Personality Changes During the Transition from Cognitive Health to Mild Cognitive Impairment

Background/Objectives

Behavioral problems in individuals with Alzheimer's disease (AD ) impose major management challenges. Current prevention strategies are anchored to cognitive outcomes, but behavioral outcomes may provide another, clinically relevant opportunity for preemptive therapy. We sought to determine whether personality changes that predispose to behavioral disorders arise during the transition from preclinical AD to mild cognitive impairment (MCI ).

Design

Longitudinal observational cohort study.

Setting

Academic medical center.

Participants

Members of an apolipoprotein E (APOE ) ?4 genetically enriched cohort of Maricopa County residents who were neuropsychiatrically healthy at entry (N = 277). Over a mean interval of 7 years, 25 who developed MCI and had the Neuroticism, Extraversion, and Openness Personality Inventory—Revised (NEO ‐PI ‐R) before and during the MCI transition epoch were compared with 252 nontransitioners also with serial NEO ‐PI ‐R administrations.

Intervention

Longitudinal administration of the NEO ‐PI ‐R and neuropsychological test battery.

Measurements

Change in NEO ‐PI ‐R factor scores (neuroticism, extraversion, openness, agreeableness, conscientiousness) from entry to the epoch of MCI diagnosis or an equivalent follow‐up duration in nontransitioners.

Results

NEO ‐PI ‐R neuroticism T‐scores increased significantly more in MCI transitioners than in nontransitioners (mean 2.9, 95% confidence interval (CI ) = 0.9–4.9 vs 0, 95% CI = ?0.7–0.7, P = .02), and openness decreased more in MCI transitioners than in nontransitioners (?4.8, 95% CI = ?7.3 to ?2.4 vs ?1.0, 95% CI = ?1.6 to ?0.4, P < .001). Concurrent subclinical but statistically significant changes in behavioral scores worsened more in MCI transitioners than nontransitioners for measures of depression, somatization, irritability, anxiety, and aggressive attitude.

Conclusion

Personality and subclinical behavioral changes begin during the transition from preclinical AD to incident MCI and qualitatively resemble the clinically manifest behavioral disorders that subsequently arise in individuals with frank dementia.

     

Targeting Behavioral Symptoms and Functional Decline in Dementia: A Randomized Clinical Trial

Background/Objectives

Dementia‐related behavioral symptoms and functional dependence result in poor quality of life for persons with dementia and their caregivers. The goal was to determine whether a home‐based activity program (Tailored Activity Program; TAP ‐VA ) would reduce behavioral symptoms and functional dependence of veterans with dementia and caregiver burden.

Design

Single‐blind (interviewer), parallel, randomized, controlled trial (Clinicaltrials.gov: NCT 01357564).

Setting

Veteran's homes.

Participants

Veterans with dementia and their family caregivers (N = 160 dyads).

Intervention

Dyads in TAP ‐VA underwent 8 sessions with occupational therapists to customize activities to the interests and abilities of the veterans and educate their caregivers about dementia and use of customized activity. Caregivers assigned to attention control received up to 8 telephone‐based dementia education sessions with a research team member.

Measurements

Primary outcomes included number of behaviors and frequency of their occurrence multiplied by severity of occurrence; secondary outcomes were functional dependence, pain, emotional well‐being, caregiver burden (time spent caregiving, upset with behaviors) and affect at 4 (primary endpoint) and 8 months.

Results

Of 160 dyads (n = 76 TAP ‐VA ; n = 84 control), 111 completed 4‐month interviews (n = 51 TAP ‐VA ; n = 60 control), and 103 completed 8‐month interviews (n = 50 TAP ‐VA ; n = 53 control). At 4 months, compared to controls, the TAP ‐VA group showed reductions in number (difference in mean change from baseline = ?0.68, 95% CI = ?1.23 to ?0.13) and frequency by severity (?24.3, 95% CI = ?45.6 to ?3.1) of behavioral symptoms, number of activities needing assistance with (?0.80, 95% CI = ?1.41 to ?0.20), functional dependence level (4.09, 95% CI = 1.06, 7.13), and pain (?1.18, 95% CI = ?2.10 to ?0.26). Caregivers of veterans in TAP ‐VA reported less behavior‐related distress. Benefits did not extend to 8 months.

Conclusion

TAP ‐VA had positive immediate effects and no adverse events. Because TAP ‐VA reduces behavioral symptoms, slows functional dependence, and alleviates pain and caregiver distress, it is a viable treatment option for families.

     

Periventricular White Matter Hyperintensities and Functional Decline

Background/Objectives

We previously showed that global brain white matter hyperintensity volume (WMHV ) was associated with accelerated long‐term functional decline. The objective of the current study was to determine whether WMHV in particular brain regions is more predictive of functional decline.

Design

Prospective population‐based study.

Setting

Northern Manhattan magnetic resonance imaging (MRI ) study.

Participants

Individuals free of stroke at baseline (N = 1,195; mean age 71 ± 9; n = 460 (39%) male).

Measurements

Participants had brain MRI with axial T1, T2, and fluid attenuated inversion recovery sequences. Volumetric WMHV distribution across 14 brain regions (brainstem; cerebellum; bilateral frontal, occipital, temporal, and parietal lobes; and bilateral anterior and posterior periventricular white matter (PVWM )) was determined using a combination of bimodal image intensity distribution and atlas‐based methods. Participants had annual functional assessments using the Barthel Index (BI ) (range 0–100) over a mean of 7.3 years and were followed for stroke, myocardial infarction (MI ), and mortality. Because there were multiple collinear variables, least absolute shrinkage and selection operator (LASSO ) regression–selected regional WMHV variables most associated with outcomes and adjusted generalized estimating equations models were used to estimate associations with baseline BI and change over time.

Results

Using LASSO regularization, only right anterior PVWM was found to meet criteria for selection, and each standard deviation greater WMHV was associated with accelerated functional decline of 0.95 additional BI points per year (95% confidence interval (CI ) = ?1.20 to ?0.70) in an unadjusted model, ?0.92 points per year (95% CI = ?1.18 to ?0.67) with baseline covariate adjustment, and ?0.87 points per year (95% CI = ?1.12 to ?0.62) after adjusting for incident stroke and MI .

Conclusion

In this large population‐based study with long‐term repeated measures of function, periventricular WMHV was particularly associated with accelerated functional decline.

     

Long Term Effect of Intensive Lifestyle Intervention on Cerebral Blood Flow

Objectives

To determine whether long‐term behavioral intervention targeting weight loss through increased physical activity and reduced caloric intake would alter cerebral blood flow (CBF ) in individuals with type 2 diabetes mellitus.

Design

Postrandomization assessment of CBF.

Setting

Action for Health in Diabetes multicenter randomized controlled clinical trial.

Participants

Individuals with type 2 diabetes mellitus who were overweight or obese and aged 45 to 76 (N = 310).

Interventions

A multidomain intensive lifestyle intervention (ILI ) to induce weight loss and increase physical activity for 8 to 11 years or diabetes support and education (DSE ), a control condition.

Measurements

Participants underwent cognitive assessment and standardized brain magnetic resonance imaging (MRI ) (3.0 Tesla) to assess CBF an average of 10.4 years after randomization.

Results

Weight changes from baseline to time of MRI averaged ?6.2% for ILI and ?2.8% for DSE (P < .001), and increases in self‐reported moderate or intense physical activity averaged 444.3 kcal/wk for ILI and 114.8 kcal/wk for DSE (P = .03). Overall mean CBF was 6% greater for ILI than DSE (P = .04), with the largest mean differences between ILI and DSE in the limbic region (3.39 mL /100 g per minute, 95% confidence interval (CI ) = 0.07–6.70 mL /100 g per minute) and occipital lobes (3.52 mL /100 g per minute, 95% CI = 0.20–6.84 mL /100 g per minute). In ILI , greater CBF was associated with greater decreases in weight and greater increases in physical activity. The relationship between CBF and scores on a composite measure of cognitive function varied between intervention groups (P = .02).

Conclusions

Long‐term weight loss intervention in overweight and obese adults with type 2 diabetes mellitus is associated with greater CBF .

     

Men Lacking a Caregiver Have Greater Risk of Long‐Term Nursing Home Placement After Stroke

Background/Objectives

Social support can prevent or delay long‐term nursing home placement (NHP ). The purpose of our study was to understand how the availability of a caregiver can affect NHP after ischemic stroke and how this affects different subgroups differently.

Design

Nested cohort study.

Setting

Nationally based RE asons for Geographic and Racial Differences in Stroke (REGARDS ) study.

Participants

Stroke survivors aged 65 to 100 (256 men, 304 women).

Measurements

Data were from Medicare claims from January 2003 to December 2013 and REGARDS baseline interviews conducted from January 2003 to October 2007. Caregiver support was measured by asking, “If you had a serious illness or became disabled, do you have someone who would be able to provide care for you on an on‐going basis?” Diagnosis of ischemic stroke was derived from inpatient claims. NHP was determined using a validated claims algorithm for stays of 100 days and longer. Risk was estimated using Cox regression.

Results

Within 5 years of stroke, 119 (21.3%) participants had been placed in a nursing home. Risk of NHP was greater in those lacking available caregivers (log‐rank P  = .006). After adjustment for covariates, lacking an available caregiver increased the risk of NHP after stroke within 1 year by 70% (hazard ratio (HR ) = 1.70, 95% confidence interval (CI ) = 0.97–2.99) and within 5 years by 68% (HR  = 1.68, 95% CI  = 1.10–2.58). The effect of caregiver availability on NHP within 5 years was limited to men (HR  = 3.15, 95% CI  = 1.49–6.67).

Conclusion

In men aged 65 and older who have survived an ischemic stroke, the lack of an available caregiver is associated with triple the risk of NHP within 5 years.

     

Can Exercise Improve Cognitive Symptoms of Alzheimer's Disease?

Objectives

To examine the effects of exercise training on cognitive function in individuals at risk of or diagnosed with Alzheimer's disease (AD ).

Design

Meta‐analysis.

Setting

PubMed, Scopus, ClinicalTrials.gov, and ProQuest were searched from inception until August 1, 2017.

Participants

Nineteen studies with 23 interventions including 1,145 subjects with a mean age of 77.0 ± 7.5 were included. Most subjects were at risk of AD because they had mild cognitive impairment (64%) or a parent diagnosed with AD (1%), and 35% presented with AD .

Intervention

Controlled studies that included an exercise‐only intervention and a nondiet, nonexercise control group and reported pre‐ and post‐intervention cognitive function measurements.

Measurements

Cognitive function before and after the intervention and features of the exercise intervention.

Results

Exercise interventions were performed 3.4 ± 1.4 days per week at moderate intensity (3.7 ± 0.6 metabolic equivalents) for 45.2 ± 17.0 minutes per session for 18.6 ± 10.0 weeks and consisted primarily of aerobic exercise (65%). Overall, there was a modest favorable effect of exercise on cognitive function (d₊ = 0.47, 95% confidence interval (CI ) = 0.26–0.68). Within‐group analyses revealed that exercise improved cognitive function (d_+w = 0.20, 95% CI  = 0.11–0.28), whereas cognitive function declined in the control group (d_+w = ?0.18, 95% CI  = ?0.36 to 0.00). Aerobic exercise had a moderate favorable effect on cognitive function (d_+w = 0.65, 95% CI  = 0.35–0.95), but other exercise types did not (d_+w = 0.19, 95% CI  = ?0.06–0.43).

Conclusion

Our findings suggest that exercise training may delay the decline in cognitive function that occurs in individuals who are at risk of or have AD , with aerobic exercise possibly having the most favorable effect. Additional randomized controlled clinical trials that include objective measurements of cognitive function are needed to confirm our findings.

     

Community Program Improves Quality of Life and Self‐Management in Older Adults with Diabetes Mellitus and Comorbidity

Objectives

To compare the effect of a 6‐month community‐based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self‐efficacy, self‐management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM ) and 2 or more comorbidities.

Design

Multisite, single‐blind, parallel, pragmatic, randomized controlled trial.

Setting

Four communities in Ontario, Canada.

Participants

Community‐dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159).

Intervention

Client‐driven, customized self‐management program with up to 3 in‐home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation.

Measurements

Quality‐of‐life measures included the Physical Component Summary (PCS , primary outcome) and Mental Component Summary (MCS , secondary outcome) scores of the Medical Outcomes Study 12‐item Short‐Form Health Survey (SF ‐12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES ‐D‐10), Summary of Diabetes Self‐Care Activities (SDSCA ), Self‐Efficacy for Managing Chronic Disease, and healthcare costs.

Results

Morbidity burden was high (average of eight comorbidities). Intention‐to‐treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI ) = 0.28–5.09, P  = .03), SDSCA (mean difference = 3.79, 95% CI  = 1.02–6.56, P  = .01), and CES ‐D‐10 (mean difference = ?1.45, 95% CI  = ?0.13 to ?2.76, P  = .03). No group differences were seen in PCS score, anxiety, self‐efficacy, or total healthcare costs.

Conclusion

Participation in a 6‐month community‐based intervention improved quality of life and self‐management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs.

     

Simple Method of Screening for Frailty in Older Adults Using a Chronometer and Tape Measure in Clinic

Objectives

Detecting frailty in older adults scheduled for surgery is important to predict the occurrence of adverse outcomes, but because of its complexity, frailty screening is not commonly performed. The objective of the current study was to assess whether frailty can be screened for using automatically measured usual gait speed (UGS ) and mid‐arm circumference (MAC ) in the outpatient clinic.

Design

Prospective, cross‐sectional study.

Setting

Geriatric center of a tertiary hospital.

Participants

Outpatients aged 65 and older (N = 113).

Measurements

Frailty status was evaluated according to a multidimensional frailty score (MFS ) using a comprehensive geriatric assessment, and participants were classified into 5 categories. UGS was evaluated by having participants walk through the clinic using an automated laser‐gated chronometer. MAC was recorded using a tape measure on a blood pressure cuff. Correlations between these two physical measurements and MFS were assessed.

Results

The mean age of the 93 participants who successfully underwent UGS evaluation was 75.8 ± 4.7; 35 were male. In this population, the mean Charlson Comorbidity Index was 2.2 ± 1.4, mean MFS was 4.1 ± 2.0, and 20 participants were considered to be at high risk of experiencing adverse outcomes. Mean UGS was 0.75 ± 0.16 m/s, and mean MAC was 31.2 ± 1.9 cm); both physical parameters were correlated with MFS (UGS : standardized beta = ?0.420, P < .001; MAC : standardized beta = ?0.457, P < .001). Using UGS and MFS , the area under curve of receiver operating curve for determining which participants were at high risk of experiencing adverse outcomes was 0.809 (P < .001).

Conclusion

UGS and MAC are viable methods of clinically screening for frailty.

     

Adherence to Mediterranean Diet Reduces Incident Frailty Risk: Systematic Review and Meta‐Analysis

Objectives

To conduct a systematic review of the literature on prospective cohort studies examining associations between adherence to a Mediterranean diet and incident frailty and to perform a meta‐analysis to synthesize the pooled risk estimates.

Design

Systematic review and meta‐analysis.

Setting

Embase, MEDLINE , CINAHL , PsycINFO , and Cochrane Library were systematically searched on September 14, 2017. We reviewed references of included studies and relevant review papers and performed forward citation tracking for additional studies. Corresponding authors were contacted for additional data necessary for a meta‐analysis.

Participants

Community‐dwelling older adults (mean age ≥60).

Measurements

Incident frailty risk according to adherence to a Mediterranean diet.

Results

Two reviewers independently screened the title, abstract, and full text to ascertain the eligibility of 125 studies that the systematic search of the literature identified, and four studies were included (5,789 older people with mean follow‐up of 3.9 years). Two reviewers extracted data from the studies independently. All four studies provided adjusted odds ratios (OR s) of incident frailty risk according to three Mediterranean diet score (MDS ) groups (0–3, 4–5, and 6–9). Greater adherence to a Mediterranean diet was associated with significantly lower incident frailty risk (pooled OR = 0.62, 95% CI = 0.47–0.82, P  = .001 for MDS 4–5; pooled OR  = 0.44, 95% CI  = 0.31–0.64, P  < .001 for MDS 6–9) than poorer adherence (MDS 0–3). Neither significant heterogeneity (I ² = 0–16%, P  = .30) nor evidence of publication bias was observed.

Conclusion

Greater adherence to a Mediterranean diet is associated with significantly lower risk of incident frailty in community‐dwelling older people. Future studies should confirm these findings and evaluate whether adherence to a Mediterranean diet can reduce the risk of frailty, including in non‐Mediterranean populations.

     

Overcoming Reluctance to Accept Home‐Based Support from an Older Adult Perspective

Objectives

To understand older adult perceptions about accepting help at home, in particular fears related to potential loss of independence.

Design

Qualitative focus groups.

Setting

Rural, suburban, and urban areas of Fort Wayne, Indiana, and Chicago, Illinois.

Participants

Community‐dwelling adults aged 65 and older (N=68).

Measurements

Participants discussed decision‐making, reluctance to accept home‐based care, barriers, and resources that might affect remaining in the home. Three independent coders used constant comparative analysis to interpret results.

Results

Analysis revealed that reluctance to accept home‐based support was associated with concerns over inability to complete tasks, perceptions of being burdensome to others, lack of trust in others, and lack of control. To overcome these concerns, some participants reframed the concept of independence to be “interdependence,” with people continually depending on each other throughout their lives. Subjects noted that, even if one becomes more limited over time, the recognition that one is still contributing something meaningful to society is important to overcoming refusal of home assistance. Another strategy presented to overcome negative perceptions of accepting assistance in the home was the recognition that helping someone who is in need may engender positive emotions in those providing the help.

Conclusion

Older adults perceived multiple reasons for refusing home‐based assistance and offered potential strategies to overcome this reluctance. Addressing the reasons and promoting strategies to accept home‐based support may lead older adults to have fewer unmet home‐based needs, enabling them to remain safely in their homes.

     

Epidemiology,treatment, disposition and outcome of patients with acute exacerbation of COPD presenting to emergency departments in Australia and South East Asia: An AANZDEM study

Background and objective

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common presentation to emergency departments (ED) but data regarding its epidemiology and outcomes are scarce. We describe the epidemiology, clinical features, treatment and outcome of patients treated for AECOPD in ED.

Methods

This was a planned sub‐study of patients with an ED diagnosis of AECOPD identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. The AANZDEM was a prospective, interrupted time series cohort study conducted in 46 ED in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72‐h periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality).

Results

Forty‐six ED participated. There were 415 patients with an ED primary diagnosis of AECOPD (13.6% of the overall cohort; 95% CI: 12.5–14.9%). Median age was 73 years, 60% males and 65% arrived by ambulance. Ninety‐one percent had an existing COPD diagnosis. Eighty percent of patients received inhaled bronchodilators, 66% received systemic corticosteroids and 57% of those with pH < 7.30 were treated with non‐invasive ventilation (NIV). Seventy‐eight percent of patients were admitted to hospital, 7% to an intensive care unit. In‐hospital mortality was 4% and median LOS was 4 days (95% CI: 2–7).

Conclusion

Patients treated in ED for AECOPD commonly arrive by ambulance, have a high admission rate and significant in‐hospital mortality. Compliance with evidence‐based treatments in ED is suboptimal affording an opportunity to improve care and potentially outcomes.

     

Association between subclinical thyroid dysfunction and change in bone mineral density in prospective cohorts

Background

Subclinical hyperthyroidism (SH yper) has been associated with increased risk of hip and other fractures, but the linking mechanisms remain unclear.

Objective

To investigate the association between subclinical thyroid dysfunction and bone loss.

Methods

Individual participant data analysis was performed after a systematic literature search in MEDLINE /EMBASE (1946–2016). Two reviewers independently screened and selected prospective cohorts providing baseline thyroid status and serial bone mineral density (BMD ) measurements. We classified thyroid status as euthyroidism (thyroid‐stimulating hormone [TSH ] 0.45–4.49 mIU/L), SH yper (TSH < 0.45 mIU/L) and subclinical hypothyroidism (SH ypo, TSH ≥ 4.50–19.99 mIU/L) both with normal free thyroxine levels. Our primary outcome was annualized percentage BMD change (%ΔBMD) from serial dual X‐ray absorptiometry scans of the femoral neck, total hip and lumbar spine, obtained from multivariable regression in a random‐effects two‐step approach.

Results

Amongst 5458 individuals (median age 72 years, 49.1% women) from six prospective cohorts, 451 (8.3%) had SH ypo and 284 (5.2%) had SH yper. During 36 569 person‐years of follow‐up, those with SH yper had a greater annual bone loss at the femoral neck versus euthyroidism: %ΔBMD = ?0.18 (95% CI: ?0.34, ?0.02; I ² = 0%), with a nonstatistically significant pattern at the total hip: %ΔBMD = ?0.14 (95% CI: ?0.38, 0.10; I ² = 53%), but not at the lumbar spine: %ΔBMD = 0.03 (95% CI: ?0.30, 0.36; I ² = 25%); especially participants with TSH < 0.10 mIU/L showed an increased bone loss in the femoral neck (%Δ BMD = ?0.59; [95% CI: ?0.99, ?0.19]) and total hip region (%ΔBMD = ?0.46 [95% CI: ?1.05, ?0.13]). In contrast, SH ypo was not associated with bone loss at any site.

Conclusion

Amongst adults, SH yper was associated with increased femoral neck bone loss, potentially contributing to the increased fracture risk.

     

A comprehensive meta‐analysis of stem cell therapy for chronic angina

Background

A substantial proportion of patients with coronary artery disease do not achieve complete revascularization and continue to experience refractory angina despite optimal medical therapy. Recently, stem cell therapy has emerged as a potential therapeutic option for these patients. However, findings of individual trials have been scrutinized because of their small sample sizes and lack of statistical power. Therefore, we conducted an updated comprehensive meta‐analysis of available randomized controlled trials (RCTs) with the largest sample size ever reported on this subject.

Hypothesis

In patients with chronic angina stem cell therapy improves clinical outcomes.

Methods

Scientific databases and websites were searched for RCTs. Data were independently collected by 2 investigators, and disagreements were resolved by consensus. Data from 10 trials including 658 patients were analyzed.

Results

Stem cell therapy improved Canadian Cardiovascular Society angina class (risk ratio: 1.53, 95% CI: 1.09 to 2.15, P = 0.013), exercise capacity (standardized mean difference [SMD]: 0.56, 95% CI: 0.23 to 0.88, P = 0.001), and left ventricular ejection fraction (SMD: 0.63, 95% CI: 0.27 to 1.00, P = 0.001) compared with placebo. It also decreased anginal episodes (SMD: –1.21, 95% CI: –2.40 to ?0.02, P = 0.045) and myocardial perfusion defects (SMD: –0.70, 95% CI: –1.11 to ?0.29, P = 0.001). However, no improvements in all‐cause mortality were observed after a relatively short follow‐up.

Conclusions

In patients with chronic angina on optimal medical therapy, stem cell therapy improves symptoms, exercise capacity, and left ventricular ejection fraction. These findings warrant confirmation using larger trials.

     

Acute effect of multiple ozone metrics on mortality by season in 34 Chinese counties in 2013–2015

Background

Although numerous multicentre studies have estimated the association between ozone exposure and mortality, there are currently no nationally representative multicentre studies of the ozone–mortality relationship in China.

Objective

To investigate the effect on total (nonaccidental) and cause‐specific mortality of short‐term exposure to ambient ozone, and examine different exposure metrics.

Methods

The effects of short‐term exposure to ozone were analysed using various metrics (daily 1‐h maximum, daily 8‐h maximum and daily average) on total (nonaccidental) and cause‐specific (circulatory and respiratory) mortality from 2013 to 2015 in 34 counties in 10 cities across China. We used distributed lag nonlinear models for estimating county‐specific relative risk of mortality and combined the county‐specific relative rates by conducting a random‐effects meta‐analysis.

Results

In all‐year analyses, a 10 μg m^?3 increase in daily average, daily 1‐h maximum and daily 8‐h maximum ozone at lag02 corresponded to an increase of 0.6% (95% CI : 0.33, 0.88), 0.26% (95% CI : 0.12, 0.39) and 0.37% (95% CI : 0.2, 0.55) in total (nonaccidental) mortality, 0.66% (95% CI : 0.28, 1.04), 0.31% (95% CI : 0.11, 0.51) and 0.39% (95% CI : 0.16, 0.62) in circulatory mortality, and 0.57% (95% CI : ?0.09, 1.23), 0.11% (95% CI : ?0.22, 0.44) and 0.22% (95% CI : ?0.28, 0.72) in respiratory mortality, respectively. These estimates had a different seasonal pattern by cause of death. In general, the seasonal patterns were consistent with the times of year when ozone concentrations are highest.

Conclusions

Our findings suggest that in China, the acute effects of ozone are more closely related to daily average exposure than any other metric.

     

Complications with Angio‐Seal™ Vascular Closure Devices Compared with Manual Compression after Diagnostic Cardiac Catheterization and Percutaneous Coronary Intervention

Objectives

This study assessed and compared vascular complications in CATHs and PCIs using an Angio‐Seal? vascular closure device (VCD) versus manual compression (MC).

Methods

Secondary data analysis of a population‐based multiyear cohort database was conducted to compare femoral access‐related vascular outcomes in cardiac procedures using VCD and MC between May 1, 2006 and December 31, 2010. The primary outcome was any vascular complication. Propensity score adjusted analysis was conducted to reduce bias associated with covariate imbalance between the groups compared.

Results

Of the 11,897 procedures, 7,063 (59.4%) used a VCD. Vascular complications occurred in 174/8,796 (2.0%) of CATHs and 82/3,004 (2.7%) of PCIs. In the CATH sample, the odds of vascular complication were 57% lower if a VCD was used (OR = 0.43, 95% CI 0.31–0.60). For the PCI sample, the risk was 49% lower if a VCD was used (OR = 0.51, 95% CI 0.31–0.81).

Conclusions

A low incidence of vascular complications was observed with the use of an Angio‐Seal VCD relative to MC for both procedures.

     

Olfactory dysfunction and cognition among older adults in the United States

Background

In this work we assess the association between olfactory dysfunction and cognition in a nationally representative sample of older adults in the United States.

Methods

Participants aged ≥60 years (n = 1236) from the 2013–2014 National Health and Nutritional Examination Survey underwent both olfactory and cognitive testing. Olfaction was assessed by both objective test (8‐odor Pocket Smell Test: smell impairment defined as score ≤2) and self‐report. Cognitive assessment consisted of the Digit Symbol Substitution Test (DSST), the Animal Fluency Test, and the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Regression models were used to examine the association between olfaction and cognition while adjusting for demographics, cardiovascular factors, and associated medical history.

Results

The prevalence of smell impairment in US older adults was 18.0% (95% confidence interval [CI], 14.0‐22.0%) and 22.0% (95% CI, 18.5‐25.6%) based on objective smell test and self‐report, respectively. In a multivariate model adjusted for relevant factors, low smell test scores were consistently associated with low scores on cognitive assessments, with a DSST score difference of ?1.5 (95% CI, ?2.2 to ?0.8), Animal Fluency Test score difference of ?0.4 (95% CI, ?0.7 to ?0.1), and CERAD Word List score difference of ?0.4 (95% CI, ?0.6 to ?0.2) per 1‐point decrease in smell test score. There was no association between self‐reported smell impairment and cognition.

Conclusion

Objectively measured olfactory dysfunction is independently associated with cognitive impairment. These findings are consistent with previous studies and suggest the utility of objective olfactory tests as an indicator for cognitive impairment as compared with self‐reported olfactory dysfunction, which is an uncertain indicator.

     

Efficacy of a web‐based intervention with and without guidance for employees with risky drinking: results of a three‐arm randomized controlled trial

Aims

To test the efficacy of a web‐based alcohol intervention with and without guidance.

Design

Three parallel groups with primary end‐point after 6 weeks.

Setting

Open recruitment in the German working population.

Participants

Adults (178 males/256 females, mean age 47 years) consuming at least 21/14 weekly standard units of alcohol (SUA) and scoring ≥ 8/6 on the Alcohol Use Disorders Identification Test.

Intervention

Five web‐based modules including personalized normative feedback, motivational interviewing, goal setting, problem‐solving and emotion regulation during 5 weeks. One intervention group received an unguided self‐help version (n=146) and the second received additional adherence‐focused guidance by eCoaches (n=144). Controls were on a waiting list with full access to usual care (n=144).

Measurements

Primary outcome was weekly consumed SUA after 6 weeks. SUA after 6 months was examined as secondary outcome, next to numbers of participants drinking within the low‐risk range, and general and work‐specific mental health measures.

Findings

All groups showed reductions of mean weekly SUA after 6 weeks (unguided: ?8.0; guided: ?8.5; control: ?3.2). There was no significant difference between the unguided and guided intervention (P=0.324). Participants in the combined intervention group reported significantly fewer SUA than controls [B=?4.85, 95% confidence interval (CI)=?7.02 to ?2.68, P < 0.001]. The intervention groups also showed significant reductions in SUA consumption after 6 months (B=?5.72, 95% CI=?7.71 to ?3.73, P < 0.001) and improvements regarding general and work‐related mental health outcomes after 6 weeks and 6 months.

Conclusions

A web‐based alcohol intervention, administered with or without personal guidance, significantly reduced mean weekly alcohol consumption and improved mental health and work‐related outcomes in the German working population.

     

Dynamic Effects of Depressive Symptoms on Osteoarthritis Knee Pain

Objective

To estimate the dynamic causal effects of depressive symptoms on osteoarthritis (OA) knee pain.

Methods

Marginal structural models were used to examine dynamic associations between depressive symptoms and pain over 48 months among older adults (n = 2,287) with radiographic knee OA (Kellgren/Lawrence grade 2 or 3) in the Osteoarthritis Initiative. Depressive symptoms at each annual visit were assessed (threshold ≥16) using the Center for Epidemiologic Studies Depression Scale. OA knee pain was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, rescaled to range from 0 to 100.

Results

Depressive symptoms at each visit were generally not associated with greater OA knee pain at subsequent time points. Causal mean differences in WOMAC pain score comparing depressed to nondepressed patients ranged from 1.78 (95% confidence interval [95% CI] ?0.73, 4.30) to 2.58 (95% CI 0.23, 4.93) within the first and fourth years, and the depressive symptoms by time interaction were not statistically significant (P = 0.94). However, there was a statistically significant dose‐response relationship between the persistence of depressive symptoms and OA knee pain severity (P = 0.002). Causal mean differences in WOMAC pain score comparing depressed to nondepressed patients were 0.89 (95% CI ?0.17, 1.96) for 1 visit with depressive symptoms, 2.35 (95% CI 0.64, 4.06) for 2 visits with depressive symptoms, and 3.57 (95% CI 0.43, 6.71) for 3 visits with depressive symptoms.

Conclusion

The causal effect of depressive symptoms on OA knee pain does not change over time, but pain severity significantly increases with the persistence of depressed mood.

     

Post‐dilation in transcatheter aortic valve replacement: A systematic review and meta‐analysis

Objectives

The aim of this study was to perform a meta‐analysis to compare the outcomes of patients undergoing TAVR with and without balloon post‐dilation (PD).

Background

PD is a commonly used technique in TAVR to minimize paravalvular regurgitation (PVR), albeit supported by little evidence.

Methods

Systematic review and meta‐analysis of 6 studies comparing 889 patients who had PD compared to 4118 patients without PD.

Results

Patients undergoing PD were more likely male (OR 1.92; 95% CI, 1.41‐2.61; P < 0.001) and to have coronary artery disease (OR 1.31; 95% CI, 1.03‐1.68; P = 0.03) than those patients not requiring PD. There were no significant differences in 30‐day mortality (OR 1.24; 95% CI, 0.88‐1.74; P = 0.22) and myocardial infarction (OR 0.93; 95% CI, 0.46‐1.90; P = 0.85). Patients undergoing TAVR did not have higher 1‐year mortality rates (OR 0.98; 95% CI, 0.61‐1.56; P = 0.92). The incidence of stroke was significantly greater in patients with PD (OR, 1.71; 95% CI, 1.10‐2.66). PD was able to reduce the incidence of moderate‐severe PVR by 15 fold (OR 15.0; 95% CI, 4.2‐54.5; P < 0.001), although rates of moderate‐severe PVR were still higher after PD than patients who did not require PD (OR 3.64; 95% CI, 1.96‐6.75; P < 0.001).

Conclusions

PD significantly improves rates of PVR, however careful patient selection is needed to minimize increased risk of strokes.