Computerized cognitive training for memory functions in mild cognitive impairment or dementia: a systematic review and meta-analysis

Dementia is a common medical condition in the ageing population, and cognitive intervention is a non-pharmacologic strategy to improve cognitive functions. This meta-analysis evaluated the benefits of computerized cognitive training (CCT) on memory functions in individuals with MCI or dementia. The study was registered prospectively with PROSPERO under CRD42022363715 and received no funding. The search was conducted on MEDLINE, Embase, and PsycINFO on Sept 19, 2022, and Google Scholar on May 9, 2023, to identify randomized controlled trials that examined the effects of CCT on memory outcomes in individuals with MCI or dementia. Mean differences and standard deviations of neuropsychological assessment scores were extracted to derive standardized mean differences. Our search identified 10,678 studies, of which 35 studies were included. Among 1489 participants with MCI, CCT showed improvements in verbal memory (SMD (95%CI) = 0.55 (0.35-0.74)), visual memory (0.36 (0.12-0.60)), and working memory (0.37 (0.10-0.64)). Supervised CCT showed improvements in verbal memory (0.72 (0.45-0.98)), visual memory (0.51 (0.22-0.79)), and working memory (0.33 (0.01-0.66)). Unsupervised CCT showed improvement in verbal memory (0.21 (0.04-0.38)) only. Among 371 participants with dementia, CCT showed improvement in verbal memory (0.64 (0.02-1.27)) only. Inconsistency due to heterogeneity (as indicated by I2 values) is observed, which reduces our confidence in MCI outcomes to a moderate level and dementia outcomes to a low level. The results suggest that CCT is efficacious on various memory domains in individuals with MCI. Although the supervised approach showed greater effects, the unsupervised approach can improve verbal memory while allowing users to receive CCT at home without engaging as many healthcare resources.

Use of probiotics, prebiotics, and synbiotics in non-alcoholic fatty liver disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Patients with non-alcoholic fatty liver disease (NAFLD) exhibit compositional changes in their gut microbiome, which represents a potential therapeutic target. Probiotics, prebiotics, and synbiotics are microbiome-targeted therapies that have been proposed as treatment for NAFLD. We aim to systematically review the effects of these therapies in liver-related outcomes of NAFLD patients.

METHODS

We conducted a systematic search in Embase (Ovid), Medline (Ovid), Scopus, Cochrane, and EBSCOhost from inception to August 19, 2022. We included randomized controlled trials (RCTs) that treated NAFLD patients with prebiotics and/or probiotics. We meta-analyzed the outcomes using standardized mean difference (SMD) and assessed study heterogeneity using Cochran's Q test and I2 statistics. Risk of bias was assessed using the Cochrane Risk-of-Bias 2 tool.

RESULTS

A total of 41 (18 probiotics, 17 synbiotics, and 6 prebiotics) RCTs were included. Pooled data demonstrated that the intervention had significantly improved liver steatosis (measured by ultrasound grading) (SMD: 4.87; 95% confidence interval [CI]: 3.27, 7.25), fibrosis (SMD: -0.61 kPa; 95% CI: -1.12, -0.09 kPa), and liver enzymes including alanine transaminase (SMD: -0.86 U/L; 95% CI: -1.16, -0.56 U/L), aspartate transaminase (SMD: -0.87 U/L; 95% CI: -1.22, -0.52 U/L), and gamma-glutamyl transferase (SMD: -0.77 U/L; 95% CI: -1.26, -0.29 U/L).

CONCLUSIONS

Microbiome-targeted therapies were associated with significant improvements in liver-related outcomes in NAFLD patients. Nevertheless, limitations in existing literature like heterogeneity in probiotic strains, dosage, and formulation undermine our findings. This study was registered with PROSPERO (CRD42022354562) and supported by the Nanyang Technological University Start-up Grant and Wang Lee Wah Memorial Fund.

Post-Traumatic Stress Disorder after Subarachnoid Hemorrhage: A Systematic Review

Background

Post-traumatic stress disorder (PTSD) frequently follows neurological disorders such as non-traumatic subarachnoid hemorrhage (SAH) and has debilitating consequences.

Objective

The aim of this systematic review was the critical appraisal of the literature on the frequency, severity, and temporal progression of PTSD in patients with SAH, the etiology of PTSD, and its effect on patients' quality of life (QoL).

Material and Methods

Studies were obtained from three databases: PubMed EMBASE, PsycINFO, and Ovid Nursing. The inclusion criteria were English-language studies on adults (defined as at least 18 years of age) in which ≥10 of the participants received a diagnosis of PTSD following SAH. Applying these criteria, 17 studies (N = 1,381) were included.

Results

Between 1% and 74% of the participants in each study had PTSD, with a weighted average of 36.6% across all studies. Post-SAH PTSD showed significant correlations with premorbid psychiatric disorders, neuroticism, and maladaptive coping styles. The risk of PTSD was also higher in participants with comorbid depression and anxiety. Stress related to post-ictal events and fear of recurrence were associated with PTSD. However, the risk of PTSD was lower in participants with effective social support networks. The participants' QoL was negatively affected by PTSD.

Conclusions

This review highlights the high occurrence of PTSD in SAH patients. The temporal progression and chronicity of post-SAH PTSD warrant further research, as do its neuroanatomical and neurochemical correlates. We call for more randomized controlled trials investigating these aspects.

Time series models show comparable projection performance with joinpoint regression: A comparison using historical cancer data from World Health Organization

Background

Cancer is one of the major causes of death and the projection of cancer incidences is essential for future healthcare resources planning. Joinpoint regression and average annual percentage change (AAPC) are common approaches for cancer projection, while time series models, traditional ways of trend analysis in statistics, were considered less popular. This study aims to compare these projection methods on seven types of cancers in 31 geographical jurisdictions.

Methods

Using data from 66 cancer registries in the World Health Organization, projection models by joinpoint regression, AAPC, and autoregressive integrated moving average with exogenous variables (ARIMAX) were constructed based on 20 years of cancer incidences. The rest of the data upon 20-years of record were used to validate the primary outcomes, namely, 3, 5, and 10-year projections. Weighted averages of mean-square-errors and of percentage errors on predictions were used to quantify the accuracy of the projection results.

Results

Among 66 jurisdictions and seven selected cancers, ARIMAX gave the best 5 and 10-year projections for most of the scenarios. When the ten-year projection was concerned, ARIMAX resulted in a mean-square-error (or percentage error) of 2.7% (or 7.2%), compared with 3.3% (or 15.2%) by joinpoint regression and 7.8% (or 15.0%) by AAPC. All the three methods were unable to give reasonable projections for prostate cancer incidence in the US.

Conclusion

ARIMAX outperformed the joinpoint regression and AAPC approaches by showing promising accuracy and robustness in projecting cancer incidence rates. In the future, developments in projection models and better applications could promise to improve our ability to understand the trend of disease development, design the intervention strategies, and build proactive public health system.

The genetic architecture of blood pressure variability: A genome-wide association study of 9370 participants from UK Biobank

Long-term blood pressure variability (BPV) is a risk factor for cardiovascular diseases, dementia, and stroke. However, its genetic architecture is not fully understood. This study aims to explore its genetic factors and provide more evidence on the mechanisms and further pathological study of BPV. The genome-wide association study (GWAS) is based on the UK Biobank cohort. There were four data collection rounds from 2006 to 2020, and 9370 participants with more than three blood pressure measurements were included. They had a median age of 55 and a male percentage of 50.1%. The phenotypes (BPV) were calculated by four methods and the genetic data contains 6 884 260 single nucleotide polymorphisms (SNPs) after imputation and quality control. A linear regression model was performed with adjustments for sex, age, genotype array, and a significant principal component. Subgroup analysis was performed on hypertension-free participants. The significant and suggestive significant P thresholds were set as 5 × 10-8 and 1 × 10-6 . Six genetic loci (BAD, CCDC88B, GPR137, PLCB3, RPS6KA4 for systolic BPV, and WWC2 for diastolic BPV) were identified by coding region SNPs at the suggestive significant P threshold (1 × 10-6 ). Among them, gene CCDC88B and RPS6KA4 reached the significant P threshold (5 × 10-8 ), with the strongest signal of SNP rs1229536170 (P = 6.36 × 10-8 , β = -.29). The annotation results indicate that genes CCDC88B, GPR137, RPS6KA4, and BAD are associated with long-term SBPV. Their functions of inflammation, epithelial dysfunction, and apoptosis are related to artery stiffness, which was reported as potential mechanisms of BPV.

Risk of self-harm in post TIA patients: A population-based cohort study

OBJECTIVE

The purpose of this study was to determine whether individuals who have experienced a transient ischemic attack (TIA) have an increased risk of self-harm behaviors.

METHODS

In this matched cohort study, we reviewed the electronic health records of all patients admitted for any reason to Hong Kong public hospitals between January 1, 1993, and December 31, 2019. We selected a post-TIA cohort consisting of 37,356 patients and a comparison cohort comprising 37,352 subjects. All participants enrolled in this study were followed up until a diagnosis of self-harm, death from other causes, or the end of 2020, whichever occurred first. Univariate Cox proportional hazards regression models were used to calculate the risk of self-harm since the onset of TIA.

RESULTS

Throughout the 27-year study period, the number of individuals exhibiting self-harm behavior in the TIA and comparison groups was 1031 (2.76%) and 512 (1.37%), respectively. The TIA group had a higher proportion of subjects with self-harm (χ² = 178, p < .001). The incidence rates of self-harm were 33.94 and 19.27 per 10,000 person-years in TIA patients and comparators, respectively. Compared with the comparators, the adjusted hazard ratio for self-harm in TIA patients was 1.63 (95% confidence interval, 1.46-1.82).

CONCLUSIONS

TIA is associated with an increased risk of self-harm. Healthcare professionals should help identify patients at heightened risk and provide efficient and targeted prevention strategies for this population.

Comparing drawing under instructions with image copying for mild cognitive impairment (MCI) or dementia screening: a meta-analysis of 92 diagnostic studies

OBJECTIVES

Drawing is a major component of cognitive screening for dementia. It can be performed without language restriction. Drawing pictures under instructions and copying images are different screening approaches. The objective of this study was to compare the diagnostic performance between drawing under instructions and image copying for MCI and dementia screening.

METHOD

A literature search was carried out in the OVID databases with keywords related to drawing for cognitive screening. Study quality and risk of bias were assessed by QUADAS-2. The level of diagnostic accuracy across different drawing tests was pooled by bivariate analysis in a random effects model. The area under the hierarchical summary receiver-operating characteristic curve (AUC) was constructed to summarize the diagnostic performance.

RESULTS

Ninety-two studies with sample size of 22,085 were included. The pooled results for drawing under instructions showed a sensitivity of 79% (95% CI: 76 - 83%) and a specificity of 80% (95% CI: 77 - 83%) with AUC of 0.87 (95% CI: 0.83 - 0.89). The pooled results for image copying showed a sensitivity of 71% (95% CI: 62 - 79%) and a specificity of 83% (95% CI: 72 - 90%) with AUC of 0.83 (95% CI: 0.80 - 0.86). Clock-drawing test was the screening test used in the majority of studies.

CONCLUSION

Drawing under instructions showed a similar diagnostic performance when compared with image copying for cognitive screening and the administration of image copying is relatively simpler. Self-screening for dementia is feasible to be done at home in the near future.

Personality changes after subarachnoid hemorrhage: A systematic review and meta-analysis

OBJECTIVE

Personality changes (PC) comprise a common and debilitating illness that accompanies many neurological disorders, including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity, and time course of PC after SAH, the factors associated with the development of PC and the effects of PC on patients' lives after SAH.

METHODS

We searched the PubMed, EMBASE, PsycINFO, and Ovid Nursing databases for studies published in English that recruited at least 10 patients (>18 years old) after SAH who were also diagnosed with PC.

RESULTS

We found eight studies involving 1227 patients met the study entry criteria. The frequency of PC ranged from 32% to 59%, with a pooled frequency of 44%. The clinical course of PC after SAH was unclear. PC after SAH may be associated with the clinical features and treatment factors related to SAH and comorbid conditions. Neurological signs, disability and surgical treatment increased the risk of PC. PC reduced the study participants' chance of employment.

CONCLUSION

In summary, PC commonly occurs after SAH. Further research is needed to clarify the time course of PC and identify the risk factors, neurochemical factors, and brain circuits associated with the development of post-SAH PC. Randomized controlled treatment trials targeting SAH-related PC are warranted.

Cost-effectiveness of pharmacological therapies for people with Alzheimer's disease and other dementias: a systematic review and meta-analysis

Objectives

This study aims to synthesize the empirical economic evidence of pharmaceutical therapies for people with dementia.

Study design

Systematic review and meta-analysis. Literature evaluating the costs and effects of drug therapies for dementia was indexed until December 2021. Quality of study was assessed using the Cochrane Risk of Bias Tool and Consensus on Health Economic Criteria list. Cost data were standardized to 2020 US dollars and analyzed from healthcare service and societal perspectives. Random-effects models were used to synthesize economic and clinical data, based on mean differences (MDs) and standardized MDs.

Results

Ten unique studies were identified from 11,771 records. Acetylcholinesterase inhibitors (AChEIs) and memantine improved dementia-related symptoms, alongside nonsignificant savings in societal cost (AChEIs: MD-2002 [− 4944 ~ 939]; memantine: MD-6322 [− 14355 ~ 1711]). Despite decreases in cost, antidepressants of mirtazapine and sertraline and second-generation antipsychotics were limited by their significant side effects on patients’ cognitive and activity functions. Subgroup analysis indicated that the impacts of AChEIs on cost were affected by different analytical perspectives, follow-up periods, and participant age.

Conclusions

AChEIs and memantine are cost-effective with improvements in dementia-related symptoms and trends of cost-savings. More empirical evidence with non-industrial sponsorships and rigorous design in different settings is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00354-3.

Apathy after subarachnoid haemorrhage: A systematic review

BACKGROUND

Apathy is a common and debilitating symptom accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH).

OBJECTIVES

The aim of this systematic review was to identify and critically appraise all published studies that have reported the prevalence, severity, and time course of apathy after SAH, the factors associated with its development, and the impact of apathy on patients' quality of life after SAH.

METHODS

The PubMed, EMBASE, PsycINFO, and Ovid Nursing databases were searched for studies published in English that recruited at least 10 patients (>18 years old) after SAH who were also diagnosed with apathy.

RESULTS

Altogether 10 studies covering 595 patients met the study's inclusion criteria. The prevalence of apathy ranged from 15 to 68%, with a weighted proportion of 38%. The time course of apathy was unknown. Comorbid cognitive impairment increases the risk of apathy. Blood in lateral ventricles and hydrocephalus may also be related to apathy. Apathy reduces participation in leisure and sexual activities. There were several methodological shortcomings in the included studies, namely, heterogeneity in study design and timing of apathy assessment, hospitalized /clinic-based and biased sampling, small sample sizes and some had high attrition rates, and uncertain validity of the measures of apathy.

CONCLUSIONS

Apathy is common after SAH. Further research is needed to clarify its time course and identify the neurochemical factors and brain circuits associated with the development of post-SAH apathy. Randomized controlled treatment trials targeting SAH-related apathy are warranted.

Supporting Informal Caregivers of People With Dementia in Cost-Effective Ways: A Systematic Review and Meta-Analysis

OBJECTIVES

Caring for persons with dementia is a heavy burden for informal caregivers. This study aimed to appraise the economic evidence of interventions supporting informal caregivers of people with dementia.

METHODS

Literature was searched, and trial-based studies evaluating the costs and effects of interventions supporting informal caregivers of people with dementia were included. Cost data were analyzed from both healthcare and societal perspectives. Random-effects models were used to synthesize cost and effect data, based on mean differences (MDs) or standardized MDs.

RESULTS

Of 33 eligible studies identified from 48 588 records, 14 (42.4%) showed net savings in total cost regardless of analytical perspectives. Among 22 studies included in meta-analyses, caregiver-focused psychosocial interventions showed improvements in caregivers' psychological health (n = 4; standardized MD 0.240; 95% confidence interval 0.094-0.387); nevertheless, the increases in societal cost were significant (n = 5; MD 3144; 95% confidence interval 922-5366). Psychological intervention and behavioral management engaging patient-caregiver dyads showed positive effects on caregivers' subjective burden, also with increases in total cost. Subgroup analyses indicated that the inclusion of different intervention components, the caregiver characteristics, and the follow-up periods could affect the costs and effects of interventions supporting informal caregivers.

CONCLUSIONS

Psychosocial interventions directed at informal caregivers and dyad-based psychological and behavioral interventions are effective but also expensive. The use of these interventions depends on the society's willingness to pay. More comprehensive economic evidence of interventions supporting informal caregivers is required, and the design of intervention should focus more on different intervention components, characteristics of patients and caregivers, and healthcare systems.

Antihypertensive treatments and risks of lung Cancer: a large population-based cohort study in Hong Kong

BACKGROUND

There is a growing concern that the use of anti-hypertensives may be associated with an increased risk of cancer, but it remains uncertain for the association between anti-hypertensives and lung cancer risk, as well as their interaction with aspirin in chemoprotective effects.

METHODS

The goal of this study is to assess the association between anti-hypertensives use and the risk of lung cancer, as well as the chemopreventive impacts from the combination usage of aspirin and anti-hypertensives. A retrospective cohort study was conducted based on all the public hospital electronic medical records in Hong Kong. Patients with prescription records of anti-hypertensives (ACEi/ARB, CCB, β-blocker,α-blocker) and/or aspirin were included as the exposure groups. Using the Cox proportional hazards model with inverse probability weighting, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for lung cancer risk from anti-hypertensives usage or combination usage of aspirin with anti-hypertensives. The likelihood ratio test and interaction model were adopted for exploring the interaction effects with aspirin.

RESULTS

A total of 6592 and 84,116 lung cancer cases were identified from the groups of anti-hypertensives users and anti-hypertensives users with aspirin, respectively. The group of non-aspirin patients who received anti-hypertensives showed a significantly lower risk of lung cancer (HR: 0.63, 95% CI: 0.60-0.66), compared to those without anti-hypertensives. When aspirin and α-blocker were used simultaneously, it could lower the risk of lung cancer significantly (HR: 0.53, 95% CI: 0.34-0.84). Moreover, the lower risk of lung cancer persisted with a longer follow-up period of anti-hypertensives usage. Combination usage with aspirin in the users of ACEi/ARB, CCB, and α-blocker showed significant interaction effects. However, the smoking effect could not be eliminated in this analysis.

DISCUSSION

Anti-hypertensive treatment was associated with a lower risk of lung cancer, which is associated with the anti-hypertensives exposure period. The potential interaction on the chemopreventive influence from combination usage of α-blocker and aspirin might exist. More corroborations on these findings are needed to focus on the different settings in future studies.

Evaluation of Digital Drawing Tests and Paper-and-Pencil Drawing Tests for the Screening of Mild Cognitive Impairment and Dementia: A Systematic Review and Meta-analysis of Diagnostic Studies

Digital drawing tests have been proposed for cognitive screening over the past decade. However, the diagnostic performance is still to clarify. The objective of this study was to evaluate the diagnostic performance among different types of digital and paper-and-pencil drawing tests in the screening of mild cognitive impairment (MCI) and dementia. Diagnostic studies evaluating digital or paper-and-pencil drawing tests for the screening of MCI or dementia were identified from OVID databases, included Embase, MEDLINE, CINAHL, and PsycINFO. Studies evaluated any type of drawing tests for the screening of MCI or dementia and compared with healthy controls. This study was performed according to PRISMA and the guidelines proposed by the Cochrane Diagnostic Test Accuracy Working Group. A bivariate random-effects model was used to compare the diagnostic performance of these drawing tests and presented with a summary receiver-operating characteristic curve. The primary outcome was the diagnostic performance of clock drawing test (CDT). Other types of drawing tests were the secondary outcomes. A total of 90 studies with 22,567 participants were included. In the screening of MCI, the pooled sensitivity and specificity of the digital CDT was 0.86 (95% CI = 0.75 to 0.92) and 0.92 (95% CI = 0.69 to 0.98), respectively. For the paper-and-pencil CDT, the pooled sensitivity and specificity of brief scoring method was 0.63 (95% CI = 0.49 to 0.75) and 0.77 (95% CI = 0.68 to 0.84), and detailed scoring method was 0.63 (95% CI = 0.56 to 0.71) and 0.72 (95% CI = 0.65 to 0.78). In the screening of dementia, the pooled sensitivity and specificity of the digital CDT was 0.83 (95% CI = 0.72 to 0.90) and 0.87 (95% CI = 0.79 to 0.92). The performances of the digital and paper-and-pencil pentagon drawing tests were comparable in the screening of dementia. The digital CDT demonstrated better diagnostic performance than paper-and-pencil CDT for MCI. Other types of digital drawing tests showed comparable performance with paper-and-pencil formats. Therefore, digital drawing tests can be used as an alternative tool for the screening of MCI and dementia.

Long-Term Blood Pressure Variability Increases Risks of Dementia and Cognitive Decline: A Meta-Analysis of Longitudinal Studies

[Figure: see text].

Diagnostic accuracy of dementia screening tools in the Chinese population: a systematic review and meta-analysis of 167 diagnostic studies

BACKGROUND

The rate of undetected dementia is high in China. However, the performance of dementia screening tools may differ in the Chinese population due to the lower education level and cultural diversity. This study aimed to evaluate the diagnostic accuracy of dementia screening tools in the Chinese population.

METHODS

Eleven electronic databases were searched for studies evaluating the diagnostic accuracy of dementia screening tools in older Chinese adults. The overall diagnostic accuracy was estimated using bivariate random-effects models, and the area under the summary receiver operating characteristic curve was presented.

RESULTS

One hundred sixty-seven studies including 81 screening tools were identified. Only 134 studies qualified for the meta-analysis. The Mini-Mental State Examination (MMSE) was the most commonly studied tool, with a combined sensitivity (SENS) and specificity (SPEC) of 0.87 (95%CI 0.85-0.90) and 0.89 (95%CI 0.86-0.91), respectively. The Addenbrooke's Cognitive Examination-Revised (ACE-R) (SENS: 0.96, 95%CI 0.89-0.99; SPEC: 0.96, 95%CI 0.89-0.98) and Montreal Cognitive Assessment (MoCA) (SENS: 0.93, 95%CI 0.88-0.96; SPEC: 0.90, 95%CI 0.86-0.93) showed the highest performance. The General Practitioner Assessment of Cognition (GPCOG), Hasegawa's Dementia Scale and Cognitive Abilities Screening Instrument had performances comparable to that of the MMSE. The cut-off scores ranged widely across studies, especially for the MMSE (range: 15-27) and MoCA (range: 14-26).

CONCLUSIONS

A number of dementia screening tools were validated in the Chinese population after cultural and linguistical adaptations. The ACE-R and MoCA had the best diagnostic accuracy, whereas the GPCOG, with an administration time < 5 minutes, could be considered as a rapid screening tool.

Electronic Cognitive Screen Technology for Screening Older Adults With Dementia and Mild Cognitive Impairment in a Community Setting: Development and Validation Study

BACKGROUND

A digital cognitive test can be a useful and quick tool for the screening of cognitive impairment. Previous studies have shown that the diagnostic performance of digital cognitive tests is comparable with that of conventional paper-and-pencil tests. However, the use of commercially available digital cognitive tests is not common in Hong Kong, which may be due to the high cost of the tests and the language barrier. Thus, we developed a brief and user-friendly digital cognitive test called the Electronic Cognitive Screen (EC-Screen) for the detection of mild cognitive impairment (MCI) and dementia of older adults.

OBJECTIVE

The aim of this study was to evaluate the performance of the EC-Screen for the detection of MCI and dementia in older adults.

METHODS

The EC-Screen is a brief digital cognitive test that has been adapted from the Rapid Cognitive Screen test. The EC-Screen uses a cloud-based platform and runs on a tablet. Participants with MCI, dementia, and cognitively healthy controls were recruited from research clinics and the community. The outcomes were the performance of the EC-Screen in distinguishing participants with MCI and dementia from controls, and in distinguishing participants with dementia from those with MCI and controls. The cohort was randomly split into derivation and validation cohorts based on the participants' disease group. In the derivation cohort, the regression-derived score of the EC-Screen was calculated using binomial logistic regression. Two predictive models were produced. The first model was used to distinguish participants with MCI and dementia from controls, and the second model was used to distinguish participants with dementia from those with MCI and controls. Receiver operating characteristic curves were constructed and the areas under the curves (AUCs) were calculated. The performances of the two predictive models were tested using the validation cohorts. The relationship between the EC-Screen and paper-and-pencil Montreal Cognitive Assessment-Hong Kong version (HK-MoCA) was evaluated by the Pearson correlation coefficient.

RESULTS

A total of 126 controls, 54 participants with MCI, and 63 participants with dementia were included in the study. In differentiating participants with MCI and dementia from controls, the AUC of the EC-Screen in the derivation and validation cohorts was 0.87 and 0.84, respectively. The optimal sensitivity and specificity in the derivation cohorts were 0.81 and 0.80, respectively. In differentiating participants with dementia from those with MCI and controls, the AUC of the derivation and validation cohorts was 0.90 and 0.88, respectively. The optimal sensitivity and specificity in the derivation cohort were 0.83 and 0.83, respectively. There was a significant correlation between the EC-Screen and HK-MoCA (r=-0.67, P<.001).

CONCLUSIONS

The EC-Screen is suggested to be a promising tool for the detection of MCI and dementia. This test can be self-administered or assisted by a nonprofessional staff or family member. Therefore, the EC-Screen can be a useful tool for case finding in primary health care and community settings.

Cognitive training interventions and depression in mild cognitive impairment and dementia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Depression is common in people with cognitive impairment but the effect of cognitive training in the reduction of depression is still uncertain.

AIMS

The purpose of this paper is to evaluate the effect of cognitive training interventions in the reduction of depression rating scale score in people with cognitive impairment.

METHODS

Literature searches were conducted via OVID databases. Randomized controlled trials (RCTs) evaluated the effect of cognitive training interventions for the reduction of depression rating scale score in people with mild cognitive impairment (MCI) or dementia were included. Mean difference (MD) with 95% confidence interval (CI) was used to combine the results of Geriatric Depression Scale (GDS). Standardized mean difference (SMD) was used to combine the results of different depression rating scales. Subgroup analyses were conducted according to the types of cognitive training and severity of cognitive impairment, i.e. MCI and dementia.

RESULTS

A total of 2551 people with MCI or dementia were extracted from 36 RCTs. The baseline mean score of GDS-15 was 4.83. Participants received cognitive training interventions had a significant decrease in depression rating scale score than the control group (MD of GDS-15 = -1.30, 95% CI = -2.14--0.47; and SMD of eight depression scales was -0.54 (95% CI = -0.77--0.31). In subgroup analyses, the effect size of computerized cognitive training and cognitive stimulation therapy were medium-to-large and statistically significant in the reduction of depression rating scale score.

CONCLUSIONS

Cognitive training interventions show to be a potential treatment to ameliorate depression in people with cognitive impairment.

Effects of virtual reality on moods in community older adults. A multicenter randomized controlled trial

INTRODUCTION

Virtual reality (VR) technology is a potential method to use in cognitive intervention, but the use of VR in cognitive stimulation intervention for older adults has not been investigated. Therefore, the aim of this study was to investigate the mood change of older adults after participating in the VR cognitive stimulation activity.

METHODS

This is a multicenter randomized controlled, cross-over trial. The intervention was a VR cognitive stimulation activity, and the control was a paper-and-pencil activity. The participants were older adults with age over 60 and recruited in the elderly community centers. The Positive and Negative Affect Score (PANAS) was used to measure mood change. Mean difference (MD) with 95% confidence interval (95% CI) was calculated. The Simulator sickness questionnaire was used to measure adverse events.

RESULTS

A total of 236 participants from 19 community centers were recruited. After the VR activity, the participants had a significant increase in total PANAS positive affect score (MD = 2.09, 95% CI = 0.69 to 3.49), and a significant reduction in total negative affect score (MD = -1.99, 95% CI = -2.55 to -1.43). The reduction in negative affect score was significantly larger in VR activity than paper-and-pencil activity (MD = -0.48, 95% CI = -0.98 to 0.00). Besides, only three participants reported severe advance events after VR activity.

CONCLUSIONS

The use of VR technology is well accepted by older adults. Therefore, the use of VR technology through smartphone and a mobile app can be a potential method for future cognitive training interventions.

Machine Learning Clustering for Blood Pressure Variability Applied to Systolic Blood Pressure Intervention Trial (SPRINT) and the Hong Kong Community Cohort

Visit-to-visit blood pressure variability (BPV) has been shown to be a predictor of cardiovascular disease. We aimed to classify the BPV levels using different machine learning algorithms. Visit-to-visit blood pressure readings were extracted from the SPRINT study in the United States and eHealth cohort in Hong Kong (HK cohort). Patients were clustered into low, medium, and high BPV levels with the traditional quantile clustering and 5 machine learning algorithms including K-means. Clustering methods were assessed by Stability Index. Similarities were assessed by Davies-Bouldin Index and Silhouette Index. Cox proportional hazard regression models were fitted to compare the risk of myocardial infarction, stroke, and heart failure. A total of 8133 participants had average blood pressure measurement 14.7 times in 3.28 years in SPRINT and 1094 participants who had average blood pressure measurement 165.4 times in 1.37 years in HK cohort. Quantile clustering assigned one-third participants as high BPV level, but machine learning methods only assigned 10% to 27%. Quantile clustering is the most stable method (stability index: 0.982 in the SPRINT and 0.948 in the HK cohort) with some levels of clustering similarities (Davies-Bouldin Index: 0.752 and 0.764, respectively). K-means clustering is the most stable across the machine learning algorithms (stability index: 0.975 and 0.911, respectively) with the lowest clustering similarities (Davies-Bouldin Index: 0.653 and 0.680, respectively). One out of 7 in the population was classified with high BPV level, who showed to have higher risk of stroke and heart failure. Machine learning methods can improve BPV classification for better prediction of cardiovascular diseases.

Prediction model for air particulate matter levels in the households of elderly individuals in Hong Kong

Air pollution has shown to cause adverse health effects on mankind. Aging causes functional decline and leaves elderly people more susceptible to health threats associated with air pollution exposure. Elderly spend approximately 80% of their lifetime at home every day. To understand air pollution exposure, indoor air pollutants are the targets for consideration especially for the elderly population. However, indoor air monitoring for epidemiological studies requires a large population, is labor intensive and time consuming. As a result, a prediction model is necessary. For 3 consecutive days in summer and winter, 24-h average of mass concentrations of fine particulate matter (aerodynamic diameter <2.5 μm: PM_2.5) were measured in indoors for 116 households. A PM_2.5 prediction model for elderly households in Hong Kong has been developed by combining ambient PM_2.5 concentrations obtained from land use regression model and questionnaire-elicited information related to the indoor PM_2.5 sources. The fitted linear mixed-effects model is moderately predictive for the observed indoor PM_2.5, with R² = 0.67 (or R² = 0.61 by cross-validation). The model shows indoor PM_2.5 was positively influenced by outdoor PM_2.5 levels. Meteorological factors (e.g. temperature and relative humidity) were related to the indoor PM_2.5 in a relatively complex manner. Congested living areas, opening windows for extended periods for ventilation and use of liquefied petroleum gas for cooking were the factors determining the ultimate indoor air quality. This study aims to provide information about controlling household air quality and can be used for future epidemiological studies associated with indoor air pollution in large population.

An Integrated Approach of Machine Learning and Systems Thinking for Waiting Time Prediction in an Emergency Department

OBJECTIVE

The objective of this study is to apply machine learning algorithms for real-time and personalized waiting time prediction in emergency departments. We also aim to introduce the concept of systems thinking to enhance the performance of the prediction models.

METHODS

Four popular algorithms were applied: (i) stepwise multiple linear regression; (ii) artificial neural networks; (iii) support vector machines; and (iv) gradient boosting machines. A linear regression model served as a baseline model for comparison. We conducted computational experiments based on a dataset collected from an emergency department in Hong Kong. Model diagnostics were performed, and the results were cross-validated.

RESULTS

All the four machine learning algorithms with the use of systems knowledge outperformed the baseline model. The stepwise multiple linear regression reduced the mean-square error by almost 15%. The other three algorithms had similar performances, reducing the mean-square error by approximately 20%. Reductions of 17 - 22% in mean-square error due to the utilization of systems knowledge were observed.

DISCUSSION

The multi-dimensional stochasticity arising from the ED environment imposes a great challenge on waiting time prediction. The introduction of the concept of systems thinking led to significant enhancements of the models, suggesting that interdisciplinary efforts could potentially improve prediction performance.

CONCLUSION

Machine learning algorithms with the utilization of the systems knowledge could significantly improve the performance of waiting time prediction. Waiting time prediction for less urgent patients is more challenging.

Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications.

OBJECTIVE

To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs.

METHODS

Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations.

RESULTS

Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases.

CONCLUSION

NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.

Depression after Subarachnoid Hemorrhage: A Systematic Review

Background and Purpose

Depression is common and debilitating illness accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity and time course of depression after SAH, the factors associated with its development and the impact of depression on patients’ quality of life after SAH.

Methods

The PubMed database was searched for studies published in English that recruited at least 40 patients (>18 years old) after SAH who were also diagnosed with depression.

Results

Altogether 55 studies covering 6,327 patients met study entry criteria. The frequency of depression ranged from 0% to 61.7%, with a weighted proportion of 28.1%. Depression remained common even several years after the index SAH. Depression after SAH was associated with female sex, premorbid depression, anxiety, substance use disorders or any psychiatric disorders, and coping styles. Comorbid cognitive impairment, fatigue, and physical disability also increased the risk of depression. Aneurysmal SAH and infarction may be related to depression as well. Depression reduces the quality of life and life satisfaction in patients after SAH.

Conclusions

Depression is common after SAH and seems to persist. Further research is needed to clarify its time course and identify the neuroendocrine and neurochemical factors and brain circuits associated with the development of post-SAH depression. Randomized controlled treatment trials targeting SAH-related depression are warranted.

Global incidence of prostate cancer in developing and developed countries with changing age structures

To investigate the global incidence of prostate cancer with special attention to the changing age structures. Data regarding the cancer incidence and population statistics were retrieved from the International Agency for Research on Cancer in World Health Organization. Eight developing and developed jurisdictions in Asia and the Western countries were selected for global comparison. Time series were constructed based on the cancer incidence rates from 1988 to 2007. The incidence rate of the population aged ≥ 65 was adjusted by the increasing proportion of elderly population, and was defined as the “aging-adjusted incidence rate”. Cancer incidence and population were then projected to 2030. The aging-adjusted incidence rates of prostate cancer in Asia (Hong Kong, Japan and China) and the developing Western countries (Costa Rica and Croatia) had increased progressively with time. In the developed Western countries (the United States, the United Kingdom and Sweden), we observed initial increases in the aging-adjusted incidence rates of prostate cancer, which then gradually plateaued and even decreased with time. Projections showed that the aging-adjusted incidence rates of prostate cancer in Asia and the developing Western countries were expected to increase in much larger extents than the developed Western countries.

Low-dose aspirin can reduce colorectal cancer mortality after surgery: A 10-year follow-up of 13 528 colorectal cancer patients

BACKGROUND AND AIM

The chemopreventive effect of aspirin in colorectal cancer (CRC) is well studied, but its benefit in patients after CRC diagnosis and surgery is unclear. This study aims to investigate the effects of low-dose aspirin use in mortality among CRC patients after surgery.

METHODS

Patients were analyzed in two cohorts: (i) patients taking aspirin before CRC diagnosis and continued or discontinued aspirin after surgery and (ii) patients, who never used aspirin before CRC diagnosis, received or did not receive aspirin after surgery. CRC-related mortality and all-cause mortality were the primary and secondary outcomes. Sub-distribution hazard ratio (SHR) for competing-risk CRC mortality was fitted to adjust for other causes of death; hazard ratio (HR) was used to compare all-cause mortality.

RESULTS

A total of 13 528 CRC patients were included. Among 3292 patients with regular aspirin use before CRC diagnosis, 2658 (80.7%) continued aspirin and 634 (19.3%) discontinued aspirin after surgery. Continuous use of aspirin significantly reduced CRC-related mortality (SHR: 0.69, 95% confidence interval [CI]: 0.59-0.81) and all-cause mortality (HR: 0.61, 95% CI: 0.55-0.68). Among 10 236 patients who did not use aspirin before CRC diagnosis, 1054 patients (10.3%) received aspirin after surgery and 9182 (89.7%) did not. Aspirin initiated after surgery reduced CRC-related mortality (SHR: 0.88, 95% CI: 0.80-0.98) and all-cause mortality (HR: 0.87, 95% CI: 0.81-0.94).

CONCLUSIONS

Irrespective of aspirin use before surgery for CRC, low-dose aspirin after surgery lowers risk of both CRC-related mortality and overall mortality.

Global Increasing Incidence of Young-Onset Colorectal Cancer Across 5 Continents: A Joinpoint Regression Analysis of 1,922,167 Cases

BACKGROUND

Colorectal cancer incidence among young adults in the United States is on the rise, but whether this phenomenon is present in other parts of the world is not well documented. This study aims to explore the temporal change of incidence rates for colorectal cancer in various countries across the globe.

METHODS

We extracted colorectal cancer incidence and population data from 1988 to 2007 based on data from the International Agency for Research on Cancer and compared incidence between age groups. Twelve representative jurisdictions from five continents were selected. Young-onset colorectal cancer cases were defined as those ages <50 years. Joinpoint regression was used to measure the trends of colorectal cancer incidence and to estimate the annual percent change (APC).

RESULTS

The APC for those ages <50 years was noted to be increasing at a faster rate as compared with those ages ≥50 years in many regions, including Australia (+1.10% vs. -0.35%), Brazil (+9.20% vs. +5.72%), Canada (+2.60% vs. -0.91%), China-Hong Kong (+1.82% vs. -0.10%), China-Shanghai (+1.13% vs. -2.68%), Japan (+2.63% vs. +0.90%), the United Kingdom (+3.33% vs. +0.77%), and the United States (+1.98% vs. -2.88%). These trends were largely driven by rectal cancer, except in Brazil and the United Kingdom.

CONCLUSIONS

Increasing incidence of young-onset colorectal cancer was noted in many regions across the globe.

IMPACT

Further studies focusing on young-onset colorectal cancer, particularly with regard to risk factors and establishing the optimal age of screening, are warranted.

Depression and Antidepressants as Potential Risk Factors in Dementia: A Systematic Review and Meta-analysis of 18 Longitudinal Studies

OBJECTIVE

To investigate whether depression and/or antidepressants can be a potential risk factor for the development of dementia and mild cognitive impairment (MCI).

DESIGN

Systematic review and meta-analysis of longitudinal studies.

SETTING AND PARTICIPANTS

Community or clinical settings. Participants included patients with depression, antidepressant users, and the general population.

MEASURES

Longitudinal studies evaluating the risks of dementia or MCI in patients with depression and/or antidepressant users were identified from the OVID database. The outcomes were the number of patients who developed dementia or MCI among the antidepressant users and nonusers. Relative risk (RR) with 95% confidence interval (95% CI) was used to evaluate the association between the use of antidepressants and the risk of dementia and MCI. Meta-analysis was used for combining the effect sizes of individual studies, and the heterogeneity test was performed. Risk of bias and reporting quality of included studies was assessed. Subgroup analyses were conducted for different types of antidepressants.

RESULTS

A total of 18 studies with 2,119,627 participants with mean age ranging from 55 to 81 years were included. Among patients with depression, antidepressant users showed a significantly higher risk of dementia (RR = 1.37, 95% CI = 1.11-1.70) and MCI (RR = 1.20, 95% CI = 1.02-1.42) than the nonusers. Besides, patients with depression who used antidepressants and who did not use antidepressants also showed significantly higher risk of dementia than the general population (RR = 1.50, 95% CI = 1.26-1.78, and RR = 1.31, 95% CI = 1.15-1.51, respectively).

CONCLUSIONS/IMPLICATIONS

Patients with depression are associated with a higher risk of dementia, and the use of antidepressants is not shown to be a protective factor of dementia. Further large-scale trials are required for investigation of the benefit-risk ratio between depression relapse and dementia when prescribing antidepressants.

A population-based age-period-cohort study of colorectal cancer incidence comparing Asia against the West

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer worldwide but incidence varied widely. Despite the role of genetics, CRC is also sensitive to macro-environmental factors. Few studies have ever compared across different countries/regions to suggest possible macro-environmental risk factors of CRC. We estimated the effects of age, period and cohort on the changes of incidence of colorectal cancer across different countries/regions.

METHODS

Poisson regression age-period-cohort (APC) models were conducted to estimate the age, period and cohorts effects on CRC incidence across the West (i.e., the UK, the US and Australia) and Asia (i.e. Japan, Hong Kong, Shanghai, Singapore and India). We maximized the length of the study period according to each country's data availability.

RESULTS

Western populations show upward inflections for their 1950s-1960s cohorts, while Asian populations (except India) show downward inflections for their 1950s cohorts. Japanese population also shows upward inflections for its 1960s cohorts, similar to the Western populations. There are apparent upward inflections towards the more recent cohorts for Hong Kong, Shanghai and Singapore; nevertheless, the confidence intervals are wider towards the more recent cohorts.

CONCLUSION

Our findings imply an increasing risk of CRC in both Western and Asian populations as their younger cohorts reach older ages. These findings are consistent with the life course argument that macro-environmental changes associated with socio-economic development have specific effects that extend over the life course. Actions that pertain to altering lifestyle-related exposures over the life course are of great importance in combating young CRC risks in the future.

Long-term use of low-dose aspirin for cancer prevention: A 10-year population cohort study in Hong Kong

Aspirin, commonly used for prevention of cardiovascular and cerebrovascular diseases, has been found to possess protective effects against cancer development in the Western populations. Such effects among Asian populations remain uncertain. The objective of this study is to investigate the use of aspirin on prevention of different cancers among Chinese users. This population-based study utilized database from the Hong Kong Hospital Authority; adults with aspirin prescription for at least 6 months between 2000 and 2004 were included and followed up until 2013. Aspirin users were age-sex matched with non-aspirin users at a 1:2 ratio. Incidences of cancer were the primary outcome measured by relative risk (RR). A total of 204,170 aspirin users and 408,339 non-aspirin users were included, with the mean age 67.5 years, 7.7 years average duration of aspirin prescription and 80 mg as the median dose of aspirin. Cancer incidences were found in 26,929 (13.2%) aspirin users and 70,755 (17.3%) non-aspirin users. Compared with patients who had not been prescribed aspirin, aspirin usage led to significant reduction of cancers in liver (RR: 0.49), stomach (RR: 0.42), colorectum (RR: 0.71), lung (RR: 0.65), pancreas (RR: 0.54), oesophagus (RR: 0.59) and leukaemia (RR: 0.67). There was no demonstrable reduction of kidney cancer, bladder cancer, prostate cancer and multiple myeloma in association with the usage of aspirin. Risk of breast cancer was shown to marginally increase (RR: 1.14) with aspirin usage. This study demonstrated that the long-term use of low-dose aspirin is associated with the reduction in risk of various cancers but not for breast cancer. Further investigation is needed before promoting aspirin as a primary chemoprotective agent.

Comparison of Computerized and Paper-and-Pencil Memory Tests in Detection of Mild Cognitive Impairment and Dementia: A Systematic Review and Meta-analysis of Diagnostic Studies

OBJECTIVES

To compare the diagnostic performance of computerized and paper-and-pencil memory tests in detection of mild cognitive impairment (MCI) and dementia.

DESIGN

Diagnostic studies comparing computerized or paper-and-pencil memory tests with the standard diagnostic criterion for MCI or dementia were identified from OVID databases. The primary outcome was the diagnostic performance of memory tests for detection of MCI, and detection of dementia was the secondary outcome. Risk of bias and reporting quality in included studies was assessed.

SETTING AND PARTICIPANTS

Participants with MCI and dementia in any kind of setting.

MEASURES

Bivariate random-effects models were used to combine the diagnostic performance of memory tests and presented with a summary receiver-operating characteristic curve.

RESULTS

A total of 58 studies with 18,450 participants with mean age ranging from 55 to 84 years were included. For the verbal memory tests on patients with MCI, computerized tests showed diagnostic accuracy of 0.89 sensitivity (95% confidence interval [CI] 0.69-0.97) and 0.82 specificity (95% CI 0.70-0.90), whereas paper-and-pencil tests showed diagnostic accuracy of 0.86 sensitivity (95% CI 0.82-0.90) and 0.82 specificity (95% CI 0.76-0.86). For the visual memory tests on MCI patients, computerized tests showed diagnostic accuracy of 0.79 sensitivity (95% CI 0.71-0.84) and 0.80 specificity (95% CI 0.71-0.86), whereas paper-and-pencil tests showed diagnostic accuracy of 0.80 sensitivity (95% CI 0.67-0.89) and 0.68 specificity (95% CI 0.51-0.81). The findings were also comparable to those with dementia.

CONCLUSIONS/IMPLICATIONS

Both verbal and visual computerized memory tests showed comparable diagnostic performance to the paper-and-pencil tests. Computerized cognitive tests show a great potential to use as an alternative to paper-and-pencil tests. When the records can be digitalized, long-term monitoring of cognitive function will be feasible for better management of dementia.

Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines

This Guideline is a joint official statement of the Asian Pacific Association of Gastroenterology (APAGE) and the Asian Pacific Society for Digestive Endoscopy (APSDE). It was developed in response to the increasing use of antithrombotic agents (antiplatelet agents and anticoagulants) in patients undergoing gastrointestinal (GI) endoscopy in Asia. After reviewing current practice guidelines in Europe and the USA, the joint committee identified unmet needs, noticed inconsistencies, raised doubts about certain recommendations and recognised significant discrepancies in clinical practice between different regions. We developed this joint official statement based on a systematic review of the literature, critical appraisal of existing guidelines and expert consensus using a two-stage modified Delphi process. This joint APAGE-APSDE Practice Guideline is intended to be an educational tool that assists clinicians in improving care for patients on antithrombotics who require emergency or elective GI endoscopy in the Asian Pacific region.

Receptive Music Therapy Is More Effective than Interactive Music Therapy to Relieve Behavioral and Psychological Symptoms of Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

Music therapy is demonstrated to be effective to relieve the agitation among people with dementia, but the comparative effectiveness of methods of music engagement for people with dementia is uncertain.

OBJECTIVE

To evaluate the effects on cognitive functions and behavioral symptoms between interactive and receptive music therapies for people with dementia.

METHODS

Prospective studies evaluating interactive and receptive music therapies were identified from the OVID databases, included MEDLINE, EMBASE, PsycINFO, and CINAHL. Supplementary search was conducted in Google Scholar. The primary outcome focused on cognitive function; the secondary outcomes were apathy, anxiety, depressive symptoms, agitation, and other behavioral problems. All outcomes were measured by the standard assessment tools. The heterogeneity of studies was examined, and the effects were pooled by meta-analysis. Quality of studies and risk of bias were assessed.

RESULTS

Thirty-eight trials involving 1418 participants with dementia were included. The mean age ranged from 75 to 90 years, and the percentage of male participants ranged from 6% to 83%. No significant difference was found between participants receiving interactive or receptive music therapy and usual care in cognitive function; the mean difference (MD) of Mini-Mental State Examination was 0.18 [95% confidence interval (CI) -1.34 to 1.69], and -0.15 (95% CI -0.55 to 0.25), respectively. Participants with receptive music therapy had significant decrease in agitation (Cohen-Mansfield Agitation Inventory: MD = -7.99, 95% CI -5.11 to -0.87) and behavioral problems (Neuropsychiatric Inventory: MD = -3.02 95% CI -5.90 to -0.15) compared to usual care, while no significant difference was found between interactive music therapy and usual care in behavioral problems and psychiatric symptoms.

CONCLUSIONS

This study demonstrated that receptive music therapy could reduce agitation, behavioral problems, and anxiety in older people with dementia, and appears to be more effective than interactive music therapy. It is easy and convenient to implement receptive music therapy; therefore, we recommended the use of receptive music therapy in nursing homes, day care centers, and client homes.

Data Visualization with IBM Watson Analytics for Global Cancer Trends Comparison from World Health Organization

Visual analytics is widely used to explore data patterns and trends. This work leverages cancer data collected by World Health Organization (WHO) across a hundred of cancer registries worldwide. In this study, the authors present a visual analytics platform, IBM Watson Analytics, to explore the patterns of global cancer incidence. They included 26 forms of cancers from eight different geographic regions which are United States, the United Kingdom, Costa Rica, Sweden, Croatia, Japan, Hong Kong and China (Shanghai). An interactive interface was applied to plot a choropleth map to show global cancer distribution, and line charts to demonstrate historical cancer trends over 29 years. Subgroup analyses were conducted for different age groups. With real-time interactive features, one can easily explore the data with a selection of any cancer type, gender, age group, or geographical region. This platform is running on the cloud, so it can handle data in huge volumes, and is accessible by any computer connected to the Internet. IBM Watson Analytics released a latest version named “IBM Watson Analytics New User Experience” in the end of 2016. The new version streamlined the process to add data, discover data meaning and display result visually. The authors discuss the new features in the end of this paper.

A modified colorectal screening score for prediction of advanced neoplasia: A prospective study of 5744 subjects

BACKGROUND AND AIM

We validated a modified risk algorithm based on the Asia-Pacific Colorectal Screening (APCS) score that included body mass index (BMI) for prediction of advanced neoplasia.

METHODS

Among 5744 Chinese asymptomatic screening participants undergoing a colonoscopy in Hong Kong from 2008 to 2012, a random sample of 3829 participants acted as the derivation cohort. The odds ratios for significant risk factors identified by binary logistic regression analysis were used to build a scoring system ranging from 0 to 6, divided into "average risk" (AR): 0; "moderate risk" (MR): 1-2; and "high risk" (HR): 3-6. The other 1915 subjects formed a validation cohort, and the performance of the score was assessed.

RESULTS

The prevalence of advanced neoplasia in the derivation and validation cohorts was 5.4% and 6.0%, respectively (P = 0.395). Old age, male gender, family history of colorectal cancer, smoking, and BMI were significant predictors in multivariate regression analysis. A BMI cut-off at > 23 kg/m² had better predictive capability and lower number needed to screen than that of > 25 kg/m² . Utilizing the score developed, 8.4%, 57.4%, and 34.2% in the validation cohort were categorized as AR, MR, and HR, respectively. The corresponding prevalence of advanced neoplasia was 3.8%, 4.3%, and 9.3%. Subjects in the HR group had 2.48-fold increased prevalence of advanced neoplasia than the AR group. The c-statistics of the modified score had better discriminatory capability than that using predictors of APCS alone (c-statistics = 0.65 vs 0.60).

CONCLUSIONS

Incorporating BMI into the predictors of APCS score was found to improve risk prediction of advanced neoplasia and reduce colonoscopy resources.

Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis

BackgroundScreening for depression in older adults is recommended.AimsTo evaluate the diagnostic accuracy of the Two-Question Screen for older adults and compare it with other screening instruments for depression.MethodWe undertook a literature search for studies assessing the diagnostic performance of depression screening instruments in older adults. Combined diagnostic accuracy including sensitivity and specificity were the primary outcomes. Potential risks of bias and the quality of studies were also assessed.ResultsA total of 46 506 participants from 132 studies were identified evaluating 16 screening instruments. The majority of studies (63/132) used various versions of the Geriatric Depression Scale (GDS) and 6 used the Two-Question Screen. The combined sensitivity and specificity for the Two-Question Screen were 91.8% (95% CI 85.2-95.6) and 67.7% (95% CI 58.1-76.0), respectively; the diagnostic performance area under the curve (AUC) was 90%. The Two-Question Screen showed comparable performance with other instruments, including clinician-rated scales. The One-Question Screen showed the lowest diagnostic performance with an AUC of 78%. In subgroup analysis, the Two-Question Screen also had good diagnostic performance in screening for major depressive disorder.ConclusionsThe Two-Question Screen is a simple and short instrument for depression screening. Its diagnostic performance is comparable with other instruments and, therefore, it would be favourable to use it for older adult screening programmes.

The effectiveness of group-based behavioral activation in the treatment of depression: An updated meta-analysis of randomized controlled trial

BACKGROUND

Depression is a common mental health problem associated with significant morbidity and mortality. Amongst various psychological treatments for depression, individual behavioral activation (BA) has been shown to be effective and relatively simple in its delivery by health care providers although its effectiveness as a group based intervention requires further evidence. The objective of this study is to evaluate and update on the effectiveness of group-based BA to relieve symptoms of depression.

METHODS

A meta-analysis was performed and prospective randomized trials were systematically searched from the OVID databases. The trials comparing group-based BA intervention versus usual care or waitlist controls were included. Depressive symptom measured by various validated scales was the primary outcome. As the interventions can be heterogeneous across the included studies, all analyses were performed by random-effects model.

RESULTS

Seven randomized control trials were identified from the United States, United Kingdom, Sweden and Iran from 2003 to 2013. A total of 240 subjects were randomly assigned to group-based BA, and all participants included met the criteria for moderate to severe depression at baseline with the majority of participants being females. Participants who joined the group-based BA showed lower depressive symptoms (MD of BDI-II: -6.06 (95% CI: -8.28 to -3.85 and MD of HRSD: -2.82 (95% CI: -4.62 to -1.02)) than participants randomized to the control group with usual treatment. The group-based BA also showed significant reduction in anxiety level (MD of BAI: -3.66 (95% CI: -6.11 to -1.22)) but not quality of life according to two studies. Risk of bias was evident amongst the studies as blinding of health providers and patients were not feasible in psychological studies.

CONCLUSIONS

Group-based behavioral activation remains promising in relieving depressive symptoms for people with moderate to severe depression from this meta-analysis. Future studies should be higher quality research with larger sample size, longer follow-up periods, and synchronized clinical outcome measures. Patient feedback for group-based behavioral activation can also be further evaluated in order to ensure long term satisfaction and usage in health services.

Cancer burden with ageing population in urban regions in China: projection on cancer registry data from World Health Organization

BACKGROUND

China is facing the challenges of an expanding ageing population and the impact of rapid urbanization, cancer rates are subsequently increasing. This study focuses on the changes of the ageing population and projects the incidence of common ageing-related cancers in the urban regions in China up to 2030.

SOURCES OF DATA

Cancer incidence data and population statistics in China were extracted from the International Agency for Research on Cancer.

AREAS OF AGREEMENT

Due to improving longevity in China, continuous and remarkable increasing trends for the lung, colorectal and prostate cancers are expected.

GROWING POINTS

The rate of expanding ageing population was taken into account when predicting the trend of cancer incidence; the estimations of ageing-related cancers were more factual and significant than using the conventional approach of age standardization.

AREAS TIMELY FOR DEVELOPING RESEARCH

The incidence rates of lung, colorectal and prostate cancers will continue to rise in the future decades due to the rise of ageing population. Lifestyle modification such as cutting tobacco smoking rates and promoting healthier diets as well as cancer screening programs should be a health system priority in order to decrease the growing burden of cancer-related mortality and morbidity.

Epidemiological characteristics and methodological quality of meta-analyses on diabetes mellitus treatment: a systematic review

OBJECTIVE

Well-conducted meta-analyses (MAs) are considered as one of the best sources of clinical evidence for treatment decision. MA with methodological flaws may introduce bias and mislead evidence users. The aim of this study is to investigate the characteristics and methodological quality of MAs on diabetes mellitus (DM) treatments.

DESIGN

Systematic review.

METHODS

Cochrane Database of Systematic Review and Database of Abstract of Reviews of Effects were searched for relevant MAs. Assessing methodological quality of systematic reviews (AMSTAR) tool was used to evaluate the methodological quality of included MAs. Logistic regression analysis was used to identify association between characteristics of MA and AMSTAR results.

RESULTS

A total of 252 MAs including 4999 primary studies and 13,577,025 patients were included. Over half of the MAs (65.1%) only included type 2 DM patients and 160 MAs (63.5%) focused on pharmacological treatments. About 89.7% MAs performed comprehensive literature search and 89.3% provided characteristics of included studies. Included MAs generally had poor performance on the remaining AMSTAR items, especially in assessing publication bias (39.3%), providing lists of studies (19.0%) and declaring source of support comprehensively (7.5%). Only 62.7% MAs mentioned about harm of interventions. MAs with corresponding author from Asia performed less well in providing MA protocol than those from Europe.

CONCLUSIONS

Methodological quality of MA on DM treatments was unsatisfactory. There is considerable room for improvement, especially in assessing publication bias, providing lists of studies and declaring source of support comprehensively. Also, there is an urgent need for MA authors to report treatment harm comprehensively.

Combination Therapy Showed Limited Superiority Over Monotherapy for Alzheimer Disease: A Meta-analysis of 14 Randomized Trials

BACKGROUND

Acetylcholinesterase inhibitor (AChEI) and memantine are recognized drug treatments with limited clinical efficacy. Combination therapy for patients with Alzheimer disease (AD) was suggested, but the additional benefit of combination therapy is still controversial.

AIM

To evaluate the additional benefit of combination therapy over monotherapy with either AChEI or memantine.

METHODS

Prospective randomized controlled trials were searched from the OVID databases. The trials were eligible if study subjects were diagnosed with AD, and were randomized to compare combination therapy with monotherapy. Any clinical assessment measured using validated scales on cognitive function, activities of daily living, behavioral problems, and global changes were the primary outcomes, and any reported adverse events were the secondary outcomes. Quality of studies and risk of bias were evaluated.

RESULTS

Fourteen randomized trials were identified between 2004 and 2015 from the United States, Canada, Germany, Japan, China, and Korea. A total of 5019 patients with AD were randomly assigned to receive combination therapy of AChEI and memantine or monotherapy with AChEI or memantine. Combination therapy showed no significant benefit on cognitive function (mean difference [MD] of MMSE = 0.06, 95% CI -0.52 to 0.65), activities of daily living (MD of ADCS-ADL = -0.15, 95% CI -1.08 to 0.78), neuropsychiatric symptoms and behavioral problems (MD of NPI = -1.85, 95% CI -4.83 to 1.13), and global changes (MD of CIBIC-plus = 0.01, 95% CI -0.25 to 0.28). In subgroup analyses, combination therapy can improve cognitive function more than memantine alone; and it can significantly relieve neuropsychiatric symptoms and behavioral problems when concomitantly used with donepezil. No additional adverse event was reported in the combination therapy.

CONCLUSION

Combination therapy only showed the benefit on neuropsychiatric symptoms and behavioral problems in moderate-to-severe AD, but no other superiority in terms of cognitive function, activities of daily living, and global changes. Although reported adverse events were comparable, the additional cost for combination therapy may be unnecessary.

Systematic review with network meta-analysis: comparative effectiveness and safety of strategies for preventing NSAID-associated gastrointestinal toxicity

BACKGROUND

Many strategies are used to prevent nonsteroidal anti-inflammatory drug (NSAID)-associated gastrointestinal toxicity, but the comparative effectiveness remains unclear.

AIM

To evaluate the comparative effectiveness of clinical strategies for preventing gastrointestinal toxicity induced by NSAIDs.

METHODS

MEDLINE, EMBASE and the Cochrane Library (from their inception to May 2015) were searched for randomised controlled trials comparing the risk of gastrointestinal adverse events in patients taking nonselective NSAIDs, selective cyclooxygenase(COX)-2 inhibitors or nonselective NSAIDs/COX-2 inhibitors plus gastroprotective agents [proton pump inhibitors (PPIs), histamine-2 receptor antagonists, misoprostol]. Both pairwise meta-analysis and Bayesian network meta-analysis were performed.

RESULTS

Analyses were based on 82 trials including 125 053 participants. Network meta-analysis demonstrated that selective COX-2 inhibitors + PPIs [Risk ratio (RR), 95% Credible Interval (CrI): ulcer complications 0.07, 0.02-0.18], selective COX-2 inhibitors (RR, 95% CrI: ulcer complications 0.25, 0.15- 0.38; symptomatic ulcer 0.12, 0.04-0.30), nonselective NSAIDs + PPIs (RR, 95% CrI: ulcer complications 0.28, 0.18-0.41; symptomatic ulcer 0.11, 0.04-0.23), nonselective NSAIDs + misoprostol (RR, 95% CrI: ulcer complications 0.47, 0.24-0.81; symptomatic ulcer 0.41, 0.13-1.00) were associated with significantly lower risk of clinical gastrointestinal events compared with nonselective NSAIDs. For all effectiveness endpoints, selective COX-2 inhibitors + PPIs was associated with the lowest absolute event probability and the highest rank, followed by selective COX-2 inhibitors and thirdly by nonselective NSAIDs + PPIs.

CONCLUSION

The combination of selective COX-2 inhibitors plus PPIs provides the best gastrointestinal protection, followed by selective COX-2 inhibitors, and thirdly by nonselective NSAIDs plus PPIs.

Systematic review with meta-analysis: faecal occult blood tests show lower colorectal cancer detection rates in the proximal colon in colonoscopy-verified diagnostic studies

BACKGROUND

The performance of faecal occult blood tests (FOBTs) to screen proximally located colorectal cancer (CRC) has produced inconsistent results.

AIM

To assess in a meta-analysis, the diagnostic accuracy of FOBTs for relative detection of CRC according to anatomical location of CRC.

METHODS

Diagnostic studies including both symptomatic and asymptomatic cohorts assessing performance of FOBTs for CRC were searched from MEDINE and EMBASE. Primary outcome was accuracy of FOBTs according to the anatomical location of CRC. Bivariate random-effects model was used. Subgroup analyses were performed to evaluate test performance of guaiac-based FOBT (gFOBT) and immunochemical-based FOBT (iFOBT).

RESULTS

Thirteen studies, with 17 cohorts, reporting performance of FOBT were included; a total of 26 342 patients (mean age 58.9 years; 58.1% male) underwent both colonoscopy and FOBT. Pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of FOBTs for CRC detection in the proximal colon were 71.2% (95% CI 61.3-79.4%), 93.6% (95% CI 90.7-95.7%), 11.1 (95% CI 7.8-15.8) and 0.3 (95% CI 0.2-0.4) respectively. Corresponding findings for CRC detection in distal colon were 80.1% (95% CI 70.9-87.0%), 93.6% (95% CI 90.7-95.7%), 12.6 (95% CI 8.8-18.1) and 0.2 (95% CI 0.1-0.3). The area-under-curve for FOBT detection for proximal and distal CRC were 90% vs. 94% (P = 0.0143). Both gFOBT and iFOBT showed significantly lower sensitivity but comparable specificity for the detection of proximally located CRC compared with distal CRC.

CONCLUSION

Faecal occult blood tests, both guaiac- and immunochemical-based, show better diagnostic performance for the relative detection of colorectal cancer in the distal colon than in the proximal bowel.

Effect of immunosuppressive therapy on interferon γ release assay for latent tuberculosis screening in patients with autoimmune diseases: a systematic review and meta-analysis

Objective

Interferon γ release assay (IGRA) is commonly used to diagnose latent TB infection (LTBI). Immunosuppressive therapy may affect its performance but data are conflicting. We aimed to determine the effect of immunosuppressive therapy on the performance of IGRA in patients with autoimmune diseases.

Methods

We searched PubMed, MEDLINE, EMBASE and the Cochrane Library up to December 2014. We included studies that reported the IGRA results in patients with autoimmune disease with or without immunosuppressive therapy. The pooled effect of immunosuppressive therapy on IGRA was estimated using a Peto fixed-effects model.

Results

We included 17 studies with 3197 participants in the meta-analysis. Among the subjects, 71.5% were taking immunosuppressive therapy and 56.7% had received Bacillus Calmette–Guérin vaccination. Compared with patients not on immunosuppressants, patients receiving immunosuppressive therapy were less likely to have a positive IGRA result (OR 0.66, 95% CI 0.53 to 0.83, I2=23%), especially patients receiving anti-tumour necrosis factor (anti-TNF) treatment (OR 0.50, 95% CI 0.29 to 0.88). The use of immunosuppressive therapy was also associated with a lower rate of positive tuberculin skin test result (OR 0.51, 95% CI 0.42 to 0.61).

Conclusions

Our meta-analysis showed that IGRA results are negatively affected by immunosuppressive therapy. IGRA alone may not be sufficiently sensitive to diagnose LTBI in patients on immunosuppressive therapy. Patients should preferably be screened for LTBI before initiation of immunosuppressive therapy, especially before anti-TNF therapy.

Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis

IMPORTANCE

Dementia is a global public health problem. The Mini-Mental State Examination (MMSE) is a proprietary instrument for detecting dementia, but many other tests are also available.

OBJECTIVE

To evaluate the diagnostic performance of all cognitive tests for the detection of dementia.

DATA SOURCES

Literature searches were performed on the list of dementia screening tests in MEDLINE, EMBASE, and PsychoINFO from the earliest available dates stated in the individual databases until September 1, 2014. Because Google Scholar searches literature with a combined ranking algorithm on citation counts and keywords in each article, our literature search was extended to Google Scholar with individual test names and dementia screening as a supplementary search.

STUDY SELECTION

Studies were eligible if participants were interviewed face to face with respective screening tests, and findings were compared with criterion standard diagnostic criteria for dementia. Bivariate random-effects models were used, and the area under the summary receiver-operating characteristic curve was used to present the overall performance.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, and positive and negative likelihood ratios were the main outcomes.

RESULTS

Eleven screening tests were identified among 149 studies with more than 49,000 participants. Most studies used the MMSE (n = 102) and included 10,263 patients with dementia. The combined sensitivity and specificity for detection of dementia were 0.81 (95% CI, 0.78-0.84) and 0.89 (95% CI, 0.87-0.91), respectively. Among the other 10 tests, the Mini-Cog test and Addenbrooke's Cognitive Examination-Revised (ACE-R) had the best diagnostic performances, which were comparable to that of the MMSE (Mini-Cog, 0.91 sensitivity and 0.86 specificity; ACE-R, 0.92 sensitivity and 0.89 specificity). Subgroup analysis revealed that only the Montreal Cognitive Assessment had comparable performance to the MMSE on detection of mild cognitive impairment with 0.89 sensitivity and 0.75 specificity.

CONCLUSIONS AND RELEVANCE

Besides the MMSE, there are many other tests with comparable diagnostic performance for detecting dementia. The Mini-Cog test and the ACE-R are the best alternative screening tests for dementia, and the Montreal Cognitive Assessment is the best alternative for mild cognitive impairment.