Community pharmacists' perceptions on managing people with oral health problems-A prioritisation survey

BACKGROUND

Alternative sources of oral health information are likely to be of benefit to the public, particularly where access to dental services is limited. There is evidence that community pharmacists are willing to advocate for oral health, but it is unclear what is needed to develop this role.

OBJECTIVES

The aims of this study were to obtain the views of community pharmacy staff on the frequency and type of oral health conditions they encounter challenges in management and training/research priorities.

METHODS

An anonymous online survey targeted pharmacy staff and elicited quantitative data related to the types and frequencies of oral health conditions experienced. Participants were stratified by age, gender, ethnicity, experience and setting. Free text responses allowed participants to detail challenging aspects of patient management, their priorities for service development and future research. Reflexive thematic analysis of free text responses identified key themes.

RESULTS

Oral/facial pain and swelling were seen weekly by most respondents, and daily by 28.8%. Other commonly presenting conditions were ulcers, dry-mouth, thrush and denture issues. Challenges in managing oral health conditions included: access to NHS dentistry, awareness of referral pathways, examination/diagnosis and understanding 'Red Flags'.

CONCLUSION

Acute and chronic oral health conditions commonly present to community pharmacists who lack necessary knowledge/training, which may result in missing 'red flag' symptoms for oral cancer or acute facial swellings which can be life threatening. There is a need to support pharmacists, who are willing to act as oral health advocates, in recognition, prevention and onward referral for oral diseases.

Reducing Indigenous suicide: Recognizing vital land and food systems for livelihoods

Colonial trauma poses a significant risk to the physical, intellectual, and mental health of Indigenous youth and young adults. Education and mental health scholars are increasingly concerned about the emotional wellbeing of young people, particularly as rates of suicide have increased across the United States. With interest in identifying the unique contextual dynamics involved in understanding Indigenous suicide, this work considers characteristics related to colonialism that may uncover strategies for both educators and mental health practitioners that address disparities. Drawing on a larger ethnographic study, this inquiry asks how settler encroachment upon Indigenous land and food systems is related to death by suicide from the perspective of Cowichan Tribes members. Comprehensive semi-structured interviews were conducted (n = 21); each interview was audio-recorded and transcribed verbatim. Data were analyzed deductively based upon a priori suppositions related to settler colonial theory. Cowichan members' narrated explanations for suicide rooted in disruptions to (1) relationships with the land and (2) traditional food systems. They described how settler encroachment infringed upon their subsistence way of living and introduced incongruent constructions of nature-culture relations (e.g., humans as distinct and separate from the natural world). Settler futurity is secured through the arrogation of territorial dominance coupled with physical or conceptual acts of erasure, placing Indigenous lives and lifeways at risk. One outcome of the disruption to Indigenous collective capacities is a dramatic increase in Indigenous suicide.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

Physical and brain frailty in ischaemic stroke or TIA: Shared occurrence and outcomes. A cohort study

BACKGROUND

There is increasing interest in the concept of frailty in stroke, including both physical frailty and imaging-evidence of brain frailty. We aimed to establish the prevalence of brain frailty in stroke survivors as well as the concurrent and predictive validity of various frailty measures against long-term cognitive outcomes.

METHODS

We included consecutively admitted stroke or transient ischaemic attack (TIA) survivors from participating stroke centres. Baseline CT scans were used to generate an overall brain frailty score for each participant. We measured frailty via the Rockwood frailty index, and a Fried frailty screening tool. Presence of major or minor neurocognitive disorder at 18-months following stroke or TIA was established via a multicomponent assessment. Prevalence of brain frailty was established based upon observed percentages within groups defined by frailty status (robust, pre-frail, frail). We assessed the concurrent validity of brain frailty and frailty scales via Spearman's rank correlation. We conducted multivariable logistic regression analyses, controlling for age, sex, baseline education and stroke severity, to evaluate association between each frailty measure and 18-month cognitive impairment.

RESULTS

Three-hundred-forty-one stroke survivors participated. Three-quarters of people who were frail had moderate-severe brain frailty and prevalence increased according to frailty status. Brain frailty was weakly correlated with Rockwood frailty (Rho: 0.336; p < 0.001) and with Fried frailty (Rho: 0.230; p < 0.001). Brain frailty (OR: 1.64, 95% CI = 1.17-2.32), Rockwood frailty (OR: 1.05, 95% CI = 1.02-1.08) and Fried frailty (OR: 1.93, 95% CI = 1.39-2.67) were each independently associated with cognitive impairment at 18 months following stroke.

CONCLUSIONS

There appears to be value in the assessment of both physical and brain frailty in patients with ischaemic stroke and TIA. Both are associated with adverse cognitive outcomes and physical frailty remains important when assessing cognitive outcomes.

A two-arm, randomised feasibility trial using link workers to improve dental visiting in people with severe mental illness: a protocol paper

BACKGROUND

People with severe mental illness (e.g. psychosis, bipolar disorder) experience poor oral health compared to the general population as shown by more decayed, missing and filled teeth and a higher prevalence of periodontal disease. Attending dental services allows treatment of oral health problems and support for prevention. However, people with severe mental illness face multiple barriers to attending routine dental appointments and often struggle to access care. Link work interventions use non-clinical support staff to afford vulnerable populations the capacity, opportunity, and motivation to navigate use of services. The authors have co-developed with service users a link work intervention for supporting people with severe mental illness to access routine dental appointments. The Mouth Matters in Mental Health Study aims to explore the feasibility and acceptability of this intervention within the context of a feasibility randomised controlled trial (RCT) measuring outcomes related to the recruitment of participants, completion of assessments, and adherence to the intervention. The trial will closely monitor the safety of the intervention and trial procedures.

METHODS

A feasibility RCT with 1:1 allocation to two arms: treatment as usual (control) or treatment as usual plus a link work intervention (treatment). The intervention consists of six sessions with a link worker over 9 months. Participants will be adults with severe mental illness receiving clinical input from secondary care mental health service and who have not attended a planned dental appointment in the past 3 years. Assessments will take place at baseline and after 9 months. The target recruitment total is 84 participants from across three NHS Trusts. A subset of participants and key stakeholders will complete qualitative interviews to explore the acceptability of the intervention and trial procedures.

DISCUSSION

The link work intervention aims to improve dental access and reduce oral health inequalities in people with severe mental illness. There is a dearth of research relating to interventions that attempt to improve oral health outcomes in people with mental illness and the collected feasibility data will offer insights into this important area.

TRIAL REGISTRATION

The trial was preregistered on ISRCTN (ISRCTN13650779) and ClinicalTrials.gov (NCT05545228).

A Mixed-Methods Study to Better Measure Patient-Reported Pain and Fatigue in Soft Tissue Sarcoma

INTRODUCTION

Pain and fatigue are commonly reported by patients with soft tissue sarcoma (STS) as distressing symptoms, yet no patient-reported outcome (PRO) measures have been validated or developed specifically for STS. This study aimed to develop novel PRO scales using existing item banks to measure pain and fatigue in STS.

METHODS

A three-stage mixed-methods approach was used. Stage 1: a literature review examined the development and validation of the European Organization for Research and Treatment of Cancer (EORTC) library, Patient-Reported Outcomes Measurement Information System (PROMIS) pain/fatigue item banks, Functional Assessment of Cancer Therapy-General, and FACIT-Fatigue. Conceptual models were developed for pain and fatigue. Stage 2: semi-structured interviews were conducted with clinical experts (n = 3) and STS patients (n = 28) to ensure conceptual coverage and cognitively debrief the selected PRO items. Stage 3: exploratory Rasch measurement theory (RMT) analyses were performed to examine the measurement properties of the proposed scales.

RESULTS

Stage 1: The conceptual model for fatigue was organized into two overarching domains: fatigability and fatigue, further split into two subdomains: symptoms and impact. The conceptual model for pain had one overarching domain split into two subdomains: descriptors and impact. Pain (n = 56) and fatigue (n = 40) items were selected from the EORTC item library. Stage 2: qualitative findings ensured conceptual coverage, provided insight into the relevance and comprehension of the items, and informed subsequent item reduction. Stage 3: The total item number was reduced to 43 (pain n = 18, fatigue n = 25). Exploratory RMT analyses supported the final scales' psychometric properties.

CONCLUSIONS

This mixed-methods research generated important information on the experience of pain and fatigue in specific subtypes of STS. Five novel PRO scales have been developed through careful item selection in consultation with experts and supported by qualitative and quantitative evidence. These scales may be of value to future clinical trials for STS.

Diagnostic test accuracy of remote, multidomain cognitive assessment (telephone and video call) for dementia

BACKGROUND

Remote cognitive assessments are increasingly needed to assist in the detection of cognitive disorders, but the diagnostic accuracy of telephone- and video-based cognitive screening remains unclear.

OBJECTIVES

To assess the test accuracy of any multidomain cognitive test delivered remotely for the diagnosis of any form of dementia. To assess for potential differences in cognitive test scoring when using a remote platform, and where a remote screener was compared to the equivalent face-to-face test.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, LILACS, and ClinicalTrials.gov (www.

CLINICALTRIALS

gov/) databases on 2 June 2021. We performed forward and backward searching of included citations.

SELECTION CRITERIA

We included cross-sectional studies, where a remote, multidomain assessment was administered alongside a clinical diagnosis of dementia or equivalent face-to-face test.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data; a third review author moderated disagreements. Our primary analysis was the accuracy of remote assessments against a clinical diagnosis of dementia. Where data were available, we reported test accuracy as sensitivity and specificity. We did not perform quantitative meta-analysis as there were too few studies at individual test level. For those studies comparing remote versus in-person use of an equivalent screening test, if data allowed, we described correlations, reliability, differences in scores and the proportion classified as having cognitive impairment for each test.

MAIN RESULTS

The review contains 31 studies (19 differing tests, 3075 participants), of which seven studies (six telephone, one video call, 756 participants) were relevant to our primary objective of describing test accuracy against a clinical diagnosis of dementia. All studies were at unclear or high risk of bias in at least one domain, but were low risk in applicability to the review question. Overall, sensitivity of remote tools varied with values between 26% and 100%, and specificity between 65% and 100%, with no clearly superior test. Across the 24 papers comparing equivalent remote and in-person tests (14 telephone, 10 video call), agreement between tests was good, but rarely perfect (correlation coefficient range: 0.48 to 0.98).

AUTHORS' CONCLUSIONS

Despite the common and increasing use of remote cognitive assessment, supporting evidence on test accuracy is limited. Available data do not allow us to suggest a preferred test. Remote testing is complex, and this is reflected in the heterogeneity seen in tests used, their application, and their analysis. More research is needed to describe accuracy of contemporary approaches to remote cognitive assessment. While data comparing remote and in-person use of a test were reassuring, thresholds and scoring rules derived from in-person testing may not be applicable when the equivalent test is adapted for remote use.

Comparative validity of informant tools for assessing pre-stroke cognitive impairment

OBJECTIVES

Various informant-based questionnaires are used in clinical practice to screen for pre-stroke cognitive problems. However, there is no guidance on which tool should be preferred. We compared the validity of the two most commonly used informant-based tools.

METHODS

We recruited consecutively admitted stroke patients. Patients' informants completed the Informant Questionnaire for Cognitive Decline in the Elderly Short Form (IQCODE-SF, 16-item) and Ascertain Dementia 8 (AD8). We assessed construct validity (accuracy) against a semi-structured clinical interview for dementia or mild cognitive impairment (MCI), describing test accuracy metrics and comparing area under ROC curves (AUROC). We described criterion validity by evaluating associations between test scores and neuroimaging markers of dementia and overall 'brain frailty'. Finally, we described prognostic validity comparing ROC curves for 18-month clinical outcomes of dementia, death, stroke, and disability.

RESULTS

One-hundred-thirty-seven patient-informant dyads were recruited. At usual clinical cut-points, the IQCODE-SF had comparable sensitivity to the AD8 (both = 92%) for pre-stroke dementia, but superior specificity (IQCODE-SF: 82% vs. AD8: 58%). Youden index suggested that the optimal AD8 threshold for diagnosis of dementia is ≥4. The IQCODE-SF demonstrated stronger associations with markers of generalised and medial-temporal lobe atrophy, neurovascular disease, and overall brain frailty. IQCODE-SF also demonstrated greater accuracy for predicting future dementia (IQCODE-SF AUROC = 0.903, 95% CI = 0.798-1.00; AD8 AUROC = 0.821, 95% CI = 0.664-0.977).

CONCLUSIONS

Both IQCODE-SF and AD8 are valid measures of pre-stroke dementia. Higher cut points for AD8 may improve performance in the acute stroke setting. Based on consistent superiority across a range of validity analyses, IQCODE-SF may be preferable to AD8 for pre-stroke dementia screening.

Research protocol - Assessing Post-Stroke Psychology Longitudinal Evaluation (APPLE) study: A prospective cohort study in stroke

BACKGROUND

Cognitive and mood problems have been highlighted as priorities in stroke research and guidelines recommend early screening. However, there is limited detail on the preferred approach.We aimed to (1) determine the optimal methods for evaluating psychological problems that pre-date stroke; (2) assess the test accuracy, feasibility and acceptability of brief cognitive and mood tests used at various time-points following stroke; (3) describe temporal changes in cognition and mood following stroke and explore predictors of change.

METHODS

We established a multi-centre, prospective, observational cohort with acute stroke as the inception point - Assessing Post-stroke Psychology Longitudinal Evaluation (APPLE). We approached patients admitted with stroke or transient ischaemic attack (TIA) from 11 different hospital sites across the United Kingdom. Baseline demographics, clinical, functional, cognitive, and mood data were collected. Consenting stroke survivors were followed up with more extensive evaluations of cognition and mood at 1, 6, 12 and 18 months.

RESULTS

Continuous recruitment was from February 2017 to February 2019. With 357 consented to full follow-up. Eighteen-month assessments were completed in September 2020 with permissions in-place for longer term in-person or electronic follow-up. A qualitative study has been completed, and a participant sample biobank and individual participant database are both available.

DISCUSSION

The APPLE study will provide guidance on optimal tool selection for cognitive and mood assessment both before and after stroke, as well as information on prognosis and natural history of neuropsychological problems in stroke. The study data, neuroimaging and tissue biobank are all available as a resource for future research.

The Patient and Clinician Assessment of Gastrointestinal (GI) Related Adverse Events Associated with Oral Disease-Modifying Therapies in Multiple Sclerosis: A Qualitative Study

INTRODUCTION

Current guidelines for relapsing-remitting multiple sclerosis (RRMS) call for treatment with disease-modifying therapies (DMTs) early in the disease to prevent relapses and accumulation of neurologic impairment and disability. However, patients taking certain oral DMTs may experience gastrointestinal (GI)-related adverse events (AEs), particularly at dose titration. We conducted qualitative research with healthcare professionals (HCPs) and patients in Canada to contextualize their experiences with three oral DMTs: dimethyl fumarate (Tecfidera^®), fingolimod (Gilenya^®), and teriflunomide (Aubagio^®). The objectives of this study were to (1) gather qualitative data to better understand the patient and HCP experience of GI AEs in oral MS DMT treatment in Canada and (2) determine to what extent two patient-reported outcome (PRO) instruments used in recent oral DMT trials capture what is important to patients regarding GI AEs in oral MS DMT treatment (content validity) and to provide qualitative data to help interpret PRO scores.

METHODS

This was a qualitative, non-interventional, descriptive, cross-sectional study comprising HCP and patient interviews conducted in English and French, using a 1:1 semi-structured interview approach.

RESULTS

Patients reported 16 unique GI AE concepts related to oral DMTs. The most commonly reported symptoms were diarrhea, indigestion, and nausea. While patients acknowledged the negative impact associated with GI-related AEs, most characterized the treatment experience as positive, focusing on preference for oral administration, perceived efficacy of DMTs in terms of lack of MS relapses, slowed progression of their disease, and improvement in MS symptoms. Results supported the content validity (relevance, comprehension, and comprehensiveness) of the two PROs assessed. HCP feedback reinforced patient perspectives on both GI concepts and the two PRO instruments.

CONCLUSION

Outcomes of these research activities include experiential data on the symptom and impact experience of oral DMTs in MS from both patients and HCPs that contribute to the process of determining therapeutic value.

A multi-centre early evaluation of the effectiveness of workshop teaching to improve the confidence of UK and Irish dental students when addressing patient mental health

Background Dental practitioners can have low confidence when addressing patient mental health as part of wider patient management. This is increasingly relevant due to the rising prevalence of mental health conditions and the relationship that can exist between mental and oral health. Interactive workshop teaching on patient mental health may enhance the confidence of dental students when addressing mental health conditions in patients. This study trialled workshop teaching as an educational intervention in five UK and Irish dental schools.Methods A quantitative, scenario-based confidence survey to further establish the need for intervention, followed by delivery of a workshop intervention to volunteer participants. Pre- and post-workshop surveys were used to assess the effectiveness of the workshop.Results Survey data showed low confidence among dental students when addressing patient mental health. Workshop intervention improved dental student confidence on average from 2.3-3.7 on a five-point scale, with less than 0.5% likelihood that reported changes in confidence were due to chance.Discussion Low confidence of dental students addressing patient mental health scenarios echoed wider literature findings surrounding dental clinicians' ability to address patient mental health. This further demonstrated the need for educational intervention, with workshop effectiveness demonstrated within this paper.Conclusion Workshop teaching is an effective way to enhance dental student confidence when addressing patient mental health and should be considered for implementation in the Bachelor of Dental Surgery curriculum.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Challenges in the diagnosis of dementia: insights from the United Kingdom-Brazil Dementia Workshop

In July 2019, a group of multidisciplinary dementia researchers from Brazil and the United Kingdom (UK) met in the city of Belo Horizonte, Minas Gerais, Brazil, to discuss and propose solutions to current challenges faced in the diagnosis, public perception and care of dementia. Here we summarize the outcomes from the workshop addressing challenges in diagnosis. Brazil faces a major problem in dementia underdiagnosis, particularly involving the population in an adverse socioeconomic context. There is poor availability of resources and specialists, and the knowledge of general practitioners and other healthcare professionals is far from satisfactory. Low education level is a further obstacle in diagnosing dementia, as the most commonly used screening tests are not designed to evaluate this population. Patients and their families must overcome the stigma of a diagnosis of dementia, which is still prevalent in Brazil and increases the burden of this condition. Whilst the UK has greater resources, dedicated memory services and a National Dementia Strategy plan, the National Health Service (NHS) has limited funding. Therefore, some challenges regarding diagnosis are common across both countries. The authors suggest possible solutions to confront these, with the goal of improving assessment and recognition of dementia and reducing misdiagnosis.

Accuracy of Telephone-Based Cognitive Screening Tests: Systematic Review and Meta-Analysis

Background:

Telephone-based cognitive assessments may be preferable to in-person testing in terms of test burden, economic and opportunity cost.

Objective:

We sought to determine the accuracy of telephone-based screening for the identification of dementia or Mild Cognitive Impairment (MCI).

Methods:

Five multidisciplinary databases were searched. Two researchers independently screened articles and extracted data. Eligible studies compared any multi-domain telephone-based assessment of cognition to the face-to-face diagnostic evaluation. Where data allowed, we pooled test accuracy metrics using the bivariate approach.

Results:

From 11,732 titles, 34 papers were included, describing 15 different tests. There was variation in test scoring and quality of included studies. Pooled analyses of accuracy for dementia: Telephone Interview for Cognitive Status (TICS) (<31/41) sensitivity: 0.92, specificity: 0.66 (6 studies); TICSmodified (<28/50) sensitivity: 0.91, specificity: 0.91 (3 studies). For MCI: TICS-modified (<33/50) sensitivity: 0.82, specificity: 0.87 (3 studies); Telephone-Montreal Cognitive Assessment (<18/22) sensitivity: 0.98, specificity: 0.69 (2 studies).

Conclusion:

There is limited diagnostic accuracy evidence for the many telephonic cognitive screens that exist. The TICS and TICS-m have the greatest supporting evidence; their test accuracy profiles make them suitable as initial cognitive screens where face to face assessment is not possible.

Exosomes derived from mesenchymal stem cells improved core symptoms of genetically modified mouse model of autism Shank3B

BACKGROUND

Partial or an entire deletion of SHANK3 are considered as major drivers in the Phelan-McDermid syndrome, in which 75% of patients are diagnosed with autism spectrum disorder (ASD). During the recent years, there was an increasing interest in stem cell therapy in ASD, and specifically, mesenchymal stem cells (MSC). Moreover, it has been suggested that the therapeutic effect of the MSC is mediated mainly via the secretion of small extracellular vesicle that contains important molecular information of the cell and are used for cell-to-cell communication. Within the fraction of the extracellular vesicles, exosomes were highlighted as the most effective ones to convey the therapeutic effect.

METHODS

Exosomes derived from MSC (MSC-exo) were purified, characterized, and given via intranasal administration to Shank3B KO mice (in the concentration of 10⁷ particles/ml). Three weeks post treatment, the mice were tested for behavioral scoring, and their results were compared with saline-treated control and their wild-type littermates.

RESULTS

Intranasal treatment with MSC-exo improves the social behavior deficit in multiple paradigms, increases vocalization, and reduces repetitive behaviors. We also observed an increase of GABARB1 in the prefrontal cortex.

CONCLUSIONS

Herein, we hypothesized that MSC-exo would have a direct beneficial effect on the behavioral autistic-like phenotype of the genetically modified Shank3B KO mouse model of autism. Taken together, our data indicate that intranasal treatment with MSC-exo improves the core ASD-like deficits of this mouse model of autism and therefore has the potential to treat ASD patients carrying the Shank3 mutation.

Cardiovascular risk factors indirectly affect acute post-stroke cognition through stroke severity and prior cognitive impairment: a moderated mediation analysis

BACKGROUND

Cognitive impairment is an important consequence of stroke and transient ischaemic attack, but its determinants are not fully understood. Simple univariable or multivariable models have not shown clinical utility for predicting cognitive impairment. Cardiovascular risk factors may influence cognition through multiple, direct, and indirect pathways, including effects on prior cognition and stroke severity. Understanding these complex relationships may help clinical teams plan intervention and follow-up strategies.

METHODS

We analysed clinical and demographic data from consecutive patients admitted to an acute stroke ward. Cognitive assessment comprised Abbreviated Mental Test and mini-Montreal Cognitive Assessment. We constructed bias-corrected confidence intervals to test indirect effects of cardiovascular risk factors (hypertension, vascular disease, atrial fibrillation, diabetes mellitus, previous stroke) on cognitive function, mediated through stroke severity and history of dementia, and we assessed moderation effects due to comorbidity.

RESULTS

From 594 eligible patients, we included 587 in the final analysis (age range 26-100; 45% female). Our model explained R² = 62.10% of variance in cognitive test scores. We found evidence for an indirect effect of previous stroke that was associated with increased risk of prevalent dementia and in turn predicted poorer cognitive score (estimate = - 0.39; 95% bias-corrected CI, - 0.75 to - 0.13; p = 0.02). Atrial fibrillation was associated with greater stroke severity and in turn with a poorer cognitive score (estimate = - 0.27; 95% bias-corrected CI, - 0.49 to - 0.05; p = 0.02). Conversely, previous TIA predicted decreased stroke severity and, through that, lesser cognitive impairment (estimate = 0.38; 95% bias-corrected CI, 0.08 to 0.75; p = 0.02). Through an association with reduced stroke severity, vascular disease was associated with lesser cognitive impairment, conditional on presence of hypertension and absence of diabetes mellitus (estimate = 0.36; 95% bias-corrected CI, 0.03 to 0.68; p = 0.02), although the modelled interaction effects did not reach statistical significance.

CONCLUSIONS

We have shown that relationships between cardiovascular risk factors and cognition are complex and simple multivariable models may be overly reductionist. Including direct and indirect effects of risk factors, we constructed a model that explained a substantial proportion of variation in cognitive test scores. Models that include multiple paths of influence and interactions could be used to create dementia prognostic tools for use in other healthcare settings.

How confidently do students address patients with psychiatric conditions in the dental clinic? A service evaluation in a UK dental school

Background Extensive literature covers the relationship between psychiatric and dental health, but little research explores the ability of dental practitioners to confidently address patient mental health. This paper explored self-reported confidence of dental students when addressing patient mental health in a university setting.Methods Mixed-method approach involving a quantitative scenario-based survey and focus groups. Research participants were from years three, four and five of the Bachelor of Dental Surgery (BDS) degree.Results Survey data showed low confidence among dental students. Focus group themes included lack of education, prejudice and rejecting responsibility. Participants suggested communication skills workshops to help improve confidence.Discussion Self-reported confidence among dental students when addressing patient mental health was low, echoing wider literature findings. Focus groups highlighted an absence of patient mental health from the curriculum. Systematic reviews have recommended greater education around screening tools for 'assessing psychological comorbidity'. Using best practice, focus group data and psychologist guidance, we developed a communication skills case-based workshop for service improvement.Conclusion Low student confidence likely originates from limited focus within the BDS curriculum. The research will be expanded into other UK dental schools to explore the confidence of dental students nationally and to evaluate and trial the developed workshop.

Occurrence Rate of Delirium in Acute Stroke Settings

Background and Purpose—

Delirium is associated with increased mortality, length of stay, and poor functional outcome following critical illness. The epidemiology of delirium in stroke is poorly described. We sought to collate evidence around occurrence (incidence or prevalence) of delirium in acute stroke.

Methods—

We searched multiple cross-disciplinary electronic databases using a prespecified search strategy, complemented by hand searching. Eligible studies described delirium in acute (first 6 weeks) stroke. We compared delirium occurrence using random-effects models to describe summary estimates. We assessed risk of bias using the Newcastle-Ottawa tool, incorporating this in sensitivity analyses. We performed subgroup analyses for delirium diagnostic method (confusion assessment method scoring, clinical diagnosis, other), duration and timing of delirium assessment (>1 or <1 week), and performed meta-regression based on the year of publication.

Results—

Of 8822 titles, we included 32 papers (6718 participants) in the quantitative analysis. Summary estimate for occurrence of delirium was 25% (95% CI, 20%–30%; moderate quality evidence). Limiting to studies at low risk of bias (22 studies, 4422 participants), the occurrence rate was 23% (95% CI, 17%–28%). Subgroup summary estimates suggest that delirium occurrence may vary with assessment method: confusion assessment method, 21% (95% CI, 16%–27%); clinical diagnosis, 27% (95% CI, 19%–38%); other, 32% (95% CI, 22%–43%) but not with duration and timing of assessment. Meta-regression suggested decline in occurrence of delirium comparing historical to more recent studies (slope, 0.03 [SE, 0.004]; P <0.0001).

Conclusions—

Delirium is common, affecting 1 in 4 acute stroke patients. Reported rates of delirium may be dependent on assessment method. Our estimate of delirium occurrence could be used for audit, to plan intervention studies, and inform clinical practice.

Clinical Trial Registration—

URL: http://www.crd.york.ac.uk/PROSPERO/ . Unique identifier: CRD42015029251.

Delirium in an Acute Stroke Setting, Occurrence, and Risk Factors

Background and Purpose—

Delirium is a common and serious complication of acute illness. We describe delirium occurrence in an unselected, acute stroke population.

Methods—

We collected data from consecutive stroke admissions. We performed comprehensive cognitive assessment within the first week including Diagnostic Statistical Manual-5–based delirium diagnosis. We reported proportion with delirium and the clinical and demographic associations with delirium using multiple logistic regression.

Results—

Of 708 patients, median age of 71 years (interquartile range, 59–80), we recorded delirium in 187 of 708 (26.4%; 95% CI, 23.0–30.0). Across 395 patients with complete risk factor data (105 delirium), factors independently associated with delirium were: age (odds ratio, 1.05; 95% CI, 1.03–1.08), drug/alcohol misuse (odds ratio, 2.64; 95% CI, 1.10–6.26), and stroke severity (odds ratio, 1.22; 95% CI, 1.14–1.31).

Conclusions—

Delirium is common in acute stroke, affecting 1 in 4. It may be possible to predict those at risk using prestroke and stroke-specific factors.

Clinical Trial Registration—

URL: researchregistry.com . Protocol: 1147.

Accuracy of the short-form Montreal Cognitive Assessment: Systematic review and validation

INTRODUCTION

Short-form versions of the Montreal Cognitive Assessment (SF-MoCA) are increasingly used to screen for dementia in research and practice. We sought to collate evidence on the accuracy of SF-MoCAs and to externally validate these assessment tools.

METHODS

We performed systematic literature searching across multidisciplinary electronic literature databases, collating information on the content and accuracy of all published SF-MoCAs. We then validated all the SF-MoCAs against clinical diagnosis using independent stroke (n = 787) and memory clinic (n = 410) data sets.

RESULTS

We identified 13 different SF-MoCAs (21 studies, n = 6477 participants) with differing test content and properties. There was a pattern of high sensitivity across the range of SF-MoCA tests. In the published literature, for detection of post stroke cognitive impairment, median sensitivity across included studies: 0.88 (range: 0.70-1.00); specificity: 0.70 (0.39-0.92). In our independent validation using stroke data, median sensitivity: 0.99 (0.80-1.00); specificity: 0.40 (0.14-0.87). To detect dementia in older adults, median sensitivity: 0.88 (0.62-0.98); median specificity: 0.87 (0.07-0.98) in the literature and median sensitivity: 0.96 (range: 0.72-1.00); median specificity: 0.36 (0.14-0.86) in our validation. Horton's SF-MoCA (delayed recall, serial subtraction, and orientation) had the most favorable properties in stroke (sensitivity: 0.90, specificity: 0.87, positive predictive value [PPV]: 0.55, and negative predictive value [NPV]: 0.93), whereas Cecato's "MoCA reduced" (clock draw, animal naming, delayed recall, and orientation) performed better in the memory clinic (sensitivity: 0.72, specificity: 0.86, PPV: 0.55, and NPV: 0.93).

CONCLUSIONS

There are many published SF-MoCAs. Clinicians and researchers using a SF-MoCA should be explicit about the content. For all SF-MoCA, sensitivity is high and similar to the full scale suggesting potential utility as an initial cognitive screening tool. However, choice of SF-MoCA should be informed by the clinical population to be studied.

Neuronal clusterin expression is associated with cognitive protection in amyotrophic lateral sclerosis

AIMS

Clusterin is a topologically dynamic chaperone protein with the ability to participate in both intra- and extacellular proteostasis. Clusterin has been shown to be upregulated in the spinal cord of patients with amyotrophic lateral sclerosis (ALS) and has been shown to protect against TDP-43 protein misfolding in animal and cell models. Previous studies have demonstrated an association between the pathological burden of TDP-43 misfolding and cognitive deficits in ALS, demonstrating high specificity, but correspondingly low sensitivity owing to a subset of individuals with no evidence of cognitive deficits despite a high burden of TDP-43 pathology, called mismatch cases.

METHODS

Hypothesizing that differences in the ability to cope with protein misfolding in these cases may be due to differences in expression of protective mechanisms such as clusterin expression, we assessed the spatial expression of clusterin and another chaperone protein, HspB8, in post mortem brain tissue of mismatch cases. We employed a modified in situ hybridization technique called BaseScope, with single cell, single transcript resolution.

RESULTS

Mismatch cases demonstrated differential spatial expression of clusterin, with a predominantly neuronal pattern, compared to cases with cognitive manifestations of their TDP-43 pathology who demonstrated a predominantly glial distribution of expression.

CONCLUSIONS

Our data suggest that, in individuals with TDP-43 pathology, predominantly neuronal expression of clusterin in extra-motor brain regions may indicate a cell protective mechanism delaying clinical manifestations such as cognitive dysfunction.

Who Is Classified as Untestable on Brief Cognitive Screens in an Acute Stroke Setting?

Full completion of cognitive screening tests can be problematic in the context of a stroke. Our aim was to examine the completion of various brief cognitive screens and explore reasons for untestability. Data were collected from consecutive stroke admissions (May 2016–August 2018). The cognitive assessment was attempted during the first week of admission. Patients were classified as partially untestable (≥1 test item was incomplete) and fully untestable (where assessment was not attempted, and/or no questions answered). We assessed univariate and multivariate associations of test completion with: age (years), sex, stroke severity (National Institutes of Health Stroke Scale (NIHSS)), stroke classification, pre-morbid disability (modified Rankin Scale (mRS)), previous stroke and previous dementia diagnosis. Of 703 patients admitted (mean age: 69.4), 119 (17%) were classified as fully untestable and 58 (8%) were partially untestable. The 4A-test had 100% completion and the clock-draw task had the lowest completion (533/703, 76%). Independent associations with fully untestable status had a higher NIHSS score (odds ratio (OR): 1.18, 95% CI: 1.11–1.26), higher pre-morbid mRS (OR: 1.28, 95% CI: 1.02–1.60) and pre-stroke dementia (OR: 3.35, 95% CI: 1.53–7.32). Overall, a quarter of patients were classified as untestable on the cognitive assessment, with test incompletion related to stroke and non-stroke factors. Clinicians and researchers would benefit from guidance on how to make the best use of incomplete test data.

The prevalence of frailty among acute stroke patients, and evaluation of method of assessment

Objective:

We aimed to determine prevalence of pre-stroke frailty in acute stroke and describe validity of a Frailty Index–based assessment.

Design:

Cross-sectional.

Setting:

Single UK urban teaching hospital.

Subjects:

Consecutive acute stroke unit admissions, recruited in four waves (May 2016–August 2018). We performed the assessments within first week and attempted to include all admissions.

Main measures:

Our primary measure was a Frailty Index, based on cumulative disorders. A proportion of participants were also assessed with the ‘Frail non-disabled’ questionnaire. We evaluated concurrent validity of Frailty Index against variables associated with frailty in non-stroke populations. We described predictive validity of Frailty Index for stroke severity and delirium. We described convergent validity, quantifying agreement between frailty assessments and a measure of pre-stroke disability (modified Rankin Scale) using kappa statistics and correlations.

Results:

We included 546 patients. A Frailty Index–defined frailty syndrome was observed in 427 of 545 patients (78%), of whom, 151 (28%) had frank frailty and 276 (51%) were pre-frail. Phenotypic frailty was observed in 72 of 258 patients (28%). We demonstrated concurrent validity via significant associations with all variables (all p < 0.01). We demonstrated predictive validity for stroke severity and delirium ( p < 0.01). Agreement between the frailty measures was poor (kappa = –0.06) and convergent validity was moderate (Frail non-disabled ‘Cramer’s V’ = 0.25; modified Rankin Scale ‘Cramer’s V’ = 0.47).

Conclusion:

Frailty is present in around one in four patients with acute stroke; if pre-frailty is included, then a frailty syndrome is seen in three out of four patients. The Frailty Index is a valid measure of frailty in stroke; however, there is little agreement between this scale and other measurements of frailty.

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

The creative turn in evidence for public health: community and arts-based methodologies

Background

We propose that arts based methodologies can be of value in the production and exchange of evidence in supporting public health related policy. This article reports on a collaborative piece of work resulting from two projects which took place in a former coal mining town in South Wales.

Methods

We used a participatory framework whereby researchers, community members and artists co-produced 'evidence' through the creative arts to inform public policy. We collected a range of data using a number of different techniques, including interviews, focus groups and observation, but also included an extensive range of creative activities.

Results

The data provided a diverse range of perspectives on how people of different ages live their lives. The People's Platform was a performance-based debate which was the culmination of the collaboration. The show involved a series of short performances with time for facilitated discussion in-between. It was felt that the show facilitated knowledge exchange on health and wellbeing issues that are usually difficult to express and understand through traditional forms of evidence.

Conclusion

Whilst arts-based approaches are not free from risk, they offer an alternative form of knowledge as a necessary complement to the range of data available to policy makers.

Serological survey of Australian native reptiles for exposure to ranavirus

Ranaviruses have been isolated from many ectothermic vertebrates, and serological surveys of both amphibians and reptiles have shown the presence of ranaviral antibodies in a proportion of these populations. An enzyme-linked immunosorbent assay (ELISA) was developed to measure serum antibodies against ranavirus in Australian reptiles. The ELISA was validated with serum from challenge trials with Bohle iridovirus (BIV) in 6 reptilian species. A preliminary sero-survey of northern Queensland riparian reptile fauna (saw-shelled turtles Myuchelys latisternum, Krefft's river turtles Emydura macquarii krefftii, freshwater crocodiles Crocodylus johnstoni, as well as the snakes Boiga irregularis, Dendrelaphis punctulatus, Tropidonophis mairii, Morelia spilota, Liasis childreni and L. fuscus) revealed evidence of past exposure to Bohle iridoviral antigens in part of the population at several locations sampled. Furthermore, in Krefft's river turtles and freshwater crocodiles, a statistically significant trend was apparent for larger reptiles to be more likely to have BIV-reactive sera than smaller individuals. The use of adult tortoise populations as sentinels can assist in monitoring the presence of BIV in northern Australian freshwater streams, and thereby the potential dangers to native fauna from this agent.

An unusual mortality event in Johnstone River snapping turtles Elseya irwini (Johnstone) in Far North Queensland, Australia

BACKGROUND

An unusual mortality event in Johnstone River snapping turtles (Elseya irwini) in Far North Queensland, Australia, occurred during the summer months of December 2014 and January 2015. We report the data collected during the mortality event, including counts of sick and dead animals, clinical appearance and one necropsy.

OUTBREAK DESCRIPTION

Moribund animals appeared lethargic with variable degrees of necrotising dermatitis. Postmortem investigation of one freshly dead animal revealed bacterial and fungal involvement in the skin lesions as well as multifocal fibrinous hepatitis and splenitis and necrotising enteritis with vascular thrombosis. Aeromonas hydrophila was isolated from liver, spleen and skin lesions. All samples tested negative for ranavirus, and water and soil testing for environmental contaminants were negative. All affected E. irwini either died or were euthanased and no other species of animals in the river were affected.

CONCLUSION

Aeromonas hydrophila is ubiquitous in the freshwater environment and although it caused septicaemia in the one individual that was submitted for laboratory diagnosis, the primary aetiology of the outbreak may not have been identified.

The role of specialized pro-resolving mediators in maternal-fetal health

Infants developing in a pro-inflammatory intrauterine environment have a significant risk for severe complications after birth. It has been shown that omega-3 fatty acids reduce inflammation, and also reduce early preterm births and decrease risk of infant admission to the neonatal intensive care unit. However, the mechanism for omega-3 fatty acids exerting these effects was previously unknown. Recent evidence has shown that downstream products of polyunsaturated fatty acids called specialized pro-resolving mediators may mediate inflammatory physiology, thus playing an important role in maternal-fetal health. In this review, current knowledge relating to specialized pro-resolving mediators in pregnancy, delivery, and perinatal disease states will be summarized.

Chemotherapy for advanced non-pancreatic well-differentiated neuroendocrine tumours of the gastrointestinal tract, a systematic review and meta-analysis: A lost cause?

BACKGROUND

Chemotherapy is well-established in the treatment of patients with well-differentiated neuroendocrine tumours (NETs) arising from the pancreas (pNETs); however, its role in patients with gastrointestinal non-pancreatic NETs (non-pNETs) is uncertain. This systematic review assesses the evidence for the role of chemotherapy in well-differentiated non-pNET patients.

METHODS

Eligible studies (identified using MEDLINE) were those reporting response and/or survival data for patients with well-differentiated non-pNETs receiving systemic chemotherapy. The primary end-point was overall-response (OR) rate; secondary end-points were progression-free survival (PFS), overall survival (OS), disease-stabilization (DS) and disease-control (DC) rates.

RESULTS

Of 6434 studies screened, 20 were eligible: one randomised phase III trial, 2 randomised phase II studies, 10 single-arm phase II trials and 7 retrospective analyses including a total of 264 patients (median of 11 patients per study, range 6-49); and employing multiple chemotherapy schedules. The mean "median PFS" and "median OS" were 16.9 months (95%-confidence interval (CI) 3.8-30.04) and 32.2 months (95%-CI 10.4-54.2), respectively. The non-weighted mean OR, DS and DC rates were 11.5% (95%-CI 5.8-17.2), 56.5% (95%-CI 38.1-74.9) and 70.7% (95%-CI 54.9-86.5), respectively. In studies including both pNETs and non-pNET patients, meta-analysis showed a lower OR-rate in the non-pNET patients when compared to pNETs [odds ratio (OR) 0.35 (95% CI 0.18-0.66)]; however significance was lost when high-risk bias studies were excluded in a sensitivity analysis [OR 0.45 (95% CI 0.19-1.07); p-value 0.07].

CONCLUSION

Studies were of evidence level-C with heterogeneous populations and treatments; and small patient numbers. Well-designed, prospective studies are needed to adequately evaluate the role of chemotherapy in this setting.

Factors affecting treatment outcomes in drug-resistant tuberculosis cases in the Northern Cape, South Africa

The Northern Cape Province has low cure rates (21%) for multidrug-resistant tuberculosis (TB). We audited the programme to identify factors affecting treatment outcomes. Cases admitted to two drug-resistant TB units from 2007 to 2009 had data extracted from clinical folders. Unfavourable treatment outcomes were found in 58% of the 272 cases. A multivariable regression analysis found that male sex was associated with unfavourable outcome (P = 0.009). Weight at diagnosis (P < 0.001) and oral drug adherence (P < 0.001) were also associated with an unfavourable outcome; however, injectable drug adherence was not (P = 0.395). Positive baseline smear and human immunodeficiency virus positive status were not associated with unfavourable outcome. Shorter, more patient-friendly regimens may go a long way to improving adherence and outcomes.