Pediatric to Adult Transition in Inflammatory Bowel Disease: Consensus Guidelines for Australia and New Zealand

BACKGROUND

The incidence of pediatric inflammatory bowel disease (IBD) is rising, and there is an increasing need to support adolescents when they transition to adult care. Evidence supports the use of a structured transition process but there is great variation across Australasia. The study aim was to develop evidence and expert opinion-based consensus statements to guide transitional care services in IBD.

METHODS

A modified UCLA-RAND methodology was employed to develop consensus statements. An IBD expert steering committee was formed and a systematic literature review was conducted to guide the drafting of consensus statements. A multidisciplinary group was formed comprising 16 participants (clinicians, nurses, surgeons, psychologists), who anonymously voted on the appropriateness and necessity of the consensus statements using Likert scales (1 = lowest, 9 = highest) with a median ≥7 required for inclusion. Patient support groups, including direct input from young people with IBD, informed the final recommendations.

RESULTS

Fourteen consensus statements were devised with key recommendations including use of a structured transition program and transition coordinator, mental health and transition readiness assessment, key adolescent discussion topics, allied health involvement, age for transition, and recommendations for clinical communication and handover, with individualized patient considerations. Each statement reached median ≥8 for appropriateness, and ≥7 for necessity, in the first voting round, and the results were discussed in an online meeting to refine statements.

CONCLUSIONS

A multidisciplinary group devised consensus statements to optimize pediatric to adult transitional care for adolescents with IBD. These guidelines should support improved and standardized delivery of IBD transitional care within Australasia.

Human Fc gamma receptor IIIA blockade inhibits platelet destruction in a humanized murine model of ITP

ABSTRACT

Fc gamma receptor (FcγR) IIIA is an important receptor for immunoglobulin G (IgG) and is involved in immune defense mechanisms as well as tissue destruction in some autoimmune diseases including immune thrombocytopenia (ITP). FcγRIIIA on macrophages can trigger phagocytosis of IgG-sensitized platelets, and prior pilot studies observed blockade of FcγRIIIA increased platelet counts in patients with ITP. Unfortunately, although blockade of FcγRIIIA in patients with ITP increased platelet counts, its engagement by the blocking antibody drove serious adverse inflammatory reactions. These adverse events were postulated to originate from the antibody's Fc and/or bivalent nature. The blockade of human FcγRIIIA in vivo with a monovalent construct lacking an active Fc region has not yet been achieved. To effectively block FcγRIIIA in vivo, we developed a high affinity monovalent single-chain variable fragment (scFv) that can bind and block human FcγRIIIA. This scFv (17C02) was expressed in 3 formats: a monovalent fusion protein with albumin, a 1-armed human IgG1 antibody, and a standard bivalent mouse (IgG2a) antibody. Both monovalent formats were effective in preventing phagocytosis of ITP serum-sensitized human platelets. In vivo studies using FcγR-humanized mice demonstrated that both monovalent therapeutics were also able to increase platelet counts. The monovalent albumin fusion protein did not have adverse event activity as assessed by changes in body temperature, whereas the 1-armed antibody induced some changes in body temperature even though the Fc region function was impaired by the Leu234Ala and Leu235Ala mutations. These data demonstrate that monovalent blockade of human FcγRIIIA in vivo can potentially be a therapeutic strategy for patients with ITP.

Impact of bariatric surgery on cytochrome P 450 enzyme activity

Bariatric surgeries are becoming more prevalent as obesity rates continue to rise. Being that it is an effective weight-loss procedure, it can induce significant anatomical, physiological, and metabolic alterations, which affect the pharmacokinetics of various medications. Cytochrome (CYP) P450 is a group of enzymes that are primarily responsible for metabolizing most medications. Bariatric surgery may affect CYP activity and consequently alter metabolism of various medications, and the resulting weight loss may influence the metabolism of various drugs. This study investigates the impact of bariatric surgery on which CYP enzymes are affected and their effects medications. Authors of this study did an extensive literature review and research in databases including PubMed and EMBASE. The evidence was gathered for medication efficacy influenced by enzyme fluctuations to advocate for further studies for patients that undergo bariatric surgery. The search was limited to English-language results and is deemed up to date as of September 2023. There are numerous studies that indicated alterations of the CYP enzyme activity, which affects the pharmacokinetics of medications used to treat acute and chronic conditions after bariatric surgery. There are various mechanisms involved in CYP enzyme activity leading to fluctuations and the clearance of medications and subsequently compromising the efficacy and safety of these agents. It is imperative to conduct more prospective randomized control studies with longer duration to guide clinicians on how to manage medications with various CYP activity for patients' post-bariatric surgery.

Transitional care of adolescents with inflammatory bowel disease to adult services varies widely across Australia and New Zealand

Background and Aim

Children and adolescents account for approximately 14% of inflammatory bowel disease (IBD) diagnoses. At an appropriate age and level of development adolescents with IBD have their care transferred from the pediatric to adult clinical team during a process termed "transition". The study aim was to survey pediatric gastroenterologists throughout Australasia to identify commonality in the transition process to contribute to standardized guideline development.

Methods

A descriptive survey captured key variables: transition clinic format, process and infrastructure, transition assessments, and guidelines. The survey was distributed electronically to 59 Pediatric Gastroenterologists throughout Australasia in January 2023.

Results

Seventeen (29%) clinicians completed the survey: Australia 13 (76%). New Zealand 4 (24%). Thirteen (76%) respondents had access to a dedicated IBD transition clinic. Adolescents attended transition clinics 1-7 times, and the main processes transferred were: prescription provision, biologic appointments, and adult team contacts. Transition was first discussed age 13-15 years (53%), or 16-18 years (47%), with the main discussion topics including: continuing adherence (88%), smoking (59%), alcohol use (59%), recreational drug use (59%). Transition readiness assessments were done infrequently (24%). The minority (24%) used formal guidelines to inform the transition process, but 15 (88%) considered the development of a standardized Australasian guideline as beneficial/extremely beneficial.

Conclusions

This survey highlighted that transition care for adolescents with IBD is variable across Australasia. Australasian guideline development may optimize the transition process for adolescents with IBD and improve their longitudinal outcomes.

Return to sports following discectomy: does a consensus exist?

INTRODUCTION

In the USA, lumbar discectomy is one of the most commonly performed spinal procedures. As certain sports are considered to be major risk factors for disc herniation, the question remains as to when highly active patients should return to their previous level of activity. This study aimed to analyze spine surgeons' opinions on when patients may return to activities following discectomy as well as their underlying rationale for their decision.

METHODS

A questionnaire was designed by five different fellowship-trained spine surgeons for the 168 members of the Spine Society of Australia. Questions on the surgeons experience, decision making, preferred surgical technique, the postoperative rehabilitation and the response to patient expectations were included.

RESULTS

In total, 83.9% of surgeons discuss the postoperative level of activity with their patients. Sport is considered as an important contributor for good functional outcome by 71.0% of surgeons. Surgeons recommend avoiding, often permanently, weightlifting (35.7%) of the time, rugby (21.4%), horseback riding (17.9%) as well as martial arts (14.3%) postoperatively even with previous training. The return to high levels of activity is considered as a major risk factor for disc herniation recurrence by 25.8% of surgeons. Return to high level of activity is typically recommended after 3 months by 48.4% of surgeons.

CONCLUSION

So far no consensus on the rehabilitation protocol and return to level of activity exists. Recommendations depend on personal experience as well as the individuals' training, and typically, a period of avoidance of sport for up to 3 months is recommended.

LEVEL OF EVIDENCE

Level III, therapeutic and prognostic study.

A suite of selective pressures supports the maintenance of alleles of a Drosophila immune peptide

The innate immune system provides hosts with a crucial first line of defense against pathogens. While immune genes are often among the fastest evolving genes in the genome, in Drosophila, antimicrobial peptides (AMPs) are notable exceptions. Instead, AMPs may be under balancing selection, such that over evolutionary timescales multiple alleles are maintained in populations. In this study, we focus on the Drosophila antimicrobial peptide Diptericin A, which has a segregating amino acid polymorphism associated with differential survival after infection with the Gram-negative bacteria Providencia rettgeri. Diptericin A also helps control opportunistic gut infections by common Drosophila gut microbes, especially those of Lactobacillus plantarum. In addition to genotypic effects on gut immunity, we also see strong sex-specific effects that are most prominent in flies without functional diptericin A. To further characterize differences in microbiomes between different diptericin genotypes, we used 16S metagenomics to look at the microbiome composition. We used both lab reared and wild caught flies for our sequencing and looked at overall composition as well as the differential abundance of individual bacterial families. Overall, we find flies that are homozygous serine for diptericin A are better equipped to survive a systemic infection from P. rettgeri, but in general homozygous arginine flies have a longer lifespan after being fed common gut commensals. Our results suggest a possible mechanism for the maintenance of genetic variation of diptericin A through the complex interactions of sex, systemic immunity, and the maintenance of the gut microbiome.

IMscin001 Part 2: a randomised phase III, open-label, multicentre study examining the pharmacokinetics, efficacy, immunogenicity, and safety of atezolizumab subcutaneous versus intravenous administration in previously treated locally advanced or metastatic non-small-cell lung cancer and pharmacokinetics comparison with other approved indications

BACKGROUND

Atezolizumab intravenous (IV) is approved for the treatment of various solid tumours. To improve treatment convenience and health care efficiencies, a coformulation of atezolizumab and recombinant human hyaluronidase PH20 was developed for subcutaneous (SC) use. Part 2 of IMscin001 (NCT03735121) was a randomised phase III, open-label, multicentre, noninferiority study comparing the drug exposure of atezolizumab SC with atezolizumab IV.

PATIENTS AND METHODS

Eligible patients with locally advanced/metastatic non-small-cell lung cancer were randomised 2 : 1 to receive atezolizumab SC (1875 mg; n = 247) or IV (1200 mg; n = 124) every 3 weeks. The co-primary endpoints were cycle 1 observed trough serum concentration (Ctrough) and model-predicted area under the curve from days 0 to 21 (AUC0-21 d). The secondary endpoints were steady-state exposure, efficacy, safety, and immunogenicity. Exposure following atezolizumab SC was then compared with historical atezolizumab IV values across approved indications.

RESULTS

The study met both of its co-primary endpoints: cycle 1 observed Ctrough {SC: 89 μg/ml [coefficient of variation (CV): 43%] versus IV: 85 μg/ml (CV: 33%); geometric mean ratio (GMR), 1.05 [90% confidence interval (CI) 0.88-1.24]} and model-predicted AUC0-21 d [SC: 2907 μg d/ml (CV: 32%) versus IV: 3328 μg d/ml (CV: 20%); GMR, 0.87 (90% CI 0.83-0.92)]. Progression-free survival [hazard ratio 1.08 (95% CI 0.82-1.41)], objective response rate (SC: 12% versus IV: 10%), and incidence of anti-atezolizumab antibodies (SC: 19.5% versus IV: 13.9%) were similar between arms. No new safety concerns were identified. Ctrough and AUC0-21 d for atezolizumab SC were consistent with the other approved atezolizumab IV indications.

CONCLUSIONS

Compared with IV, atezolizumab SC demonstrated noninferior drug exposure at cycle 1. Efficacy, safety, and immunogenicity were similar between arms and consistent with the known profile for atezolizumab IV. Similar drug exposure and clinical outcomes following SC and IV administration support the use of atezolizumab SC as an alternative to atezolizumab IV.

Positive Bubble Study But No Evidence of Interatrial Defect in a Patient with Recurrent Cryptogenic Stroke

Pulmonary arteriovenous malformations (PAVMs) can be asymptomatic or result in a range of complications such as brain abscesses or cryptogenic emboli, which can contribute to morbidity and mortality if not diagnosed and treated in a timely manner. To date, there have been several reports of delayed diagnosis of PAVMs, which have been largely attributed to the misconception that PAVMs are too rare to be of clinical significance. Furthermore, because intracardiac shunting secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD) also results in a positive saline contrast study with echocardiography, PAVM can be easily misdiagnosed as an intracardiac right-toleft shunt. However, there are unique echocardiographic features that differentiate between intracardiac shunting due to a PFO or ASD and extracardiac shunting such as in PAVM. This case details the course of a patient with recurrent cryptogenic strokes that was initially misattributed to a PFO and was only correctly diagnosed with multiple PAVMs after two failed attempts at PFO closure. This case serves as a reminder of an alternative etiology of right-to-left shunt and its presentation on imaging, which echocardiographers must be familiar with.

Abstract 1886: Identifying T-cell engagers with optimal potency and cytokine-release profiles with a diverse panel of CD3-binding antibodies

In this study, we describe the characterization and validation of a diverse panel of fully human CD3-binding antibodies, including hundreds of human and cyno cross-reactive binders. We used two proof-of-concept TCE targets to demonstrate that this panel streamlines CD3 T-cell engager (TCE) development, enabling identification of optimal tumor cell-killing and cytokine-release profiles. CD3 TCEs have potential to be powerful cancer treatments, but the small number of available CD3-binding antibodies and limited multispecific engineering technologies have been barriers to development. Identifying TCEs that balance anti-tumor potency with potential toxicities, such as cytokine release syndrome, requires simultaneous tuning of both the CD3- and tumor-binding arms. Pairs of antibodies that achieve this balance are rare, creating a need for diverse panels of developable antibodies that can be combined and tested to identify optimal clinical candidates. To streamline TCE development, we discovered a diverse panel of CD3-binding antibodies. We screened over 5 million single cells from humanized mice and identified 585 unique CD3-specific antibody sequences. Of these, over 170 were identified as cross-reactive to human and cyno CD3 in primary screening. We then used high-throughput characterization to curate a panel of diverse and developable antibodies. We found a wide range of CD3εδ and CD3εγ binding specificities, affinities, and kinetics. Epitope binning analysis revealed multiple bins containing human and cyno cross-reactive binders, some of which are distinct from previously described cross-reactive antibodies, such as SP34-2. We assessed their biophysical properties and identified antibodies with good developability properties, including high thermal stability and low hydrophobicity, self-association, polyspecificity, and aggregation. To validate these antibodies, we used OrthoMab™ to generate proof-of-concept TCE panels with fixed tumor-binding arms. We identified CD3 x EGFR TCEs with high potency, low cytokine release, functional cross-reactivity in a cyno T cell-mediated tumor killing assay, and good pharmacokinetic properties in Tg32 mice. A second proof-of-concept CD3 x PSMA panel further validated our antibodies in bispecific formats. Together, these studies demonstrate that starting with diverse CD3-binding antibodies streamlines identification of developable TCEs with optimal potency and cytokine release. We leveraged data from our extensive characterization of CD3-binding antibodies in mono- and bispecific formats to develop a strategy for down-selection and pairing of CD3- and tumor-binding antibodies, and a high-throughput method for analysis of resulting TCEs. By categorizing antibodies based on functional properties, we are able to rapidly pinpoint optimal potential clinical candidates for specific tumor targets.

Citation Format: Juntao (Matt) Mai, Kate Caldwell, Lindsay DeVorkin, Grace P. Leung, Karine Herve, Yuri Hwang, Cristina Faralla, Wei Wei, Emma Lathouwers, Valentine de Puyraimond, Lauren Clifford, Rhys S. Chappell, Stefan Hannie, Katherine J. Lam, Harveer Dhupar, Tran N. Tran, Melissa Cid, Lena M. Bolten, Tova Pinsky, Ping Xiang, Courteney Lai, Ahn Lee, Vivian Z. Li, Patrick Chan, Jasmine Chin, Steve Booth, Amy C. Lee, Stephanie Masterman, Sherie Duncan, Aaron Yamniuk, Kush Dalal, Tim M. Jacobs, Raffi Tonikian, Bryan C. Barnhart. Identifying T-cell engagers with optimal potency and cytokine-release profiles with a diverse panel of CD3-binding antibodies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1886.

Effects of bariatric surgery on drug pharmacokinetics-Preclinical studies

With the rising worldwide obesity rates, bariatric surgeries are increasing. Although the surgery offers an effective treatment option for weight loss, the procedure causes dramatic physiological and metabolic changes. Animal models in rodents provide a valuable tool for studying the systemic effects of the surgery. Since the surgery may significantly influence the pharmacokinetic properties of medications, animal studies should provide essential insight into mechanisms underlying changes in how the body handles the drug. This review summarizes research work in rodents regarding the impact of standard bariatric procedures on pharmacokinetics. A qualitative literature search was conducted via PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE. Studies that examined bariatric surgery's effects on drug pharmacokinetics in rodent models were included. Clinical studies and studies not involving drug interventions were excluded. A total of 15 studies were identified and assessed in this review. These studies demonstrate the possible impact of bariatric surgery on drug absorption, distribution, metabolism, excretion, and potential mechanisms. Pharmacokinetic changes exhibited in the limited pre-clinical studies highlight a need for further investigation to fully understand the impact and mechanism of bariatric surgery on drug responses.

An obscure cause of gastrointestinal bleeding: Recurrent duodenal variceal hemorrhage treated with intramuscular octreotide in the absence of portal hypertension

Duodenal varices (DVs) are ectopic gastrointestinal varices (ECVs) associated with portal hypertension (PH). We present the case of an 82-year-old woman who presented with symptomatic anemia secondary to DV hemorrhage diagnosed on oesophagogastroduodenoscopy. This lesion was treated with endoscopic adrenaline injection and clip application. The patient re-presented on multiple occasions with bleeding recurrence localized to the duodenum, which was managed with intramuscular octreotide and oral beta-blockade resulting in sustained remission of bleeding. This case highlights a rare cause of upper gastrointestinal hemorrhage and highlights the value of somatostatin analogues for conservative treatment of DVs.

Objective Sleep Quality and the Underlying Functional Neural Correlates Among Older Adults with Possible Mild Cognitive Impairment

BACKGROUND

Poor sleep quality is common among older individuals with mild cognitive impairment (MCI) and may be a consequence of functional alterations in the brain; yet few studies have investigated the underlying neural correlates of actigraphy-measured sleep quality in this cohort.

OBJECTIVE

The objective of this study was to examine the relationship between brain networks and sleep quality measured by actigraphy.

METHODS

In this cross-sectional analysis, sleep efficiency and sleep fragmentation were estimated using Motionwatch8 (MW8) over a period of 14 days in 36 community-dwelling older adults with possible MCI aged 65-85 years. All 36 participants underwent resting-state functional magnetic resonance imaging (fMRI) scanning. Independent associations between network connectivity and MW8 measures of sleep quality were determined using general linear modeling via FSL. Networks examined included the somatosensory network (SMN), frontoparietal network (FPN), and default mode network (DMN).

RESULTS

Across the 36 participants (mean age 71.8 years; SD = 5.2 years), mean Montreal Cognitive Assessment score was 22.5 (SD = 2.7) and Mini-Mental State Examination score was 28.3 (SD = 1.5). Mean sleep efficiency and fragmentation index was 80.1% (SD = 10.0) and 31.8 (SD = 10.4) respectively. Higher sleep fragmentation was significantly correlated with increased connectivity between the SMN and insula, the SMN and posterior cingulate, as well as FPN and primary motor area (FDR-corrected, p <  0.004).

CONCLUSION

Functional connectivity between brain regions involved in attentional and somatosensory processes may be associated with disrupted sleep in older adults with MCI.

Spinal extradural arachnoid cyst: A rare cause of thoracic myelopathy

A spinal extradural arachnoid cyst (SEAC) is a rare condition which can lead to back pain, radiculopathy, and compressive myelopathy. It accounts for approximately 1% of spinal tumours. The exact aetiology of SEACs is not well understood; however, this study is supportive of a traumatic aetiology of this disease in addition to supporting a uni-directional valve as a mechanism of CSF accumulation. The purpose of this study is to review the presentation, work-up, treatment and postoperative course of a patient with SEAC. We present the case of a 40-year-old male with a history of trauma who developed a SEAC and was treated surgically at our unit. Although a rare disease, we highlight the importance of early diagnosis and surgical treatment as it is a surgically curable disease with a good postoperative prognosis.

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SEAC is an important differential diagnosis for compressive myelopathy.

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Trauma may be an underlying cause of SEAC development.

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Uni-directional valve is the likely mechanism of CSF accumulation in a SEAC.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Comparing the cost-effectiveness of the Otago Exercise Programme among older women and men: A secondary analysis of a randomized controlled trial

Objective

Using stratified analyses, we examined the cost-effectiveness of the Otago Exercise Programme (OEP), from a health care system perspective, among older women and men who have previously fallen.

Methods

This study was a secondary stratified analysis (by women and men), of a 12-month prospective economic evaluation of a randomized clinical trial (OEP compared with usual care). Three hundred and forty four community-dwelling older adults (≥70; 172 OEP (110 women; 62 men), 172 usual care (119 women; 53 men)) who sustained a fall in the past 12 months and received a baseline assessment at the Vancouver Falls Prevention Clinic, Canada were included. A gender by OEP/usual care interaction was examined for the falls incidence rate ratio (IRR). Outcome measures stratified by gender included: falls IRR, incremental cost-per fall prevented (ICER), incremental cost per quality adjusted life year (QALY, ICUR) gained, and mean total health care resource utilization costs.

Results

Men were frailer than women at baseline. Men incurred higher mean total healthcare costs $6794 (SD: $11906)). There was no significant gender by OEP/usual care interaction on falls IRR. The efficacy of the OEP did not vary by gender. The adjusted IRR for the OEP group demonstrated a 39% (IRR: 0.61, CI: 0.40–0.93) significant reduction in falls among men but not women (32% reduction (IRR: 0.69, CI: 0.47–1.02)). The ICER showed the OEP was effective in preventing falls and less costly for men, while it was costlier for women by $42. The ICUR showed the OEP did not impact quality of life.

Conclusion

Future studies should explore gender factors (i.e., health seeking behaviours, gender related frailty) that may explain observed variation in the cost-effectiveness of the OEP as a secondary falls prevention strategy.

Trial registrations

ClinicalTrials.gov Protocol Registration System

Identifier: NCT01029171; URL: https://clinicaltrials.gov/ct2/show/NCT01029171

Identifier: NCT00323596; URL: https://clinicaltrials.gov/ct2/show/NCT00323596

Objective Sleep Quality and the Underlying Functional Neural Correlates Among Older Adults With Probable MCI

Poor sleep is a strong risk factor for dementia and is commonly reported among older adults with mild cognitive impairment (MCI). However, the neural underpinnings of poor sleep among older adults with MCI remains equivocal. The goal of this cross-sectional analysis was to explore the relationship between resting-state functional connectivity in the brain and sleep quality as measured by actigraphy. We hypothesize lower sleep efficiency and higher sleep fragmentation may be associated with aberrant functional connectivity of brain regions involved in somatosensory, somatomotor, and attentional processing. Thirty-six community-dwelling older adults with probable MCI between 65-85 years (mean=71.8 years) were assessed for sleep quality using a motion watch to quantify sleep efficiency and fragmentation over 14 days. All participants completed resting-state functional magnetic resonance imaging (fMRI) within 14 days of sleep monitoring. Independent associations between network connectivity and sleep quality were determined using general linear models. Examined networks included the somatosensory network (SMN), dorsal attention network (DAN), ventral attention network (VAN), frontoparietal network (FPN), and default mode network (DMN). Mean Montreal Cognitive Assessment score was 22.5 (SD=2.7) and Mini-Mental State Examination score was 28.3 (SD=1.5). Mean sleep efficiency and fragmentation index was 80.1% and 31.8 respectively. Higher sleep fragmentation correlated with increased connectivity between the SMN and insula, the SMN and posterior cingulate, as well as FPN and primary motor area (Z=3.1; p<0.05). These results suggest aberrant functional connectivity between brain regions involved in attentional and somatosensory processes may be associated with disrupted sleep mechanisms in older adults with MCI.

COVID-19: Highlighting Health Disparities in the Los Angeles Latinx Community

Objective: Characterization of COVID-19 in the Latinx community is necessary for guiding public health initiatives, health system policy, clinical management practices, and improving outcomes. Our aim was to describe the socioeconomic background and clinical profile of patients with COVID-19 at a large public hospital in Los Angeles to improve health disparities leading to poor outcomes during the pandemic.Design, Setting and Participants: A single center retrospective cross-sectional study of all patients with a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to Los Angeles County (LAC)+University of Southern California (USC) Medical Center between March 15, 2020 and April 30, 2020.Methods: We describe patient characteristics, socioeconomic factors, laboratory findings, and outcomes of the first 278 patients to present to LAC+USC Medical Center with COVID-19.Results: Patients self-identified as Hispanic (82.4%) or non-Hispanic (17.6%). Hispanic patients presented later from symptom onset (6 days vs 3 days, P = 0.027) and had higher post-intubation mortality (40.9% vs. 33.3%, P = 1), intensive care unit (ICU) mortality (31.1% vs. 22.2%, P = 0.87), and overall mortality (11.1% vs 10.2%, P = 1). However, the difference in admission rates, mechanical ventilation rates, and overall mortality rates were not statistically significant. A majority of patients, 275/278 (98.9%), reported residency ZIP codes in areas of higher population density, higher percentage of Latinx, born outside the United States, lower median income, and lower high school graduation rate when compared to the rest of Los Angeles County. Regression analysis within the Hispanic cohort found that age, history of hypertension, history of diabetes, lactate dehydrogenase (LDH), and C-reactive protein (CRP) were predictors of mechanical ventilation and mortality.Conclusion: We show the Latinx community has been disproportionally affected by the pandemic in Los Angeles and we identified multiple socioeconomic and clinical characteristics that predispose this population to COVID-19 infection. This study highlights the need for change in local and national strategies to protect vulnerable communities during public health outbreaks.

Integration of clinical pharmacists into a heart failure clinic within a safety-net hospital

BACKGROUND

Management of heart failure with reduced ejection fraction (HFrEF) requires timely initiation and up-titration of guideline-directed medical therapy (GDMT). In safety-net hospitals (SNHs), limited health care staff and resources make achievement of optimal medical therapy challenging. Recent studies have shown that medication titration performed by clinical pharmacists can improve outcomes in ambulatory management of HFrEF; however, the impact of these services within an SNH remains unknown.

OBJECTIVE

Determine the impact of integrating clinical pharmacists into a heart failure (HF) clinic on initiation and titration of GDMT within an SNH.

METHODS

We performed a single-center retrospective cohort study of patients with HFrEF treated in an ambulatory HF medication titration clinic within an SNH before and after clinical pharmacist integration. Primary outcomes included dose optimization rates of GDMT, time between clinic visits, and time to optimization of GDMT. Exploratory secondary outcomes were all-cause, HF, and cardiovascular acute care service utilization and all-cause, HF, and cardiovascular mortality before and after clinical pharmacist integration up to 6 months after initial clinic visit.

RESULTS

A total of 153 patients with HFrEF were treated. Baseline characteristics in the pre- and postintervention groups were comparable. After clinical pharmacist integration, there was a statistically significant improvement in optimization of renin-angiotensin-aldosterone system inhibitor or hydralazine-nitrate equivalent (82% vs. 94%, P = 0.02). Dose optimization rates of beta-blockers (90% vs. 83%, P = 0.22) and mineralocorticoid receptor antagonists (57% vs. 57%, P > 0.99) were unchanged. There was a statistically significant reduction in mean time between clinic visits (26 vs. 14 days, P < 0.001) and in mean time to optimization of GDMT (88 vs. 45 days, P = 0.002). All-cause mortality was reduced (13% vs. 2%, P = 0.01).

CONCLUSION

In SNHs, where limited health care staff and resources present as barriers to timely initiation and titration of GDMT, integration of clinical pharmacists into HF clinics can serve as a practical solution.

Circulating microRNA breast cancer biomarker detection in patient sera with surface plasmon resonance imaging biosensor

In this article, we report for the first time, the detection of circulating miRNA as a breast cancer biomarker in patient sera using surface plasmon resonance imaging biosensor. The advantage of this approach lies in the rapid, label-free and sensitive detection. The sensor excites plasmonic resonance on the gold sensor surface and specific DNA-miRNA molecular bindings elucidate responses in the plasmonic resonance image. Experiments of detecting synthetic miRNA molecules (miR-1249) were performed and the sensor resolution was found to be 63.5 nM. The sensor was further applied to screen 17 patient serum samples from National Cancer Centre Singapore and Tan Tock Seng Hospital. Sensor intensity response was found to differ by 20% between malignant and benign cases and thus forms, a potential and an important metric in distinguishing benignity and malignancy.

Is antibiotic treatment effective in the management of chronic low back pain with disc herniation? Study protocol for a randomised controlled trial

Background

There has been immense interest and debate regarding the effectiveness of antibiotic treatment for chronic low back pain. Two randomised controlled trials have examined the efficacy of antibiotics for chronic low back pain with disc herniation and Modic changes, but have reported conflicting results. The aim of this double-blind, randomised, placebo-controlled trial is to determine the efficacy of antibiotic treatment in a broader patient subgroup of chronic low back pain with disc herniation and investigate whether the presence of Modic changes predicts response to antibiotic therapy.

Methods

One hundred and seventy individuals with chronic low back pain will be recruited through hospital and private medical and allied health clinics; advertising in national, community and social media; and posting of flyers in community locations. They will be randomly allocated to receive either amoxicillin-clavulanate (500 mg/125 mg) twice per day for 90 days or placebo. The primary outcome measure of pain intensity will be assessed using the Low Back Pain Rating scale and a 100-mm visual analogue scale at 12 months. Secondary measures of self-reported low back disability and work absence and hindrance will also be examined, and an economic analysis will be conducted. Intention-to-treat analyses will be performed.

Discussion

There is uncertainty about whether antibiotic treatment is effective for chronic low back pain and, if effective, which patient subgroup is most likely to respond. We will conduct a clinical trial to investigate the efficacy of antibiotics compared with placebo in individuals with chronic low back pain and a disc herniation. Our findings will provide high-quality evidence to assist in answering these questions.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12615000958583. Registered on 11 September 2015

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05728-1.

Safety, satisfaction, and cost savings of accelerated infusions of standard and intensified-dose infliximab for inflammatory bowel disease

INTRODUCTION

Infliximab remains a mainstay for treatment of inflammatory bowel disease (IBD), but a long infusion duration and subsequent monitoring can be burdensome to patients and health care providers. We assessed the safety of accelerated infusions for standard and dose-intensified infliximab regimens, and the effect on patient satisfaction and potential cost savings.

METHODS

Patients with IBD on a stable maintenance dose of infliximab and in clinical remission received one or more accelerated infusions; over 30 min if receiving standard-dose (5 mg/kg), or over 60 min if receiving dose-intensified infliximab (up to 10 mg/kg). Outcomes included incidence of reactions (acute or delayed), patient satisfaction, and potential cost savings. We also explored infliximab trough levels after one and three accelerated infusions.

RESULTS

52 patients who received 150 infusions were studied. Incidence of reactions to accelerated infusions was 3.3% (3 out of 89) with standard-dose and 0% (out of 61) with dose-intensified infliximab. Reactions were delayed, mild, and self-limiting. None requiring drug cessation. Patient satisfaction was improved with shortened infusion time as compared to the patients' previous experiences (p = 0.00002). Mean plasma trough level of infliximab reduced from 9.3 mg/L (± 4.9) to 7.9 mg/L (± 4.1) (p = 0.02) with accelerated infusions, but none developed anti-infliximab antibodies. Nursing cost savings were estimated as $123.52 and $247.04 per-patient per-year for standard and dose-intensified infliximab, respectively.

CONCLUSION

Accelerated infliximab infusions for standard and dose-intensified regimens seems to be safe and improved patient satisfaction. Potential impact on drug trough levels requires further investigations. This article is protected by copyright. All rights reserved.

P–383 Cytogenetic analysis of products of conception from miscarriages following natural conception and IVF pregnancy: a comparative study

Study question

Do cytogenetic results from products of conception from miscarriages differ from patients conceiving by natural conception versus IVF? Summary answer: Cytogenetic results were similar, with no statistical difference from miscarriages following natural conception and assisted conception.

What is known already

Cytogenetic sampling of products of conception (POC) following recurrent miscarriages (RM) are recommended to rule out parental chromosomal rearrangements. The RCOG recommends cytogenetic testing in cases of recurrent miscarriages (3 consecutive miscarriages). However some units routinely request cytogenetic analysis following a single miscarriage following an IVF pregnancy. There is no evidence to support the routine sampling of POCs following assisted conception. Study design, size, duration: Retrospective cohort study of 117 cytogenetic samples, followed up by the outcome of parental karyotyping if applicable. Patients were categorised based on mode of conception into natural conception (NC) with recurrent miscarriages (≥3) or one miscarriage following IVF. Data collected between 2018–2020. Primary Outcome measure: Presence and type of cytogenetic abnormality; individual parental targeted G-band karyotyping result. Participants/materials, setting, methods: A total of 117 cytogenetic results were reviewed, of which 35 were unsuitable for analysis due to contamination (Total n = 79: NC = 60, IVF = 19). Main results and the role of chance: Cytogenetic analysis showed abnormal results in 59% of miscarriages following natural conception and 53% of miscarriages from IVF pregnancy (p = 0.46).

Abnormal cytogenetic results were mainly sporadic. Trisomy 16 was the commonest abnormality in both groups. Others included Trisomy 15, 22, 21, 8, 13, 5, 9, 10, 14, 18, single X (Turner’s), all occurring in the same frequency in both groups. As expected 35 out of 45 abnormal cytogenetic results occurred with a maternal age greater than 35 years.

One couple from the NC group were referred to a geneticist for a Trisomy 9 imbalance. All other parental karyotyping results were normal.

Limitations, reasons for caution

This study contains a small sample size, and would benefit from further data collection to account for a percentage of samples being inadequate for analysis. Wider implications of the findings: Cytogenetic results were similar from miscarriages following natural conception and assisted conception. IVF does not increase the risk of miscarriage from abnormal embryonic karyotype. Routine cytogenetic testing following one miscarriage in patients undergoing IVF is not cost effective.

Trial registration number

Not applicable

DNA methylation and breast cancer-associated variants

BACKGROUND

A breast cancer polygenic risk score (PRS) comprising 313 common variants reliably predicts disease risk. We examined possible relationships between genetic variation, regulation, and expression to clarify the molecular alterations associated with these variants.

METHODS

Genome-wide methylomic variation was quantified (MethylationEPIC) in Asian breast cancer patients (1152 buffy coats from peripheral whole blood). DNA methylation (DNAm) quantitative trait loci (mQTL) mapping was performed for 235 of the 313 variants with minor allele frequencies > 5%. Stability of identified mQTLs (p < 5e-8) across lifetime was examined using a public mQTL database. Identified mQTLs were also mapped to expression quantitative trait loci (eQTLs) in the Genotype-Tissue Expression Project and the eQTLGen Consortium.

RESULTS

Breast cancer PRS was not associated with DNAm. A higher proportion of significant cis-mQTLs were observed. Of 822 significant cis-mQTLs (179 unique variants) identified in our dataset, 141 (59 unique variants) were significant (p < 5e-8) in a public mQTL database. Eighty-six percent (121/141) of the matched mQTLs were consistent at multiple time points (birth, childhood, adolescence, pregnancy, middle age, post-diagnosis, or treatment). Ninety-three variants associated with DNAm were also cis-eQTLs (35 variants not genome-wide significant). Multiple loci in the breast cancer PRS are associated with DNAm, contributing to the polygenic nature of the disease. These mQTLs are mostly stable over time.

CONCLUSIONS

Consistent results from DNAm and expression data may reveal new candidate genes not previously associated with breast cancer.

Molecular response of a sub-antarctic population of the blue mussel (Mytilus edulis platensis) to a moderate thermal stress

The Kerguelen Islands (49°26'S, 69°50'E) represent a unique environment due to their geographical isolation, which protects them from anthropogenic pollution. The ability of the endemic mussel, part of the Mytilus complex, to cope with moderate heat stress was explored using omic tools. Transcripts involved in six major metabolic functions were selected and the qRT-PCR data indicated mainly changes in aerobic and anaerobic energy metabolism and stress response. Proteomic comparisons revealed a typical stress response pattern with cytoskeleton modifications and elements suggesting increased energy metabolism. Results also suggest conservation of protein homeostasis by the long-lasting presence of HSP while a general decrease in transcription is observed. The overall findings are consistent with an adaptive response to moderate stresses in mussels in good physiological condition, i.e. living in a low-impact site, and with the literature concerning this model species. Therefore, local blue mussels could be advantageously integrated into biomonitoring strategies, especially in the context of Global Change.

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BACKGROUND

Pilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures.

METHODS

Ovid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review.

RESULTS

Of the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used.

CONCLUSIONS

This review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.

Clinical and laboratory impact of concomitant syphilis infection during acute HIV

INTRODUCTION

Cognitive impairment has been reported in people living with HIV-1 (PLWH) with prior syphilis, while PLWH who present with incident syphilis have reduced blood CD4 T-lymphocyte and elevated HIV-1 RNA levels. However, the clinical, virological and neurocognitive effects of syphilis during acute HIV-1 (AHI) remain unknown.

METHODS

Pre-antiretroviral therapy laboratory outcomes and neurocognitive performance in a four-test battery in the SEARCH10/RV254 AHI cohort were compared according to syphilis status, determined by serum Treponema pallidum haemagglutination (TPHA), Venereal Disease Research Laboratory (VDRL) and syphilis treatment history. Impaired cognitive performance was defined as having z-scores ≤ -1 in at least two tests or ≤ -2 in at least one test.

RESULTS

Out of 595 AHI participants (97% male, median age of 26 years and estimated duration of HIV-1 infection of 19 days), 119 (20%) had history of syphilis (TPHA-positive), of whom 51 (9%) had untreated syphilis (TPHA-positive/VDRL-positive/without prior treatment). Compared with those without syphilis (TPHA-negative), individuals with untreated syphilis had higher CD8 T-lymphocyte levels but not higher plasma HIV-1 RNA or lower CD4 T-lymphocyte levels. Taking into account estimated duration of HIV-1 infection (P < 0.001), and later Fiebig stages (III-V) (P < 0.001), those with untreated syphilis had higher CD8 T-lymphocyte levels (P = 0.049). Individuals with any syphilis (TPHA-positive), but not untreated syphilis, had higher odds of impaired cognitive performance than those without (P = 0.002).

CONCLUSIONS

During AHI, individuals with any history of syphilis (TPHA-positive) had poorer cognitive performance than those without syphilis. However, syphilis was not associated with worsened HIV disease measures as described in chronic infection.

Cognitive Function and Functional Mobility Predict Exercise Adherence in Older Adults Who Fall

INTRODUCTION

Strength and balance exercises prevent falls. Yet, exercise adherence is often low. To maximize the benefit of exercise on falls prevention, we aimed to identify baseline cognitive and mobility factors that predict adherence to the Otago Exercise Program (OEP) - a home-based exercise program proven to prevent falls.

METHODS

We conducted a secondary longitudinal analysis of data from a randomized clinical trial (RCT) (OEP compared with usual care) among 172 participants who were assigned to the OEP intervention of the RCT. Adherence to the OEP was calculated as a percent score (i.e., [frequency of strength and balance retraining session per week/3 strength and balance retraining sessions per week] × 100). Executive function (i.e., mental flexibility) was measured using the Trail Making Tests (Part A and B: TMT B - TMT A) and the Digit Symbol Substitution Test (DSST). Short-term memory and encoding was measured using the Verbal Digits Forward test. Executive function (i.e., inhibition and working memory) was measured using the Stroop Color-Word Test and the Verbal Digits Forward minus Verbal Digits Backward test. Mobility was assessed using the Short Performance Physical Battery and the Timed Up and Go test. We used general estimation equations analysis to determine the predictors of adherence to the OEP.

RESULTS

Better set shifting (β = -0.06, z = -2.43, [SE = 0.02] p = 0.018] predicted greater OEP adherence. Greater attention and short-term memory (β = -6.99, z = -2.37 [SE = 2.95]) predicted poorer OEP adherence. Response inhibition, processing speed, working memory, and mobility assessed by the SPPB were not associated with adherence. Poorer baseline Timed Up and Go (β = 1.48 z = 1.94, [SE = 0.76]; p < 0.001), predicted better OEP adherence.

CONCLUSION

Specific cognitive processes (i.e., executive function of set shifting, attention, and short-term memory) and functional mobility predicted exercise adherence. Further research needs to explore the pathways that explain why better attention and short-term memory predicted lower adherence and why poorer functional mobility led to better OEP adherence.

Apolipoprotein E Polymorphism and Frailty: Apolipoprotein ε4 Allele Is Associated with Fatigue but Not Frailty Syndrome in a Community-Dwelling Older Population Cohort

OBJECTIVE

Frailty is known to be influenced by genetics, however, little evidence on the association of Apolipoprotein E (ApoE) genotype and frailty exists which we aim to investigate.

DESIGN

This study is a cross-sectional analysis from a prospective longitudinal study cohort.

SETTING AND PARTICIPANTS

Community-dwelling individuals aged 55 years and older from Beijing region in China.

MEASUREMENTS

A total of 3,569 older adults with a mean age of 75.06(±6.79) years were included. We investigated the association between ApoE polymorphism and frailty syndrome using the frailty index (FI) and frailty phenotype (including association with individual components of the frailty phenotype). Logistic regressions were performed to investigate the relation between ApoE variants and frailty.

RESULTS

There was no significant association between ApoE variants and frailty as assessed by the FI. In the age and sex-adjusted model, compared to the ApoE e3/e3 carriers ApoE e4 carriers had almost 1.5 times higher odds of being frail as assessed by the frailty phenotype. However, the significance was lost on the model with adjustment for cognitive impairment. Compared to the ApoE e3/e3 carriers ApoE e4 carriers had almost two times higher odds of fatigue. ApoE e4 heterozygotes had higher odds of fatigue compared to ApoE e4 non-carriers. No significant association was found between ApoE variants and other components of frailty phenotype.

CONCLUSIONS

Our findings do not support an association between ApoE genotype and frailty irrespective of the frailty assessment tools. Fatigue in older adults is the only component of frailty phenotype influenced by ApoE genotype.

Intrinsic Capacity as a Determinant of Physical Resilience in Older Adults

The traditional disease-oriented model of healthcare is inadequate to address the needs of the older population. Greater attention should be given to strategies that promote healthy aging. Recently proposed constructs of intrinsic capacity (IC) and physical resilience (PR) hold great potential to reshape geriatric medicine and aging research. These constructs accentuate the positive health attributes of older people in contrast to the popular frailty construct that is centered on functional deficits. IC was introduced by the World Health Organization (WHO) as a composite of all the physical and mental capacities. WHO has emphasized enhancement of IC throughout the life course so as to maintain functional ability in old age. PR, recently highlighted by the National Institute on Aging, is the ability to successfully cope with stressors. High levels of resilience can result in desirable clinical and functional outcomes after stressors. Therefore, it is important to understand the underlying physiology of PR and the risk factors contributing to diminished PR. The main goal of this article is to explore the potential relationship between IC and PR. Based on a classical theory of aging, we postulate that IC is a determinant of PR and is also a high-level integrative measure of physiologic reserve which is the fundamental factor underlying one's ability to withstand stressors. A major implication of our postulates is that even though IC is only one of the many determinants of PR, it could serve as an important intervenable target for enhancing resilience in older adults.

Frailty in China: From Research to Practice

Although geriatric research in general has increased in recent years, there is no effective treatment for frailty. Among older adults, those with frailty have an increased risk of falls, disability, and death. The population of older adults has increased rapidly in China, and resulting in an increased demand for medical care services for older adults, including those with frailty. However, much of the research on frailty has been conducted in Europe and the United States, and European and American standards for frailty are not always applicable to Chinese individuals. Clinicians and researchers in China have shown increasing interest in frailty in recent years. Here, we reviewed the current state of frailty research in China.

Association of acute resuscitation and post-resuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest

Background

Although survival for in-hospital cardiac arrest (IHCA) varies markedly across sites, it remains unknown whether high survival at top-performing hospitals is due to high rates of acute resuscitation survival (i.e., achievement of return of spontaneous circulation [ROSC]), post-resuscitation survival (i.e., survival to discharge among patients who achieved ROSC), or both.

Methods

Using 2015–2018 Get With The Guidelines (GWTG)-Resuscitation data, we identified 290 hospitals (86,426 patients) with IHCA. For each hospital, we calculated overall risk-standardized survival (RSSR) to discharge for IHCA using a previously validated hierarchical regression model and categorized hospitals into quartiles based on that metric. Risk-adjusted rates of acute resuscitation survival (defined as return of spontaneous circulation for &gt;20 minutes [ROSC]) and post-resuscitation survival (defined as the proportion of patients achieving ROSC who survived to hospital discharge) were also computed for each hospital. We examined the correlation between a hospital's overall RSSR with its risk-adjusted rate of acute resuscitation and post-resuscitation survival.

Results

Among study hospitals, the median RSSR was 25.1% (inter-quartile range [IQR]: 21.9%–27.7%). The median risk-adjusted rate of acute resuscitation survival was 72.4% (IQR: 67.9%–76.9%) and post-resuscitation survival was 34.0% (IQR: 31.5%–37.7%). Hospital rates of RSSR were less strongly correlated with risk-adjusted rates of acute resuscitation survival (rho=0.50, P&lt;0.001) than post-resuscitation survival (rho=0.90, P&lt;0.001). Compared with hospitals in the lowest quartile of RSSR, hospitals in the highest quartile had substantially higher rates of acute resuscitation survival (Q4: 75.4% vs. Q1: 66.8%; P&lt;0.001) and post-resuscitation survival (Q4: 40.3% vs. Q1: 28.7%; P&lt;0.001). Notably, there was no correlation between hospital risk-adjusted rates of acute resuscitation survival and post-resuscitation survival (rho=0.09, P=0.11).

Conclusion

Hospital that excel in overall IHCA survival in general excel in either acute resuscitation or post-resuscitation care. As most hospital-based quality improvement initiatives largely focus on acute resuscitation survival, our findings suggest that efforts to strengthen post-resuscitation care may offer additional opportunities to improve IHCA survival.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): NHLBI

Report from the First Clinical Trials on Alzheimer's Disease (CTAD) Asia-China 2018 : Bringing together Global Leaders

Population of older adults in Asia, and particularly in China is increasing rapidly. Older population are at increased risk of Alzheimer's disease (AD) and other dementias. Soon, the Chinese population with AD will represent almost half of the world's AD population. There is a desperate need of disease modifying therapies to delay or slow the progression of AD, to tackle this emerging healthcare emergency. In this context, the first CTAD Asia-China conference was held in China to bring together Western and Asian leaders in AD. This meeting focused largely on how to develop successful trials in China, utilizing past experiences from the West.

Action Seniors! Cost-Effectiveness Analysis of a Secondary Falls Prevention Strategy Among Community-Dwelling Older Fallers

BACKGROUND

The Otago Exercise Program (OEP) has demonstrated cost-effectiveness for the primary prevention of falls in a general community setting. The cost-effectiveness of exercise as a secondary falls prevention (ie, preventing falls among those who have already fallen) strategy remains unknown. The primary objective was to estimate the cost-effectiveness (incremental cost-effectiveness/utility ratio) of the OEP from a healthcare system perspective.

DESIGN

A concurrent 12-month prospective economic evaluation conducted alongside the Action Seniors! randomized critical trial (OEP compared with usual care).

SETTING

Vancouver Falls Prevention Clinic (Vancouver, BC, Canada; http://www.fallsclinic.ca).

PARTICIPANTS

A total of 344 community-dwelling older adults, aged 70 years and older, who attended a geriatrician-led Falls Prevention Clinic in Vancouver, after sustaining a fall in the previous 12 months.

MEASUREMENTS

Main outcome measures included: incidence rate ratio for falls, healthcare costs, incremental cost per fall prevented, and incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

The OEP costs $393 CAD per participant to implement. The incremental cost per fall prevented resulted in a savings of $2 CAD. The incremental cost per QALY gained (where QALYs were estimated using the Euro-Qol 5D three-level version [EQ-5D-3L]) indicated the OEP was less effective than usual care. The incremental cost per QALY gained (where QALYs were estimated using the Short Form 6D [SF-6D]) indicated the OEP was more effective and less costly than usual care. The incremental QALYs estimated using the EQ-5D-3L and the SF-6D were not clinically significant and close to zero, indicating no change in quality of life.

CONCLUSION

Compared with usual care, healthcare system costs are saved and falls are prevented when older fallers who attend a geriatrician-led falls clinic are allocated to, and provided, the physiotherapist-guided exercise-based falls prevention program (the OEP).

Functional connectivity underpinning changes in life-space mobility in older adults with mild cognitive impairment: A 12-month prospective study

Subtle changes in mobility exist among older adults with mild cognitive impairment (MCI). Life-space mobility defines the frequency and extent of movements in the environment, and lower life-space mobility is associated with adverse health outcomes and MCI. Currently, the underlying mechanism of this association is not well understood. This study examined the functional neural correlates of life-space mobility in community-dwelling older adults with MCI. We first conducted a cross-sectional investigation of the association between resting-state default mode network (DMN) and sensori-motor network (SMN) connectivity and life-space mobility (assessed by the Life-Space Assessment (LSA)) among 60 community-dwelling older adults with MCI using aggregated data from two studies - baseline data from a randomized controlled trial (n = 20) and baseline data from a 12-month prospective study (n = 40). Using data from the 12-month prospective study (n = 35), we then examined whether baseline internetwork connectivity predicts reduced life-space mobility over 12 months. The cross-sectional analysis showed higher DMN-SMN connectivity was associated with lower LSA scores after adjusting for baseline global cognitive function and baseline age (p < 0.01). A significant reduction in LSA scores was observed in the 35 participants of the 12-month prospective study (paired sample t-test mean change = -6.53, p = 0.01). Greater baseline DMN-SMN connectivity was associated with greater reduction in life-space mobility at 12 months (p = 0.04) after adjusting for baseline age, global cognitive function, and LSA score. Our findings suggest that lower and reduced life-space mobility in older adults with MCI may be due to altered functional architecture of the brain such that normal neuro-cognitive motor behaviours may be disrupted.

The Prevalence and Clinical Characteristics of Essential Tremor in Elderly Chineses: A Population-Based Study

OBJECTIVES

To investigate the prevalence and the clinical feature of essential tremor (ET) in a community cohort in Beijing.

METHODS

Using a door-to-door, two-phase approach, we investigated 2,835 residents aged ≥55 years old from rural, urban, and mountain areas.

RESULTS

The prevalence rate of ET was 4.29%, 2.85%, and 2.29% in rural, urban, and mountain areas, respectively. The overall age- and sex-adjusted prevalence was 3.29%. Among those aged ≥75 years, the prevalence rate in the urban area was higher than those in the rural and mountain areas. The prevalence rate increased with age, and the prevalence was higher among men (6.0%) than among women (3.6%). There was a correlation of ET prevalence with age, sex, and habitation area, but not with alcohol, tea drinking, and occupation. Women (25%) with ET were more likely to have head tremor than men (16.9%).

CONCLUSIONS

The ET prevalence in the elderly of Beijing was 3.29% which is higher in the urban area and in men.