Identifying parkinsonism in mild cognitive impairment

INTRODUCTION

Clinical parkinsonism is a core diagnostic feature for mild cognitive impairment with Lewy bodies (MCI-LB) but can be challenging to identify. A five-item scale derived from the Unified Parkinson's Disease Rating Scale (UPDRS) has been recommended for the assessment of parkinsonism in dementia. This study aimed to determine whether the five-item scale is effective to identify parkinsonism in MCI.

METHODS

Participants with MCI from two cohorts (n = 146) had a physical examination including the UPDRS and [123I]-FP-CIT SPECT striatal dopaminergic imaging. Participants were classified as having clinical parkinsonism (P+) or no parkinsonism (P-), and with abnormal striatal dopaminergic imaging (D+) or normal imaging (D-). The five-item scale was the sum of UPDRS tremor at rest, bradykinesia, action tremor, facial expression, and rigidity scores. The ability of the scale to differentiate P+D+ and P-D- participants was examined.

RESULTS

The five-item scale had an AUROC of 0.92 in Cohort 1, but the 7/8 cut-off defined for dementia had low sensitivity to identify P+D+ participants (sensitivity 25%, specificity 100%). Optimal sensitivity and specificity was obtained at a 3/4 cut-off (sensitivity 83%, specificity 88%). In Cohort 2, the five-item scale had an AUROC of 0.97, and the 3/4 cut-off derived from Cohort 1 showed sensitivity of 100% and a specificity of 82% to differentiate P+D+ from P-D- participants. The five-item scale was not effective in differentiating D+ from D- participants.

CONCLUSIONS

The five-item scale is effective to identify parkinsonism in MCI, but a lower threshold must be used in MCI compared with dementia.

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Academic clinician frontline-worker wellbeing and resilience during the COVID-19 pandemic experience: Were there gender differences?

Prior research suggests COVID-19 has amplified stress on Academic Clinician Frontline-Workers (ACFW). The aim of this paper is: (1) to better understand the experiences of ACFW during the COVID-19 pandemic including their mental-emotional wellbeing, academic productivity, clinical experiences, and (2) to examine any gender differences. A cross-sectional survey was administered to University of Minnesota/M Health Fairview systems' faculty February-June 2021. Of the 291 respondents, 156 were clinicians, with 91 (58 %) identifying as Frontline-Workers (ACFW). Faculty wellbeing was assessed using validated measures in addition to measures of productivity and sociodemographics. For example, ACFW reported a higher Work-Family Conflict (WFC) scores compared to non-ACFW (26.5 vs. 24.1, p = 0.057) but did not report higher Family-Work Conflict (FWC) scores (17.7 vs. 16.3, p = 0.302). Gender sub-analyses, revealed that women ACFW compared to men ACFW reported higher WFC scores (27.7 vs. 24.1, p = 0.021) and FWC (19.3 vs. 14.3, p = 0.004). Academically, ACFW reported submitting fewer grants and anticipated delays in promotion and tenure due to the COVID-19 (p = 0.035). Results suggest COVID-19 has exacerbated ACFW stress and gender inequities. Reports of anticipated delay in promotion for ACFW may pose a challenge for the long-term academic success of ACFW, especially women ACFW. In addition, women may experience higher FWC and WFC as compared to men. Schools of academic medicine should consider re-evaluating promotion/tenure processes and creating resources to support women ACFW as well as ACFW caregivers.

Clinical symptoms in mild cognitive impairment with Lewy bodies: Frequency, time of onset, and discriminant ability

BACKGROUND AND PURPOSE

Mild cognitive impairment with Lewy bodies (MCI-LB) is associated with a range of cognitive, motor, neuropsychiatric, sleep, autonomic, and visual symptoms. We investigated the cumulative frequency of symptoms in a longitudinal cohort of MCI-LB compared with MCI due to Alzheimer disease (MCI-AD) and analysed the ability of a previously described 10-point symptom scale to differentiate MCI-LB and MCI-AD, in an independent cohort.

METHODS

Participants with probable MCI-LB (n = 70), MCI-AD (n = 51), and controls (n = 34) had a detailed clinical assessment and annual follow-up (mean duration = 1.7 years). The presence of a range of symptoms was ascertained using a modified version of the Lewy Body Disease Association Comprehensive LBD Symptom Checklist at baseline assessment and then annually.

RESULTS

MCI-LB participants experienced a greater mean number of symptoms (24.2, SD = 7.6) compared with MCI-AD (11.3, SD = 7.4) and controls (4.2, SD = 3.1; p < 0.001 for all comparisons). A range of cognitive, parkinsonian, neuropsychiatric, sleep, and autonomic symptoms were significantly more common in MCI-LB than MCI-AD, although when present, the time of onset was similar between the two groups. A previously defined 10-point symptom scale demonstrated very good discrimination between MCI-LB and MCI-AD (area under the receiver operating characteristic curve = 0.91, 95% confidence interval = 0.84-0.98), replicating our previous finding in a new cohort.

CONCLUSIONS

MCI-LB is associated with the frequent presence of a particular profile of symptoms compared to MCI-AD. Clinicians should look for evidence of these symptoms in MCI and be aware of the potential for treatment. The presence of these symptoms may help to discriminate MCI-LB from MCI-AD.

Late-night salivary cortisol and cortisone should be the initial screening test for Cushing's syndrome

Endogenous Cushing's syndrome (CS) poses considerable diagnostic challenges. Although late-night salivary cortisol (LNSC) is recommended as a first-line screening investigation, it remains the least widely used test in many countries. The combined measurement of LNSC and late-night salivary cortisone (LNS cortisone) has shown to further improve diagnostic accuracy. We present a retrospective study in a tertiary referral centre comparing LNSC, LNS cortisone, overnight dexamethasone suppression test, low-dose dexamethasone suppression test and 24-h urinary free cortisol results of patients investigated for CS. Patients were categorised into those who had CS (21 patients) and those who did not (33 patients). LNSC had a sensitivity of 95% and a specificity of 91%. LNS cortisone had a specificity of 100% and a sensitivity of 86%. With an optimal cut-off for LNS cortisone of >14.5 nmol/L the sensitivity was 95.2%, and the specificity was 100% with an area under the curve of 0.997, for diagnosing CS. Saliva collection is non-invasive and can be carried out at home. We therefore advocate simultaneous measurement of LNSC and LNS cortisone as the first-line screening test to evaluate patients with suspected CS.

Mild cognitive impairment with Lewy bodies: neuropsychiatric supportive symptoms and cognitive profile

BACKGROUND

Recently published diagnostic criteria for mild cognitive impairment with Lewy bodies (MCI-LB) include five neuropsychiatric supportive features (non-visual hallucinations, systematised delusions, apathy, anxiety and depression). We have previously demonstrated that the presence of two or more of these symptoms differentiates MCI-LB from MCI due to Alzheimer's disease (MCI-AD) with a likelihood ratio >4. The aim of this study was to replicate the findings in an independent cohort.

METHODS

Participants ⩾60 years old with MCI were recruited. Each participant had a detailed clinical, cognitive and imaging assessment including FP-CIT SPECT and cardiac MIBG. The presence of neuropsychiatric supportive symptoms was determined using the Neuropsychiatric Inventory (NPI). Participants were classified as MCI-AD, possible MCI-LB and probable MCI-LB based on current diagnostic criteria. Participants with possible MCI-LB were excluded from further analysis.

RESULTS

Probable MCI-LB (n = 28) had higher NPI total and distress scores than MCI-AD (n = 30). In total, 59% of MCI-LB had two or more neuropsychiatric supportive symptoms compared with 9% of MCI-AD (likelihood ratio 6.5, p < 0.001). MCI-LB participants also had a significantly greater delayed recall and a lower Trails A:Trails B ratio than MCI-AD.

CONCLUSIONS

MCI-LB is associated with significantly greater neuropsychiatric symptoms than MCI-AD. The presence of two or more neuropsychiatric supportive symptoms as defined by MCI-LB diagnostic criteria is highly specific and moderately sensitive for a diagnosis of MCI-LB. The cognitive profile of MCI-LB differs from MCI-AD, with greater executive and lesser memory impairment, but these differences are not sufficient to differentiate MCI-LB from MCI-AD.

A Longitudinal Study of Plasma pTau181 in Mild Cognitive Impairment with Lewy Bodies and Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) co-pathology is common in dementia with Lewy bodies and is associated with increased decline. Plasma pTau181 is a blood-based biomarker that can detect AD co-pathology.

OBJECTIVES

We investigated whether pTau181 was associated with cognitive decline in mild cognitive impairment with Lewy bodies (MCI-LB) and MCI with AD (MCI-AD).

METHODS

We assessed plasma pTau181 using a single-molecule array (Simoa) immunoassay at baseline and follow-up in a longitudinal cohort of MCI-LB, MCI-AD, and controls.

RESULTS

One hundred forty-six subjects (56 probable MCI-LB, 22 possible MCI-LB, 44 MCI-AD, and 24 controls) were reviewed for up to 5.7 years. Probable MCI-LB had significantly higher pTau181 (22.2% mean increase) compared with controls and significantly lower (24.4% mean decrease) levels compared with MCI-AD. Receiver operating characteristic analyses of pTau181 in discriminating probable MCI-LB from controls showed an area under the curve (AUC) of 0.68 (83% specificity, 57% sensitivity); for discriminating MCI-AD from healthy controls, AUC was 0.8 (83.3% specificity, 72.7% sensitivity). pTau181 concentration was less useful in discriminating between probable MCI-LB and MCI-AD: AUC of 0.64 (71.4% specificity, 52.3% sensitivity). There was an association between pTau181 and cognitive decline in MCI-AD but not in MCI-LB. In a subset with repeat samples there was a nonsignificant 3% increase per follow-up year in plasma pTau181. The rate of change in pTau181 was not significantly different in different diagnostic subgroups.

CONCLUSIONS

pTau181 was not associated with an increased decline assessed using either baseline or repeat pTau181. pTau181 partially discriminated probable MCI-LB from controls and MCI-AD from controls but was not useful in distinguishing probable MCI-LB from MCI-AD.

Allergy education and training for physicians

The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence  to manage  mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.

Harmonizing allergy care-integrated care pathways and multidisciplinary approaches

There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care.

We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers.

The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.

A systematic review of oncoplastic volume replacement breast surgery: oncological safety and cosmetic outcome

INTRODUCTION

Oncoplastic breast conserving surgery allows higher volume excision to achieve oncological safety with minimal aesthetic compromise. The primary outcome of this study was to assess the oncological safety in the setting of volume replacement oncoplastic breast conserving surgery. The secondary objective was to assess cosmetic outcome.

METHODS

A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to explore the oncological safety of oncoplastic breast conserving surgery, with particular focus on volume replacement. Resection margin rates, re-excision rates, conversion to mastectomy rates, local and distant disease recurrence, volume replacement techniques, cosmetic outcomes and patient-reported outcome measures were assessed.

FINDINGS

The search criteria identified 155 articles, of which 40 met the inclusion criteria. These studies included 2,497 patients with a mean age of 47.8 years (range 38.4-59.6 years), a body mass index of 24.3kg/m² (22.1-28.0kg/m²), with a mean follow-up of 37.1 months (6-125 months). A variety of volume replacement techniques were used, most commonly latissimus dorsi and chest wall perforator flaps. Whole mean pathological tumour size was 29.7mm (17-65mm) and mean specimen weight was 123.6g (46.5-220g). Mean re-excision rate was 7.2% and completion mastectomy rate was 2.3%. Locoregional and distant recurrence rate was 2.5% (0-8.1%) and 3.1% (0-14.6%), respectively. There were a variety of patient-reported outcome measures employed, with overall good to excellent outcomes.

CONCLUSIONS

This review demonstrates that volume replacement oncoplastic breast conserving surgery is a safe option in terms of re-excision, completion mastectomy rates, and local and distant recurrence. Available patient-related outcome measures and cosmetic assessment tend towards better outcomes compared with wide local excision and mastectomy. However, data are significantly limited, with a paucity of high-level evidence, and it is therefore necessary to be cautious regarding the strength and interpretation of data in this review. Further prospective studies are required on this subject.

Indo-Pacific Walker circulation drove Pleistocene African aridification

Today, the eastern African hydroclimate is tightly linked to fluctuations in the zonal atmospheric Walker circulation^1,2. A growing body of evidence indicates that this circulation shaped hydroclimatic conditions in the Indian Ocean region also on much longer, glacial-interglacial timescales^3-5, following the development of Pacific Walker circulation around 2.2-2.0 million years ago (Ma)^6,7. However, continuous long-term records to determine the timing and mechanisms of Pacific-influenced climate transitions in the Indian Ocean have been unavailable. Here we present a seven-million-year-long record of wind-driven circulation of the tropical Indian Ocean, as recorded in Mozambique Channel Throughflow (MCT) flow-speed variations. We show that the MCT flow speed was relatively weak and steady until 2.1 ± 0.1 Ma, when it began to increase, coincident with the intensification of the Pacific Walker circulation^6,7. Strong increases during glacial periods, which reached maxima after the Mid-Pleistocene Transition (0.9-0.64 Ma; ref. ⁸), were punctuated by weak flow speeds during interglacial periods. We provide a mechanism explaining that increasing MCT flow speeds reflect synchronous development of the Indo-Pacific Walker cells that promote aridification in Africa. Our results suggest that after about 2.1 Ma, the increasing aridification is punctuated by pronounced humid interglacial periods. This record will facilitate testing of hypotheses of climate-environmental drivers for hominin evolution and dispersal.

Utility of the pareidolia test in mild cognitive impairment with Lewy bodies and Alzheimer's disease

OBJECTIVES

Previous research has identified that dementia with Lewy bodies (DLB) has abnormal pareidolic responses which are associated with severity of visual hallucinations (VH), and the pareidolia test accurately classifies DLB with VH. We aimed to assess whether these findings would also be evident at the earlier stage of mild cognitive impairment (MCI) with Lewy bodies (MCI-LB) in comparison to MCI due to AD (MCI-AD) and cognitively healthy comparators.

METHODS

One-hundred and thirty-seven subjects were assessed prospectively in a longitudinal study with a mean follow-up of 1.2 years (max = 3.7): 63 MCI-LB (22% with VH) and 40 MCI-AD according to current research diagnostic criteria, and 34 healthy comparators. The pareidolia test was administered annually as a repeated measure.

RESULTS

Probable MCI-LB had an estimated pareidolia rate 1.2-6.7 times higher than MCI-AD. Pareidolia rates were not associated with concurrent VH, but had a weak association with total score on the North East Visual Hallucinations Inventory. The pareidolia test was not an accurate classifier of either MCI-LB (Area under curve (AUC) = 0.61), or VH (AUC = 0.56). There was poor sensitivity when differentiating MCI-LB from controls (41%) or MCI-AD (27%), though specificity was better (91% and 89%, respectively).

CONCLUSIONS

Whilst pareidolic responses are specifically more frequent in MCI-LB than MCI-AD, sensitivity of the pareidolia test is poorer than in DLB, with fewer patients manifesting VH at the earlier MCI stage. However, the high specificity and ease of use may make it useful in specialist clinics where imaging biomarkers are not available.

Improving the diagnosis and management of Lewy body dementia: the DIAMOND-Lewy research programme including pilot cluster RCT

Background

Lewy body dementia, comprising both dementia with Lewy bodies and Parkinson’s disease dementia, is the second commonest cause of neurodegenerative dementia. Existing evidence suggests that it is underdiagnosed and without a consistent approach to management.

Objectives

To improve the diagnosis and management of Lewy body dementia by (1) understanding current diagnostic practice for dementia with Lewy bodies and Parkinson’s disease dementia; (2) identifying barriers to and facilitators of diagnosis and management; (3) developing evidence-based assessment toolkits to improve diagnosis of dementia with Lewy bodies and Parkinson’s disease dementia; (4) producing a management toolkit to facilitate management; and (5) undertaking a pilot cluster randomised clinical trial.

Design

Work package 1 assessed clinical diagnostic rates from case notes for dementia with Lewy bodies and Parkinson’s disease dementia before and after (work package 1 repeated) introduction of an assessment toolkit. In work package 2, we developed a management toolkit for Lewy body dementia. In work package 3, we developed assessment toolkits for dementia with Lewy bodies and Parkinson’s disease dementia and piloted these and the management toolkit in a clinical service. In work package 4, we undertook a pilot study of 23 services in nine NHS trusts that were cluster randomised to receiving and using the management toolkit or standard care. Work package 5 comprised a series of qualitative studies, examining barriers to and facilitators of diagnosis and management.

Setting

Secondary care memory assessment and movement disorder services in England.

Interventions

Assessment toolkits for Lewy body dementia consisted of questions for diagnostic symptoms, and management toolkits comprised 161 guidance statements grouped under five symptom domains.

Review methods

The systematic reviews of pharmacological and non-pharmacological management were based on published literature, with meta-analysis when possible, following a search of several electronic databases and the grey literature using terms related to Lewy body dementia, without restriction on time or language.

Participants

Participants aged ≥ 50 years diagnosed with dementia with Lewy bodies or Parkinson’s disease dementia and, for work package 1 and work package 1 repeated, non-dementia with Lewy bodies and non-Parkinson’s disease dementia controls. The qualitative studies included people with Lewy body dementia, carers and professionals.

Main outcome measures

For work packages 1 and 1 repeated, diagnostic rates for dementia with Lewy bodies and Parkinson’s disease dementia as a proportion of all dementia or Parkinson’s disease. For work packages 2 and 3, the production of diagnostic and management toolkits. For work package 4, feasibility of undertaking a cluster randomised trial of the toolkits, measured by number of participants recruited and use of the toolkits, assessed qualitatively.

Results

Work package 1 – 4.6% of dementia cases in secondary care received a dementia with Lewy bodies diagnosis (with significant differences in diagnostic rates between services) and 9.7% of those with Parkinson’s disease had a diagnosis of Parkinson’s disease dementia. There was evidence of delays in diagnosis for both dementia with Lewy bodies and Parkinson’s disease dementia compared with control patients, and the costs of dementia with Lewy bodies and Parkinson’s disease dementia were also greater than those for matched controls (p < 0.01 for both). Work package 2 – we produced 252 statements regarding Lewy body dementia management and, following a Delphi process, 161 statements were included in a management toolkit. Work package 3 – piloting indicated that separate assessment toolkits for use in memory clinic and movement disorder services were preferred, but a single toolkit for Lewy body dementia management was suitable. Work package 4 – we were able to recruit Lewy body dementia patients to target and recruited 131 patients within 6 months (target n = 120), of whom > 80% were retained in the study at 6 months. Work package 5 – barriers to diagnosis and management of Lewy body dementia were complex. Managing Lewy body dementia often requires input from a range of specialties and, therefore, care pathways may be fragmented. Positive attitudes to diagnosing Lewy body dementia, working with a team with expertise in Lewy body dementia and opportunities for cross-specialty discussion of patients with complex needs facilitated diagnosis and management. The toolkits were generally well received, particularly the management toolkit. Implementation, however, varied, reflecting differences in attitudes, skills, time and local leadership. Work package 1 repeated – following introduction of the assessment toolkit, we found that 9.7% of dementia cases had dementia with Lewy bodies (a significant increase from baseline; p = 0.0019), but Parkinson’s disease dementia rates were similar (8.2%) to baseline.

Limitations

We included only two geographical regions and evidence informing the management toolkit was limited. Work package 4 was a pilot study and, therefore, we did not set out to assess the extent to which use of the management toolkit altered outcomes at the individual patient level. We noted implementation of the toolkits was variable. The increase in diagnostic rates in dementia with Lewy bodies following introduction of the assessment toolkits cannot be necessarily causally attributed to them.

Conclusions

Dementia with Lewy bodies and Parkinson’s disease dementia were diagnosed in secondary care NHS services, with a lower frequency (around half) than that expected from known prevalence rates. The introduction of assessment toolkits for dementia with Lewy bodies and Parkinson’s disease dementia was associated with increased diagnostic rates of dementia with Lewy bodies, but not Parkinson’s disease dementia. Qualitative studies indicated inherent complexities of the disease itself, with treatment requiring input from different specialties and the potential for fragmented services, a workforce with variable training and confidence in Lewy body dementia, and negative attitudes towards diagnosis. The cluster randomised pilot trial demonstrated that patients could be successfully recruited, and provided preliminary evidence that the toolkits could be implemented in clinical services.

Future work

The evidence base informing the management of Lewy body dementia is limited, especially for non-pharmacological interventions. More well-designed randomised controlled trials for both cognitive and non-cognitive symptoms are needed.

Trial registration

Current Controlled Trials ISRCTN11083027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 7. See the NIHR Journals Library website for further project information.

Accuracy of dopaminergic imaging as a biomarker for mild cognitive impairment with Lewy bodies

BACKGROUND

Dopaminergic imaging is an established biomarker for dementia with Lewy bodies, but its diagnostic accuracy at the mild cognitive impairment (MCI) stage remains uncertain.

AIMS

To provide robust prospective evidence of the diagnostic accuracy of dopaminergic imaging at the MCI stage to either support or refute its inclusion as a biomarker for the diagnosis of MCI with Lewy bodies.

METHOD

We conducted a prospective diagnostic accuracy study of baseline dopaminergic imaging with [123I]N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)nortropane single-photon emission computerised tomography (123I-FP-CIT SPECT) in 144 patients with MCI. Images were rated as normal or abnormal by a panel of experts with access to striatal binding ratio results. Follow-up consensus diagnosis based on the presence of core features of Lewy body disease was used as the reference standard.

RESULTS

At latest assessment (mean 2 years) 61 patients had probable MCI with Lewy bodies, 26 possible MCI with Lewy bodies and 57 MCI due to Alzheimer's disease. The sensitivity of baseline FP-CIT visual rating for probable MCI with Lewy bodies was 66% (95% CI 52-77%), specificity 88% (76-95%) and accuracy 76% (68-84%), with positive likelihood ratio 5.3.

CONCLUSIONS

It is over five times as likely for an abnormal scan to be found in probable MCI with Lewy bodies than MCI due to Alzheimer's disease. Dopaminergic imaging appears to be useful at the MCI stage in cases where Lewy body disease is suspected clinically.

Computer-aided detection for tuberculosis and silicosis in chest radiographs of gold miners of South Africa

BACKGROUND: For over one hundred years, the gold mining sector has been a considerable source of tuberculosis (TB) and silicosis disease burden across Southern Africa. Reading chest radiographs (CXRs) is an expert and time-intensive process necessary for the screening and diagnosis of lung disease and the provision of evidence for compensation claims. Our study explores the use of computer-aided detection (CAD) of TB and silicosis in CXRs of a population with a high incidence of both diseases.METHODS: A set of 330 CXRs with human expert-determined classifications of silicosis, TB, silcotuberculosis and normal were provided to four health technology companies. The ability of each of their respective CAD systems to predict disease was assessed using receiver operating characteristic curve analysis of the under the curve metric.RESULTS: Three of the four systems differentiated accurately between TB and normal images, while two differentiated accurately between silicosis and normal images. Inclusion of silicotuberculosis images reduced each system's ability to detect either disease. In differentiating between any abnormal from normal CXR, the most accurate system achieved both a sensitivity and specificity of 98.2%.CONCLUSION: The current ability of CAD to differentiate between TB and silicosis is limited, but its use as a mass screening tool for both diseases shows considerable promise.

Accuracy of Cardiac Innervation Scintigraphy for Mild Cognitive Impairment With Lewy Bodies

Objective

To provide evidence that cardiac I-123-metaiodobenzylguanidine sympathetic innervation imaging (MIBG) scintigraphy differentiates probable mild cognitive impairment with Lewy bodies (MCI-LB) from mild cognitive impairment due to Alzheimer disease (MCI-AD), we scanned patients with MCI and obtained consensus clinical diagnoses of their MCI subtype. We also performed baseline FP-CIT scans to compare the accuracy of MIBG and FP-CIT.

Methods

We conducted a prospective cohort study into the accuracy of cardiac MIBG scintigraphy in the diagnosis of MCI-LB. Follow-up clinical assessment was used to diagnose MCI-AD (no core features of MCI-LB and normal FP-CIT), probable MCI-LB (2 or more core features, or 1 core feature with abnormal FP-CIT), or possible MCI-LB (1 core feature or abnormal FP-CIT). For the comparison between MIBG and FP-CIT, only core clinical features were used for diagnosis.

Results

We recruited 95 people with mild cognitive impairment. Cardiac MIBG was abnormal in 22/37 probable and 2/15 possible MCI-LB cases and normal in 38/43 MCI-AD cases. The sensitivity in probable MCI-LB was 59% (95% confidence interval [CI], 42%–75%), specificity 88% (75%–96%), and accuracy 75% (64%–84%). The positive likelihood ratio was 5.1 and negative likelihood ratio 0.46. With symptom-only diagnoses, the accuracies were 79% for MIBG (95% CI, 68%–87%) and 76% for FP-CIT (95% CI, 65%–85%).

Conclusions

Cardiac MIBG appears useful in early disease, with an abnormal scan highly suggestive of MCI-LB. Validation in a multicenter setting is justified.

Classification of Evidence

This study provides Class I evidence that cardiac MIBG distinguishes MCI-LB from MCI-AD.

Hippocampal and insula volume in mild cognitive impairment with Lewy bodies

INTRODUCTION

Diagnostic criteria for prodromal dementia with Lewy bodies have recently been published. These include the use of imaging biomarkers to distinguish mild cognitive impairment with Lewy bodies (MCI-LB) from MCI due to other causes. Two potential biomarkers listed, though not formally included in the diagnostic criteria, due to insufficient evidence, are relatively preserved hippocampi, and atrophy of the insula cortex on structural brain imaging.

METHODS

In this report, we sought to investigate these imaging biomarkers in 105 research subjects, including well characterised groups of patients with MCI-LB (n = 38), MCI with no core features of Lewy body disease (MCI-AD; n = 36) and healthy controls (N = 31). Hippocampal and insula volumes were determined from T1 weighted structural MRI scans, using grey matter segmentation performed with SPM software.

RESULTS

Adjusting for age, sex and intracranial volume, there were no differences in hippocampal or insula volume between MCI-AD and MCI-LB, although in both conditions volumes were significantly reduced relative to controls.

CONCLUSION

Our results do not support the use of either hippocampal or insula volume to identify prodromal dementia with Lewy bodies.

Introduction of an assessment toolkit associated with increased rate of DLB diagnosis

Background

Dementia with Lewy bodies (DLB) and dementia in Parkinson’s disease (PDD) are recognised to be under-recognised in clinical practice in the UK, with only one third to a half of expected cases diagnosed. We aimed to assess whether clinical diagnostic rates could be increased by the introduction of a structured assessment toolkit for clinicians.

Methods

We established baseline diagnostic rates for DLB and PDD in four memory clinics and three movement disorder/Parkinson’s disease (PD) clinics in two separate geographical regions in the UK. An assessment toolkit specifically developed to assist with the recognition and diagnosis of DLB and PDD was then introduced to the same clinical teams and diagnostic rates for DLB and PDD were reassessed.

For assessing DLB diagnosis, a total of 3820 case notes were reviewed before the introduction of the toolkit, and 2061 case notes reviewed after its introduction. For PDD diagnosis, a total of 1797 case notes were reviewed before the introduction of the toolkit and 3405 case notes after it. Mean values and proportions were analysed using Student’s t test for independent samples and χ² test, respectively.

Results

DLB was diagnosed in 4.6% of dementia cases prior to the introduction of the toolkit, and 6.2% of dementia cases afterwards, an absolute rise of 1.6%, equal to a 35% increase in the number of DLB cases diagnosed when using the toolkit (χ² = 4.2, P = 0.041).

The number of PD patients diagnosed with PDD was not found overall to be significantly different when using the toolkit: 9.6% of PD cases before and 8.2% of cases after its introduction (χ² = 1.8, P = 0.18), though the ages of PD patients assessed after the toolkit’s introduction were lower (73.9 years vs 80.0 years, t = 19.2, p < 0.001).

Conclusion

Introduction of the assessment toolkit was associated with a significant increase in the rate of DLB diagnosis, suggesting that a structured means of assessing symptoms and clinical features associated with DLB can assist clinicians in recognising cases. The assessment toolkit did not alter the overall rate of PDD diagnosis, suggesting that alternate means may be required to improve the rate of diagnosis of dementia in Parkinson’s disease.

Mild cognitive impairment with Lewy bodies: blood perfusion with arterial spin labelling

Objective

To use arterial spin labelling to investigate differences in perfusion in mild cognitive impairment with Lewy bodies (MCI-LB) compared to Alzheimer type MCI (MCI-AD) and healthy controls.

Methods

We obtained perfusion images on 32 MCI-LB, 30 MCI-AD and 28 healthy subjects of similar age. Perfusion relative to cerebellum was calculated, and we aimed to examine differences in relative perfusion between MCI-LB and the other groups. This included whole brain voxelwise comparisons, as well as using predefined region-of-interest ratios of medial occipital to medial temporal, and posterior cingulate to precuneus. Differences in occipital perfusion in eyes open vs eyes closed conditions were also examined.

Results

Compared to controls, the MCI-LB showed reduced perfusion in the precuneus, parietal, occipital and fusiform gyrus regions. In our predefined regions, the ratio of perfusion in occipital/medial temporal was significantly lower, and the posterior cingulate/precuneus ratio was significantly higher in MCI-LB compared to controls. Overall, the occipital perfusion was greater in the eyes open vs closed condition, but this did not differ between groups.

Conclusion

We found patterns of altered perfusion in MCI-LB which are similar to those seen in dementia with Lewy bodies, with reduction in posterior parietal and occipital regions, but relatively preserved posterior cingulate.

Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise: a systematic review and meta-analysis

AIMS

We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis.

MATERIALS AND METHODS

A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently.

RESULTS

A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low.

CONCLUSIONS

There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature.

Sex, size and isotopes: cryptic trophic ecology of an apex predator, the white shark Carcharodon carcharias

Demographic differences in resource use are key components of population and species ecology across the animal kingdom. White sharks (Carcharodon carcharias) are migratory, apex predators, which have undergone significant population declines across their range. Understanding their ecology is key to ensuring that management strategies are effective. Here, we carry out the first stable isotope analyses of free-swimming white sharks in South Africa. Biopsies were collected in Gansbaai (34.5805°S, 19.3518°E) between February and July 2015. We used Stable Isotope Bayesian Ellipsis in R and traditional statistical analyses to quantify and compare isotopic niches of male and female sharks of two size classes, and analyse relationships between isotopic values and shark length. Our results reveal cryptic trophic differences between the sexes and life stages. Males, but not females, were inferred to feed in more offshore or westerly habitats as they grow larger, and only males exhibited evidence of an ontogenetic niche shift. Lack of relationship between δ13C, δ15N and female shark length may be caused by females exhibiting multiple migration and foraging strategies, and a greater propensity to travel further north. Sharks < 3 m had much wider, and more diverse niches than sharks > 3 m, drivers of which may include individual dietary specialisation and temporal factors. The differences in migratory and foraging behaviour between sexes, life stages, and individuals will affect their exposure to anthropogenic threats, and should be considered in management strategies.

The Effect of Hemodialysis on Whole Blood, Plasma and Erythrocyte Viscosity

The effect of hemodialysis (HD) on blood viscosity has not been adequately investigated. We studied blood viscosity during HD employing coneplate viscometry. Ten patients with end-stage renal disease were studied before and immediately after HD. To dissect the possible effects of HD on plasma and red blood cell (RBC) determinants, we measured whole blood, plasma, and reconstituted erythrocyte viscosities. The latter consisted of RBC's suspended in a buffered saline solution (pH = 7.4 units). In addition, serum, electrolytes and hematocrit (HCT) were measured. The results revealed a significant rise in whole blood viscosity after dialysis. Likewise, plasma viscosity rose considerably with dialysis. However, when the RBC's were reconstituted to a constant HCT, no significant difference was noted before and after HD. As expected, body weight, blood urea nitrogen (BUN) and creatinine concentrations fell while HCT and protein concentration rose with HD. A significant correlation was found between the observed rise in HCT, and dialysis-induced rise in whole blood viscosity. Likewise, the observed rises in plasma viscosity after dialysis significantly correlated with the rise in protein concentration. In addition, the change in whole blood and plasma viscosity values correlated with the degree of ultrafiltration (weight loss). In conclusion, whole blood and plasma viscosity rises with hemodialysis. The observed rise in viscosity is primarily due to hemoconcentration.

Tracing of particulate organic C sources across the terrestrial-aquatic continuum, a case study at the catchment scale (Carminowe Creek, southwest England)

Soils deliver crucial ecosystem services, such as climate regulation through carbon (C) storage and food security, both of which are threatened by climate and land use change. While soils are important stores of terrestrial C, anthropogenic impact on the lateral fluxes of C from land to water remains poorly quantified and not well represented in Earth system models. In this study, we tested a novel framework for tracing and quantifying lateral C fluxes from the terrestrial to the aquatic environment at a catchment scale. The combined use of conservative plant-derived geochemical biomarkers n-alkanes and bulk stable δ¹³C and δ¹⁵N isotopes of soils and sediments allowed us to distinguish between particulate organic C sources from different land uses (i.e. arable and temporary grassland vs. permanent grassland vs. riparian woodland vs. river bed sediments) (p<0.001), showing an enhanced ability to distinguish between land use sources as compared to using just n-alkanes alone. The terrestrial-aquatic proxy (TAR) ratio derived from n-alkane signatures indicated an increased input of terrestrial-derived organic matter (OM) to lake sediments over the past 60years, with an increasing contribution of woody vegetation shown by the C₂₇/C₃₁ ratio. This may be related to agricultural intensification, leading to enhanced soil erosion, but also an increase in riparian woodland that may disconnect OM inputs from arable land uses in the upper parts of the study catchment. Spatial variability of geochemical proxies showed a close coupling between OM provenance and riparian land use, supporting the new conceptualization of river corridors (active river channel and riparian zone) as critical zones linking the terrestrial and aquatic C fluxes. Further testing of this novel tracing technique shows promise in terms of quantification of lateral C fluxes as well as targeting of effective land management measures to reduce soil erosion and promote OM conservation in river catchments.

Ayahuasca enhances creative divergent thinking while decreasing conventional convergent thinking

INTRODUCTION

Ayahuasca is a South American psychotropic plant tea traditionally used in Amazonian shamanism. The tea contains the psychedelic 5-HT2A receptor agonist N,N-dimethyltryptamine (DMT), plus β-carboline alkaloids with monoamine oxidase-inhibiting properties. Increasing evidence from anecdotal reports and open-label studies indicates that ayahuasca may have therapeutic effects in treatment of substance use disorders and depression. A recent study on the psychological effects of ayahuasca found that the tea reduces judgmental processing and inner reactivity, classic goals of mindfulness psychotherapy. Another psychological facet that could potentially be targeted by ayahuasca is creative divergent thinking. This mode of thinking can enhance and strengthen psychological flexibility by allowing individuals to generate new and effective cognitive, emotional, and behavioral strategies. The present study aimed to assess the potential effects of ayahuasca on creative thinking.

METHODS

We visited two spiritual ayahuasca workshops and invited participants to conduct creativity tests before and during the acute effects of ayahuasca. In total, 26 participants consented. Creativity tests included the "pattern/line meanings test" (PLMT) and the "picture concept test" (PCT), both assessing divergent thinking and the latter also assessing convergent thinking.

RESULTS

While no significant effects were found for the PLMT, ayahuasca intake significantly modified divergent and convergent thinking as measured by the PCT. While convergent thinking decreased after intake, divergent thinking increased.

CONCLUSIONS

The present data indicate that ayahuasca enhances creative divergent thinking. They suggest that ayahuasca increases psychological flexibility, which may facilitate psychotherapeutic interventions and support clinical trial initiatives.

Audit of Pulse Oximetry Screening for Critical Congenital Heart Disease (Cchd) in Newborns

BACKGROUND: UK data suggests that 25% of infants with CCHD are not diagnosed with heart disease until after discharge from the nursery (0.6 per 1000). In general SpO2 ≤ to 95% or a difference of upper and lower SpO2 of more than 3% in a newborn greater than 24 hours of age is considered significant. In March 2014 the Maternal Child Newborn Screening Committee of the Provincial Council for Maternal Child Health (PCMCH) recommended screening for critical congenital heart disease in Ontario.

OBJECTIVES: To assess the efficacy and cost related parameters of a new screening protocol for CCHD.

DESIGN/METHODS: An audit of consecutive healthy normal newborn patients over a one-year period was undertaken.

RESULTS: The cost of screening estimated for our center was approximately $7.20 per patient. The median age of screening was 25 hours (6-80 hours). Four patients were screened positive and were seen by a paediatrician in consultation. No Echocardiograms were ordered. No child in this screening survey had CCHD (specificity 99.4%). The screening compliance was 94.7%. One patient from our regional catchment area was delivered at an alternate secondary level center where there is no CCHD protocol in effect. The infant was discharged home and returned to the primary level center two days later in shock. The ultimate diagnosis was Hypoplastic Left Heart Syndrome. The estimated cost of the resuscitation was $1000. The emergency transport (direct) cost for this unstable newborn by helicopter is estimated to be $5000.00.

Conclusion: Cost analysis: The total direct costs of the CCHD screening program for a year is approximately $5200. The costs for the four patients who were falsely identified as having CCHD is estimated at $200. The total direct cost to the system of the one patient in our region who was not screened and was subsequently identified as having CCHD was estimated to be $6000. Assessment issues: In contrast to the US references, none of the false positive cases had an echocardiogram ordered. The cases were dealt with by utilizing a consultation with a paediatrician. Compliance with routine newborn orders: The screening compliance rate of 94.7%.

CONCLUSIONS: A simple screening test for Critical Congenital Heart Disease was successfully undertaken in a secondary level center over a one-year period. The test was cost effective, with high specificity (99.4%) and good compliance (94.7%).

PALEOCEANOGRAPHY. A warm and poorly ventilated deep Arctic Mediterranean during the last glacial period

Changes in the formation of dense water in the Arctic Ocean and Nordic Seas [the "Arctic Mediterranean" (AM)] probably contributed to the altered climate of the last glacial period. We examined past changes in AM circulation by reconstructing radiocarbon ventilation ages of the deep Nordic Seas over the past 30,000 years. Our results show that the glacial deep AM was extremely poorly ventilated (ventilation ages of up to 10,000 years). Subsequent episodic overflow of aged water into the mid-depth North Atlantic occurred during deglaciation. Proxy data also suggest that the deep glacial AM was ~2° to 3°C warmer than modern temperatures; deglacial mixing of the deep AM with the upper ocean thus potentially contributed to the melting of sea ice, icebergs, and terminal ice-sheet margins.

Impact of the Diabetes Inpatient Care and Education (DICE) project and the DICE Care Pathway on patient outcomes and trainee doctor's knowledge and confidence

AIM

To evaluate the impact of the Diabetes Inpatient Care and Education project and a comprehensive diabetes care pathway, the Diabetes Inpatient Care and Education Care Pathway, on patient outcomes and on the knowledge and confidence of trainee doctors.

METHODS

The effect on patient outcomes was evaluated by comparing the National Diabetes Inpatient Audit data before (2012) and after (2013) implementing the Diabetes Inpatient Care and Education project. The impact on trainee doctors was evaluated using the Modified Kirkpatrick model. Just before the project began and again 3 months later, trainee doctors were surveyed to assess their knowledge and confidence in inpatient diabetes care.

RESULTS

Patient harm was found to have been reduced significantly when National Diabetes Inpatient Audit data for 2012 and 2013 were compared. Severe hypoglycaemia decreased from 15.4 to 9.7%, medication errors from 56.9 to 21.1% and insulin errors from 31 to 7%. Across the 96 trainee doctors surveyed, the mean (sd) knowledge and confidence scores increased significantly (P < 0.001 for both) from 57.1 (16.8) and 61.8 (14.9) to 68.4 (13.3) and 74.3 (11.7), respectively.

CONCLUSION

The Diabetes Inpatient Care and Education project and the Diabetes Inpatient Care and Education Care Pathway improved patient outcomes and the knowledge and confidence of trainee doctors in this hospital. The impact of a similar project in other hospitals needs to be evaluated.

3D culture model of fibroblast-mediated collagen creep to identify abnormal cell behaviour

Native collagen gels are important biomimetic cell support scaffolds, and a plastic compression process can now be used to rapidly remove fluid to any required collagen density, producing strong 3D tissue-like models. This study aimed to measure the mechanical creep properties of such scaffolds and to quantify any enhanced creep occurring in the presence of cells (cell-mediated creep). The test rig developed applies constant creep tension during culture and measures real-time extension due to cell action. This was used to model extracellular matrix creep, implicated in the transversalis fascia (TF) in inguinal hernia. Experiments showed that at an applied tension equivalent to 15% break strength, cell-mediated creep over 24-h culture periods was identified at creep rates of 0.46 and 0.38%/h for normal TF and human dermal fibroblasts, respectively. However, hernia TF fibroblasts produced negligible cell-mediated creep levels under the same conditions. Raising the cell culture temperature from 4 to 37 °C was used to demonstrate live cell dependence of this creep. This represents the first in vitro demonstration of TF cell-mediated collagen creep and to our knowledge the first demonstration of a functional, hernia-related cell abnormality.

Femoral vein injury from a trochanteric hip fracture

A case of a comminuted trochanteric fracture where the lesser trochanteric fragment had displaced significantly injuring and becoming lodged within the common femoral vein.

PainDETECT: a suitable screening tool for neuropathic pain in patients with painful post-traumatic trigeminal nerve injuries?

The PainDETECT questionnaire (PD-Q), originally developed and validated in a multicentre study of neuropathic pain (NeP) patients with back pain, is increasingly being applied to other pain conditions. The present study assessed whether the PD-Q would be a suitable screening tool for detecting NeP in patients with post-traumatic inferior alveolar nerve injury (IANI) and lingual nerve injury (LNI). A prospective cohort of patients with clinically diagnosed neuropathy was given the PD-Q at their clinic appointment, or it was sent to them after their consultation. Eighty-nine patients (IANI = 56, LNI = 33) were included in the study, 75 of whom suffered from painful neuropathy. Of the patients who completed the questionnaire fully (n = 56), allowing a summary score to be calculated, 34% were classified as having 'likely NeP' according to the PD-Q; 41% of patients scored in the uncertain classification range and the remaining quarter in the 'likely nociceptive' classification. There was a significant association between PD-Q scores and pain intensity levels across the sample, with those classified as likely NeP reporting high levels of pain. The results suggest that the PD-Q in its current format is not a suitable screening tool for NeP associated with IANI or LNI.