Diagnostic accuracy of virtual cognitive assessment and testing: Systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Virtual (i.e., telephone or videoconference) care was broadly implemented because of the COVID-19 pandemic. Our objectives were to compare the diagnostic accuracy of virtual to in-person cognitive assessments and tests and barriers to virtual cognitive assessment implementation.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, EMBASE, CDSR, CENTRAL, PsycINFO, and gray literature (inception to April 1, 2020).

PARTICIPANTS AND INTERVENTIONS

Studies describing the accuracy or reliability of virtual compared with in-person cognitive assessments (i.e., reference standard) for diagnosing dementia or mild cognitive impairment (MCI), identifying virtual cognitive test cutoffs suggestive of dementia or MCI, or describing correlations between virtual and in-person cognitive test scores in adults.

MEASUREMENTS

Reviewer pairs independently conducted study screening, data abstraction, and risk of bias appraisal.

RESULTS

Our systematic review included 121 studies (15,832 patients). Two studies demonstrated that virtual cognitive assessments could diagnose dementia with good reliability compared with in-person cognitive assessments: weighted kappa 0.51 (95% confidence interval [CI] 0.41-0.62) and 0.63 (95% CI 0.4-0.9), respectively. Videoconference-based cognitive assessments were 100% sensitive and specific for diagnosing dementia compared with in-person cognitive assessments in a third study. No studies compared telephone with in-person cognitive assessment accuracy. The Telephone Interview for Cognitive Status (TICS; maximum score 41) and modified TICS (maximum score 50) were the only virtual cognitive tests compared with in-person cognitive assessments in >2 studies with extractable data for meta-analysis. The optimal TICS cutoff suggestive of dementia ranged from 22 to 33, but it was 28 or 30 when testing was conducted in English (10 studies; 1673 patients). Optimal modified TICS cutoffs suggestive of MCI ranged from 28 to 31 (3 studies; 525 patients). Sensory impairment was the most often voiced condition affecting assessment.

CONCLUSION

Although there is substantial evidence supporting virtual cognitive assessment and testing, we identified critical gaps in diagnostic certainty.

Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis

OBJECTIVE

To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a neuropsychiatric symptom of dementia or have a diagnosis of a major depressive disorder.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and grey literature between inception and 15 October 2020.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised trials comparing drug or non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia.

MAIN OUTCOME MEASURES

Pairs of reviewers screened studies, abstracted aggregate level data, and appraised risk of bias with the Cochrane risk of bias tool, which facilitated the derivation of standardised mean differences and back transformed mean differences (on the Cornell scale for depression in dementia) from bayesian random effects network meta-analyses and pairwise meta-analyses.

RESULTS

Of 22 138 citations screened, 256 studies (28 483 people with dementia) were included. Missing data posed the greatest risk to review findings. In the network meta-analysis of studies including people with dementia without a diagnosis of a major depressive disorder who were experiencing symptoms of depression (213 studies; 25 177 people with dementia; between study variance 0.23), seven interventions were associated with a greater reduction in symptoms of depression compared with usual care: cognitive stimulation (mean difference -2.93, 95% credible interval -4.35 to -1.52), cognitive stimulation combined with a cholinesterase inhibitor (-11.39, -18.38 to -3.93), massage and touch therapy (-9.03, -12.28 to -5.88), multidisciplinary care (-1.98, -3.80 to -0.16), occupational therapy (-2.59, -4.70 to -0.40), exercise combined with social interaction and cognitive stimulation (-12.37, -19.01 to -5.36), and reminiscence therapy (-2.30, -3.68 to -0.93). Except for massage and touch therapy, cognitive stimulation combined with a cholinesterase inhibitor, and cognitive stimulation combined with exercise and social interaction, which were more efficacious than some drug interventions, no statistically significant difference was found in the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder. Clinical and methodological heterogeneity precluded network meta-analysis of studies comparing the efficacy of interventions specifically for reducing symptoms of depression in people with dementia and a major depressive disorder (22 studies; 1829 patients).

CONCLUSIONS

In this systematic review, non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017050130.

Safety of pharmacologic interventions for neuropsychiatric symptoms in dementia: a systematic review and network meta-analysis

Background

Prescribing trends suggest that pharmacologic alternatives to antipsychotics are gaining in popularity, but randomized trial (RCT) data of their comparative safety is scarce. Our objective was to describe the comparative safety of pharmacologic interventions for treating neuropsychiatric symptoms in dementia.

Methods

We searched MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO, from inception to May 28, 2019, for studies of pharmacologic interventions used to treat neuropsychiatric symptoms in dementia. Dementia care partners selected fracture risk as our primary outcome. Pairs of reviewers, working independently, conducted all study screening, data abstraction, and risk of bias appraisal. We conducted Bayesian random-effects network meta-analyses (NMAs) using data from RCTs to derive odds ratios (ORs). In secondary analyses, we conducted frequentist random-effects NMAs using data from RCTs and Bayesian three-level hierarchical random-effects NMAs incorporating data from RCTs and non-randomized studies.

Results

Our systematic review included 209 randomized and non-randomized studies (889,378 persons with dementia). In NMAs of data from randomized trials, there were no increased odds of fracture associated with any intervention in primary analyses; however, data were sparse. We found increased odds of cerebrovascular events associated with antipsychotics (odds ratio [OR] 2.12, 95% credible interval [CrI] 1.29 to 3.62; number needed to harm [NNH] = 99) and increased odds of falls associated with dextromethorphan-quinidine (OR 4.16, 95% CrI 1.47 to 14.22; NNH = 55) compared to placebo in persons with dementia. In a subgroup of persons with Alzheimer disease, antipsychotics were associated with increased odds of fracture compared to anticonvulsants (OR 54.1, 95% CrI 1.15 to 38,300; NNH = 18). In older persons (mean age ≥ 80 years) with dementia, anticonvulsants were associated with increased odds of death compared to placebo (OR 8.36, 95% CrI 1.17 to 203.4; NNH = 35) and antipsychotics were associated with increased odds of death compared to antidepressants (OR 5.28, 95% CrI 1.06 to 3.51; NNH = 47).

Conclusion

Although antipsychotics were associated with greater harm than antidepressants and anticonvulsants in subgroups of persons with dementia, medications used in lieu of antipsychotics for treating neuropsychiatric symptoms in dementia, such as anticonvulsants and dextromethorphan-quinidine, were also associated with harm. Decision-making concerning treatments prescribed in lieu of antipsychotics should include potential harms.

PROSPERO registration

CRD42017050130.

Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis

BACKGROUND

Both pharmacologic and nonpharmacologic interventions are used to treat neuropsychiatric symptoms in persons with dementia.

PURPOSE

To summarize the comparative efficacy of pharmacologic and nonpharmacologic interventions for treating aggression and agitation in adults with dementia.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO between inception and 28 May 2019 without language restrictions; gray literature; and reference lists scanned from selected studies and systematic reviews.

STUDY SELECTION

Randomized controlled trials comparing interventions for treating aggression and agitation in adults with dementia.

DATA EXTRACTION

Pairs of reviewers independently screened studies, abstracted data, and appraised risk of bias.

DATA SYNTHESIS

After screening of 19 684 citations, 163 studies (23 143 patients) were included in network meta-analyses. Analysis of interventions targeting aggression and agitation (148 studies [21 686 patients]) showed that multidisciplinary care (standardized mean difference [SMD], -0.5 [95% credible interval {CrI}, -0.99 to -0.01]), massage and touch therapy (SMD, -0.75 [CrI, -1.12 to -0.38]), and music combined with massage and touch therapy (SMD, -0.91 [CrI, -1.75 to -0.07]) were clinically more efficacious than usual care. Recreation therapy (SMD, -0.29 [CrI, -0.57 to -0.01]) was statistically but not clinically more efficacious than usual care.

LIMITATIONS

Forty-six percent of studies were at high risk of bias because of missing outcome data. Harms and costs of therapies were not evaluated.

CONCLUSION

Nonpharmacologic interventions seemed to be more efficacious than pharmacologic interventions for reducing aggression and agitation in adults with dementia.

PRIMARY FUNDING SOURCE

Alberta Health Services Critical Care Strategic Clinical Network. (PROSPERO: CRD42017050130).

Therapeutic targeting of ependymoma as informed by oncogenic enhancer profiling

Genomic sequencing has driven precision-based oncology therapy; however, genetic drivers remain unknown or non-targetable for many malignancies, demanding alternative approaches to identify therapeutic leads. Ependymomas are chemotherapy-resistant brain tumours, which, despite genomic sequencing, lack effective molecular targets. Intracranial ependymomas are segregated based on anatomical location – supratentorial region (ST) or posterior fossa (PF) – and further divided into distinct molecular subgroups that reflect differences in age of onset, gender predominance, and response to therapy^1–3. The most common and aggressive subgroup, Posterior Fossa Ependymoma Group A (PF-EPN-A), occurs in young children and appears to lack recurrent somatic mutations². Conversely, Posterior Fossa Ependymoma Group B (PF-EPN-B) tumours display frequent large-scale copy number gains and losses yet favourable clinical outcomes^1,3. Greater than 70% of supratentorial ependymomas are defined by highly recurrent gene fusions in the NFκB subunit RELA (ST-EPN-RELA), and less frequently involve fusion of the gene encoding the transcriptional activator YAP1 (ST-EPN-YAP1).^1,3,4 Subependymomas, a distinct histologic variant, can also be found within the ST and PF compartments accounting for the majority of tumours in the molecular subgroups ST-EPN-SE and PF-EPN-SE, respectively¹. Here, we mapped active chromatin landscapes in 42 primary ependymomas in two non-overlapping primary ependymoma cohorts with the goal of identifying essential super enhancer associated genes on which tumour cells were dependent. Enhancer regions revealed putative oncogenes, molecular targets, and pathways, which when subjected to small molecule inhibitor or shRNA treatment, diminished proliferation of patient-derived neurospheres and increased survival in mouse models of ependymomas. Through profiling of transcriptional enhancers, our study provides a framework for target and drug discovery in other cancers recalcitrant to therapeutic development because of their lack of known genetic drivers.

Spinal Myxopapillary Ependymomas Demonstrate a Warburg Phenotype

PURPOSE

Myxopapillary ependymoma (MPE) is a distinct histologic variant of ependymoma arising commonly in the spinal cord. Despite an overall favorable prognosis, distant metastases, subarachnoid dissemination, and late recurrences have been reported. Currently, the only effective treatment for MPE is gross-total resection. We characterized the genomic and transcriptional landscape of spinal ependymomas in an effort to delineate the genetic basis of this disease and identify new leads for therapy.

EXPERIMENTAL DESIGN

Gene expression profiling was performed on 35 spinal ependymomas, and copy number profiling was done on an overlapping cohort of 46 spinal ependymomas. Functional validation experiments were performed on tumor lysates consisting of assays measuring pyruvate kinase M activity (PKM), hexokinase activity (HK), and lactate production.

RESULTS

At a gene expression level, we demonstrate that spinal grade II and MPE are molecularly and biologically distinct. These are supported by specific copy number alterations occurring in each histologic variant. Pathway analysis revealed that MPE are characterized by increased cellular metabolism, associated with upregulation of HIF1α. These findings were validated by Western blot analysis demonstrating increased protein expression of HIF1α, HK2, PDK1, and phosphorylation of PDHE1A. Functional assays were performed on MPE lysates, which demonstrated decreased PKM activity, increased HK activity, and elevated lactate production.

CONCLUSIONS

Our findings suggest that MPE may be driven by a Warburg metabolic phenotype. The key enzymes promoting the Warburg phenotype: HK2, PKM2, and PDK are targetable by small-molecule inhibitors/activators, and should be considered for evaluation in future clinical trials for MPE.

E-selectin expression on human brain microvascular endothelial cells

E-Selectin is an endothelial adhesion molecule involved in binding and targeting of neutrophils. Little is known of its expression in the brain. We examined the expression of E-selectin on cultured human brain microvascular endothelial cells (HBMEC). There was no basal expression of E-selectin on HBMEC but with I1-1b, tumor necrosis factor (TNF), or lipopolysaccharide (LPS) stimulation there was surface expression at 4 h. The expression was quantitatively less than on cultured human umbilical vein endothelial cells (HUVEC). The cytokine-induced upregulation was partially inhibited with the glutathione donor, N-acetylcysteine (NAC), the free radical scavenger, dimethylthiourea (DMTU; 15 mM) and dexamethasone (1 microM). Allopurinol (100 microM) had no effect. TNF activated nuclear factor kappa B (NF kappa B) in HBMEC. This activation could be attenuated by prior treatment with NAC and dexamethasone. Thiol donors and corticosteroids could play a role in inhibiting potentially deleterious neutrophil-endothelial interactions in inflammatory conditions involving the brain.

Characterization of the regulatory function of the ICP22 protein of equine herpesvirus type 1

The IR4 gene (inverted repeat gene 4) of equine herpesvirus type 1 (EHV-), the homolog of the herpes simplex virus type 1 ICP22 gene, is differentially expressed as a 1.4-kb early transcript and a 1.7-kb late transcript that encode a series of proteins that migrate between 42 to 47 kDa, localize to the nucleus of EHV-1-infected cells, and become packaged within EHV-1 virions (V. R. Holden, G. B. Caughman, Y. Zhao, R. N. Harty, and D. J. O'Callaghan, J. Virol. 68, 4329-4340, 1994). To assess the role of the IR4 protein in EHV-1 gene regulation, an IR4 expression vector was cotransfected with EHV-1 chimeric promoter-CAT reporter constructs and EHV-1 effector plasmids to determine the effects of the IR4 protein on the expression of immediate-early (IE), early, and late promoters. These studies revealed that the IR4 protein: (i) minimally trans-activates EHV-1 promoters, (ii) acts synergistically with the UL3 (ICP27) gene product to trans-activate the IE promoter, (iii) does not interfere with the trans-repression of the IE promoter by the IE protein, (iv) enhances transactivation of early promoters by the IE protein, (v) enhances the transactivation of both early and late promoters by the IE and UL3 proteins, and (vi) interacts synergistically with the IE protein to trans-activate the heterologous HSV-1 ICP4 promoter. These data suggest that the IR4 gene product plays a significant role in EHV-1 gene regulation.

Blood group frequencies of the population of Trinidad and Tobago, West Indies

The results of grouping tests performed on blood samples collected over a five-year period at the Trinidad and Tobago Forensic Science Centre are presented. The samples were tested using the ABO, PGM, EAP and GLO blood group systems. Phenotypic frequencies and allele frequencies for each system were calculated for the two major ethnic groups of the population, the African and East Indian. Matching probabilities, which can be used in the interpretation of physical evidence in forensic cases, were also calculated.