risk (CHR) for psychosis.

Methods

265 CHR individuals and 92 healthy controls were recruited as part of a prospective multi-center study. After a baseline assessment using magnetic resonance imaging (MRI), participants were followed for at least two years to determine clinical and functional outcomes, including transition to psychosis (according to the Comprehensive Assessment of an At Risk Mental State, CAARMS), level of functioning (according to the Global Assessment of Functioning), and symptomatic remission (according to the CAARMS). GMV was measured in selected cortical and subcortical regions of interest (ROI) based on previous studies (ie orbitofrontal gyrus, cingulate gyrus, gyrus rectus, inferior temporal gyrus, parahippocampal gyrus, striatum, and hippocampus). Using voxel-based morphometry, we analysed the relationship between GMV and clinical and functional outcomes.

Results

Within the CHR sample, a poor functional outcome (GAF < 65) was associated with relatively lower GMV in the right striatum at baseline (P < .047 after Family Wise Error correction). There were no significant associations between baseline GMV and either subsequent remission or transition to psychosis.

Conclusions

In CHR individuals, lower striatal GMV was associated with a poor level of overall functioning at follow-up. This finding was not related to effects of antipsychotic or antidepressant medication. The failure to replicate previous associations between GMV and later psychosis onset, despite studying a relatively large sample, is consistent with the findings of recent large-scale multi-center studies.

Old age mental health services in Southern Balkans: Features, geospatial distribution, current needs, and future perspectives

BACKGROUND

Healthcare services are increasingly confronted with challenges related to old age mental disorders. The survey aimed to provide an overview of existing psychogeriatric services in Albania, Bulgaria, Greece, and North Macedonia.

METHODS

After identification of psychogeriatric units across the four countries, their head physicians were asked to provide data on their clinical, teaching, and research activity, as well as staff composition. Moreover, the attitudes of head physicians to current needs and future service development were explored.

RESULTS

A total of 15 psychogeriatric units were identified (3 in Bulgaria, 8 in Greece, and 4 in North Macedonia). Results show wide variation regarding the location, team size and composition, service availability, numbers of patients attending, and inpatient treatment length. Most head physicians underscored the urgent need for breakthroughs in the graduate and postgraduate education in psychogeriatrics of medical and nonmedical professionals, as well as in the interconnection of their units with community primary healthcare services and long-term care facilities for seniors via telemedicine. They would welcome the development of national standards for psychogeriatric units, potentially embodying clear pointers for action. A number of head physicians advocated the development of nationwide old age mental health registries.

CONCLUSIONS

Regional disparities in resources and services for seniors' mental health services were unveiled. These data may enrich the dialogue on optimizing psychogeriatric services through planning future cross-border collaborations mainly based on telemedicine services, especially in the era of the novel coronavirus pandemic, and training/education in psychogeriatrics of mental health professionals.

[European Join Action on Dementia: Dementia Friendly Communities in Greece (DFC), the project "Aeneas"]

The Health Care system has a vital role in improving services and support people with dementia, but it cannot prevent fear and lack of understanding of dementia. Lack of awareness and poor understanding in communities has a major impact on the experience of people with dementia and their caregivers. "Dementia Friendly Communities" is a program of EU as part of the Act on Dementia Joint Action, in order to advance common recommendations for the development of better services for people with dementia, which will improve their quality of life. Ιt has been proposed that within a "Dementia friendly Community, people with dementia will not be marginalized and will be respected by their fellow citizens. The citizens, the public organizations and private sector enterprises cooperate in order to eliminate the obstacles which exclude dementia patients and their caregivers from participating in the life of their community". The Dementia Friendly Communities involve four fields: the environment (places), the citizens (people), the networks and the resources. Based on this model, pilot actions have been developed in Greece (Municipalities of Athens, Byron and Vrilissia), Bulgaria and UK and it is expected to provide important guidelines for the development of Dementia Friendly Communities in EU. In Greece the goal of the Join Action on Dementia was to promote the development of strong alliances within the local communities (municipalities) and the networking of organizations (State, Municipalities, NGOs, enterprises etc) with dementia patients and their caregivers and to educate more people in the municipalities in order to fight stigma and understand dementia.

[The effect of physical activity on dementia]

Τhe rate of patients suffering from mild cognitive impairment or any type of dementia has been constantly on the rise. Considering that no effective treatment of dementia has been discovered to date and that drug use can have numerous side effects, there is an urgent need for the application of alternative, non-pharmacological interventions. To this end, the aim of this study was to investigate the effects of physical activity on the cognitive impairment of the elderly, and its use as a form of non-pharmacological intervention for the treatment of dementia. Taking a review of the relevant literature, as its data collection method, this study examined peer-reviewed papers published between 2010 and 2018 that met the criteria for their inclusion. The articles were drawn from three electronic databases (PubMed, ScienceDirect and Web of Science), and were examined with regard to the populations under consideration, research design, type of intervention programs and assessment tools applied. The vast majority of these research papers tend to support that physical activity offers significant benefits to people suffering from Alzheimer's disease or other dementias. Specifically, it helps stabilize and improve cognitive function as well as reduce and delay the onset of severe neuropsychiatric symptoms such as depression, confusion, apathy, etc. In addition, physical exercise plays an important role in improving the executive functioning of patients with dementia, increasing autonomy in their everyday activities and reducing the risk of falls. In conclusion, recent research shows physical activity to be a promising intervention for the prevention and non-pharmacological treatment of dementia in that it contributes to the improvement of patients' quality of life. However, results vary according to the particularly characteristics of the exercise under review, such as type, intensity, frequency, and duration. It is therefore important to gain both awareness and understanding of the specific factors that give physical activity its therapeutic potential leading to the development of exercise programs designed specially to treat dementia.

Assessing depression in Greek dementia patients: Which scale to use?

Depression in dementia is known to deteriorate patients' cognitive function and Quality of Life and to increase the burden of care. Although detecting depression in dementia is crucial, there is no gold standard for its screening and diagnosis. We examined the psychometric properties of 3 different scales in detecting depression in dementia. Results will be useful as community services for dementia in the country are developing and the need for reliable detection of depression in dementia patients is urgent. Our sample consisted of 136 Greek dementia patients who consulted a memory clinic. For the diagnosis of depression, DSM-IV criteria for major depression and 3 different depression measures were used: a self-assessment scale (Geriatric Depression Scale; GDS), a caregiver assessment scale (Neuropsychiatric Inventory-Depression; NPI-D) and a clinician rated scale (Cornell Scale for Depression in Dementia; CSDD). For the evaluation of the screening performance of the three depression scales receiver operating characteristic curve (ROC) analysis was applied. The DSMIV criteria served as the gold standard method for the diagnosis of major depression. CSDD showed the best psychometric properties for the diagnosis of depression in dementia. The ROC curve analysis revealed that among the three measures, the CSDD had the wider AUC (0.919), second in the width of the AUC was the GDS (0.871), and last was the NPI-D (0.812). The prevalence of depression ranged from 18.4% according to DSM-IV criteria to 42.6% using the NPI-D. Using the GDS (cut off point: 7/8) and the CSDD (cut off point: 6/7), depression was present in 26.9% and 33.1% of the patients, respectively. Correlations between scales used were significant (r from 0.432 to 0.660; p<0.001). Caregivers tend to report more depressive symptoms in dementia compared to patients' and clinicians' ratings. CSDD should be used in specialized centers, but GDS may be an alternative in patients able to complete the assessment. The need to establish valid criteria for the diagnosis of depression in dementia is urgent.

The burden of caring for patients with dementia and its predictors

Dementia not only affects patients but also care providers. The assessment of Caregivers' Burden (CB) has grown exponentially in the dementia field, as studies have shown that it is higher in dementia than in other diseases. Dementia care in Greece is different compared to other developed countries, as most of the patients receive care at home from family members. The aim of the present study was to examine the level of burden in Greek caregivers who live in Athens, and its association with patient and caregiver factors. This was a cross-sectional study of 161 primary caregivers of dementia patients living in the community and attending a secondary clinic. CB was assessed with the Zarit Burden Interview (ZBI) and caregivers' depression with the Center for Epidemiological Studies Depression Scale (CES-D). Clinical characteristics of the patients were also assessed using validated scales (cognitive status, functional ability, neuropsychiatric symptoms). In order to find predictors of caregiver Burden, we conducted a 3-step hierarchical regression analysis. Most patients were suffering from Alzheimer's Dementia (n=101; 62.73%) and had moderate and severe dementia according to the MMSE score (mean MMSE=11.50), with patients being unable to perform 2 basic activities of daily living on average. 45 patients (27.95%) had depression according to the CSDD; only 5 patients didn't have any behavioral problem in the NPI, while patients had more than 5 behavioral problems on average. Caregivers were involved in their role for 3.6 years on average and the mean weekly caregiving time was more than 70 hours. Nearly half (n=80; 49.06%) of the 161 caregivers demonstrated high CB (ZBI>40) and nearly one fourth had depression according to the CES-D scale. All blocks of variables entered into the regression model independently predicted caregiver burden's variance (demographics, clinical factors and caregiving characteristics). Lower caregiver's age, high behavioral symptoms of dementia patients and caregivers' depression were found to be independently associated with CB. The final regression model explained 47.2% of the variance in CB. Dementia causes a great burden in caregivers. CB is a complex issue that is associated with several patients and caregivers' factors. The level of CB should be assessed in everyday dementia clinical practice.

[Mini Mental State Examination (MMSE): determination of cutoff scores according to age and educational level]

For the last 38 years, Mini Mental State Examination (MMSE) has been widely used as a dementia screening measure in everyday clinical practice as well as in both cohort and cross-sectional studies. Its validity and reliability for the Greek population has explicitly been documented. However, the effect of age and education on the subject's performance makes it necessary to reckon them in the estimation of the "cutoff score". The purpose of this study is to estimate the prevalence of dementia in Greek population and determine the "cutoff score" by age and education-corrected norms. Cross sectional study of 630 patients older than 55 years, who live independently in Ilion and Helioupolis Municipalities was conducted, 27.3% of the subjects tested in the study were diagnosed with memory disorder according to their MMSE scores and the validation for the Greek population. The effect of age and education to the subjects' performance was statistically significant (p=.000). The use of standard "cutoff score" was not proved to be useful for the personalized interpretation of the results, as documented by the fact that older individuals with lower education had a poorer performance relatively to younger, highly educated subjects. Comparatively to the group age of 55-60 years, the odds ratio after the age of 75 years varies from 2.58 to 4.91. Regarding the variable factor of education, the odds ratio for the first degree education graduates decreases from 1.43 to 3.19 for the third degree education graduates in comparison with the group of illiterates. In conclusion, the use of the "cutoff score" algorithm and the simultaneous estimation of age and education effect on MMSE score may prove useful for the proper evaluation of MMSE performance. According to the age and education of examine candidates in the community and the primary care, we propose the use of the 25th percentile as a more useful cutoff score in order to decrease the false positive results.

Loading rate patterns in scoliotic children during gait: the impact of the schoolbag carriage and the importance of its position

PURPOSE

Concerns have been raised regarding the effects of schoolbag carriage on adolescent schoolchildren and particularly those with a pre-existing spinal deformity. The purpose of this study was to determine the effect of school backpack loads in scoliotic and healthy school-age children during walking, in terms of peak vertical ground reaction forces and loading rates. We hypothesized that walking with a loaded backpack would have a greater effect on gait kinetics of scoliotic compared to healthy.

METHODS

Eight children with idiopathic scoliosis and eight healthy children were assessed. Kinetic data were collected using two AMTI OR6-7 force-plates, while the subjects walked freely along a 6-m walkway under three walking conditions: (1) without a schoolbag, (2) carrying a schoolbag bilaterally (over both shoulders-symmetrical load) and (3) carrying a schoolbag unilaterally (over each shoulder-asymmetrical load). Kinetic data were collected and four parameters were calculated; peak ground reaction force at the first maximum force peak (F1), time needed to reach F1 (T1), loading rate of F1 (LRF1) and total contact time (T2).

RESULTS

We found no significant differences between the scoliotic and healthy children for any of the kinetic variables examined. In addition, the position of the bag did not seem to have any effect on loading rate.

CONCLUSIONS

The results of this study indicate that in terms of kinetic parameters during normal gait, the schoolbag load (symmetrical or asymmetrical) does not have a different effect on children with mild adolescent idiopathic scoliosis compared to normal controls.

The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia

BACKGROUND

Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages).

METHODS

Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity.

RESULTS

Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains.

CONCLUSION

Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

Acquired competence in cognitive therapy following a two level course

The objective of this study was to examine the predictive value of trainees' previous experience and performance at an introductory course in Cognitive Therapy for their subsequent success in an advanced course. From 203 completers of an introductory course during seven consecutive years 32 participated in an advanced course. In a linear regression analysis previous clinical and psychotherapeutic experience as well as performance at the introductory course were studied as predictors for trainees' success in the advanced course. Performance at the introductory course was the only significant predictor of trainees' successful completion of the advanced course. An introductory course might help to select those trainees who have the desired qualities to succeed in a formal psychotherapeutic training program.

Development and use of online mental health services in Greece

E-mental health refers to the use of telecommunication and information technology in mental health services. In Greece, ordinary telephone communications have been used to provide mental health services, such as a psychiatric crisis intervention line (METB). E-psychiatry is a relatively new approach to delivering psychiatric services through the Internet. We have developed an e-psychiatry Website, Glaucopis-net. The main objective is to provide information on a broad range of psychiatric conditions, such as dementia, depression and anxiety. Email mental health services will be offered as an alternative way of accessing help. Confidentiality issues concerning patient records and personal data will be treated in accordance with Greek legislation. Glaucopis-net will integrate new telecommunication and information services with classical mental health services.