Demenzscreening per Telefon

Background

To assess cognitive impairment or dementia in epidemiologic studies using telephone interviews for data acquisition, valid, reliable and short instruments suitable for telephone administration are required. For the Telephone Interview for Cognitive Status (TICS) in its modified German version, the only instrument used in Germany so far, more data on reliability and practicability are needed.

Material and methods

Participants were recruited in the offices of nine primary care physicians. Data from 197?participants (115?females, mean age 78.5±4.1?years) who were tested by telephone and in the office by means of the Mini-Mental State Examination (MMSE) were used for the evaluation. For assessing reliability, a group of 91?participants (55?females, mean age 78.1±4.1?years) was contacted twice during 30?days to be tested during a telephone interview by means of the TICS in its modified German version.

Results

The intraclass correlation coefficient (ICC), a measure of reliability, was 0.67 [95% confidence interval (CI): 0.53; 0.77]. The Bland–Altman plot did not reveal any relationship between the variability of the difference between repeated measures and the total amount of the measure. For the overall TICS score, no differences were found between repeated measurements. However, the tasks recall of the word list and counting backwards showed some improvement in the repeated tests. TICS and MMSE showed only moderate correlation, with a correlation coefficient of 0.48 (95% CI: 0.36; 0.58). TICS values were dependent on age and educational level of the person tested.

Conclusions

The TICS in its modified German version appears to be of acceptable reliability for the assessment of cognitive impairment during a telephone interview. TICS values depend on age and educational level of the person tested. TICS and MMSE correlate only moderately.     

Validity of the telephone interview for cognitive status (TICS) and modified TICS (TICSm) for mild cognitive imparment (MCI) and dementia screening

This study aimed to validate the TICS and modified TICS (TICSm) in Korean elderly population and to compare MCI and dementia screening ability between TICS and TICSm. TICS and TICSm were administered to 70 cognitively normal (CN), 75 MCI, and 85 dementia subjects, with mini-mental state examination (MMSE) and other cognitive and functional measures. TICS and TICSm scores were highly correlated with other global cognitive and functional scores. The CN vs. dementia discrimination ability of both instruments was as excellent as that of MMSE (sensitivity/specificity at optimal cutoff: 87.1/90.1 for TICS; 88.2/90.0 for TICSm). Although their CN vs. MCI discrimination performances were comparable to that of MMSE, they were far from perfect (sensitivity/specificity: 69.3/68.6 for TICS; 73.3/67.1 for TICSm). There was no significant difference in dementia or MCI screening accuracy between TICS and TICSm. Both of them also showed high test-retest reliability. Our findings indicate that TICS and TICSm are reliable and as valid as MMSE in regard of screening cognitively impaired elderly. In terms of the comparison between TICSm and TICS, however, TICSm has little advantage over TICS for screening dementia and even MCI, in spite of longer administration time and more efforts required.     

Glaucoma and cognitive function trajectories in a population-based study: Findings from the health and retirement study

Introduction

Prior studies on the association of glaucoma and cognitive function have reported mixed results.

Methods

The Health and Retirement Study (HRS) is a nationally representative panel survey of Americans age ≥ 51 years. HRS-linked Medicare claims data were used to identify incident glaucoma cases (by glaucoma type). Cognitive function was measured using the Telephone Interview for Cognitive Status (TICS), administered in each wave (every 2 years). Separate linear mixed models were fitted with either prevalent or incident glaucoma as a predictor of TICS trajectories and adjusting for age, race/ethnicity, educational attainment, gender, and medical history. Negative model estimates indicate associations of glaucoma with worse cognitive function scores or steeper per-year declines in cognitive function scores.

Results

Analyses of prevalent glaucoma cases included 1344 cases and 5729 controls. Analyses of incident glaucoma included 886 cases and 4385 controls. In fully-adjusted models, those with prevalent glaucoma had similar TICS scores to controls (β = 0.01; 95% Confidence Interval [CI]: −0.15, 0.18; p = 0.86). However, in those with incident glaucoma, we detected a statistically significant association between glaucoma and lower TICS scores (β = −0.29; 95% CI: −0.50, −0.08; p = 0.007). However, there was no statistically significant association between either prevalent or incident glaucoma and per-year rates of change in TICS scores. When categorizing glaucoma by type (primary open angle glaucoma, normal tension glaucoma, or other glaucoma), no significant associations were detected between either prevalent or incident glaucoma and levels of or rates of change in TICS scores in fully covariate adjusted models.

Conclusion

The observed associations between glaucoma and cognitive function were small and unlikely to be clinically meaningful. Compared to prior studies on this topic, this investigation provides robust evidence based on its larger sample size, longitudinal follow-up, and repeated measures of cognitive function in a population-based sample.

     

A pilot randomized control trial to evaluate the feasibility of an Internet‐based self‐management and transitional care program for youth with haemophilia

Adolescents with haemophilia must assume responsibility for their health and management of their disease. An online self‐management program was developed to support adolescents during this transition. To determine the feasibility of the program using a randomized control trial (RCT) design in terms of 1 accrual/attrition rates, 2 willingness to be randomized, 3 compliance with the program/outcome measures and 4 satisfaction. Adolescents, ages 13–18, were enrolled in a pilot RCT (NCT01477437) and randomized to either the intervention (8‐week program with telephone coaching) or the control arm (no access to the website, weekly telephone call as attention‐strategy). All participants completed pre/postoutcome measures. Twenty‐nine teens participated (intervention n = 16, control n = 13). Participants in the intervention arm spent an average of 50 min on the website per week and completed the modules in an average of 14 weeks (SD = 4.9). Attrition was higher in the control group compared to the intervention group (54% vs. 25%). 17/18 (94%) who completed the program also completed the poststudy measures. Teens on the intervention arm showed significant improvement in disease‐specific knowledge (P = 0.004), self‐efficacy (P = 0.007) and transition preparedness (P = 0.046). There was a statistically significant improvement in knowledge in the intervention group when compared to the control group (P = 0.01). Overall, the teens found the website to be informative, comprehensive and easy to use and were satisfied with the program. This pilot RCT study suggests benefit to the program and indicates an RCT design to be feasible with minor adjustments to the protocol.     

Both conventional indices of cognitive function and frailty predict levels of care required in a long‐term care insurance program for memory clinic patients in Japan

Aim: To delineate relationships among cognitive function, frailty and level of care required in the Japanese long‐term care insurance program (LTCIP) in outpatient memory clinic patients. Methods: This was a cross‐sectional study carried out at an outpatient memory clinic. Participants were 201 cognitively impaired patients. Cognitive function was measured by the Mini‐Mental State Examination (MMSE). Frailty was measured by Timed Up & Go (TUG) and grip strength. Waist circumference, body mass index, living arrangement and level of care required in the LTCIP (rank 1 minor disability to rank 7 severe disability) were also assessed. Results: Mean age, MMSE score, TUG score and grip strength were 78.8 ± 6.9 years, 19.6 ± 6.1, 14.6 ± 6.7 s and 16.9 ± 7.5 kg, respectively. A total of 70 patients (34.8%) had not applied for the certification, at least in part because of their younger age and existence of family caregivers. LTCIP rank was correlated both with MMSE score (β: ?0.49, P = 0.001), grip strength (β: ?0.27, P = 0.005) and living alone (β: ?0.18, P = 0.03), but not with TUG score (β: 0.14, P = 0.105). Conclusion: In outpatients of a memory clinic, care ranks, which define the upper limit of monthly benefit in the Japanese LTCIP, were influenced by age, cognitive function, frailty and living arrangements. Understanding the relationship among these parameters would be useful in predicting the needs of cognitively impaired patients and important when comparing the possible services provided by long‐term care systems for them worldwide. Geriatr Gerontol Int 2012; ??: ??–?? .     

Knowledge regarding hepatitis B mother‐to‐child transmission among healthcare workers in South China

To determine the knowledge regarding hepatitis B virus (HBV) mother‐to‐child transmission (MTCT) and its prevention and treatment among healthcare workers (HCWs) in Guangdong Province, China, an HBV endemic area. An HBV knowledge questionnaire was administered to 900 HCWs from the 3rd Affiliated Hospital of Sun Yat‐Sen University and 2 rural hospitals in Guangdong Province. The 27 items in the questionnaire fell into 3 sections: HBV MTCT general knowledge, respondents’ practices of preventing HBV MTCT and awareness of the resources of preventing HBV MTCT. The data collected were coded and analysed using SPSS software version 20. In total, 503 of 900 HCWs responded to the survey (response rate: 55.9%). Eighty‐four individuals responded correctly to all of the knowledge questions: 58 were doctors, and 26 were nurses (P < .05). Doctors more often performed practices than nurses (t = 3.591, P < .01). Participants from the infectious disease department demonstrated a significantly higher proportion of correct answers and resource utilization than other specialties (χ² = 14.052, 7.998, P < .01). In terms of the average knowledge score, t test or ANOVA showed that there were significant differences between the specialty groups (t = 3.110, P < .01), hospital level groups (t = 2.337, P < .05) and age groups (F = 3.020, P < .05). Respondents’ initiative increased with hospital level and age (t = 2.993, 7.493, P < .01). A considerable percentage of HCWs has misconceptions about HBV MTCT. Healthcare workers, in particular nurses, those working in noninfectious disease departments or township hospitals and younger medical staff, lack systematic and comprehensive knowledge about HBV MTCT and are in urgent need of HBV‐related training.     

Evaluation of a Japanese version of the Mini‐Mental State Examination in elderly persons

Aim: This study aimed to examine the validity and item‐response characteristics of the Mini‐Mental State Examination (MMSE), which is used for assessing cognitive function, in Japanese older adults. Methods: Factor analysis and item response analysis were carried out for MMSE responses (n = 1971) from older adults living in the community (n = 1339) or in a nursing home (n = 632), including Alzheimer‐type dementia (n = 330), vascular dementia (n = 36), frontotemporal dementia (n = 7), mixed Alzheimer‐type and frontotemporal type dementia (n = 27), and age‐related cognitive decline (n = 29). When choosing the cut‐off score of 23 points for the MMSE, sensitivity and specificity for each item were calculated. Results: A three‐factor solution was found to be most appropriate by factor analysis: complex processing, simple processing and working memory. The item characteristics curves showed unidimensionality with high reproducibility. We identified a simplified scale comprising 10 items in all participants: “naming”, “three‐step command”, “registration”, “repeat a sentence”, “write a complete sentence”, “copies drawing of two polygons”, “orientation to place”, “delayed recall”, “orientation to time” and “serial sevens” tasks. Sensitivity and specificity for both “year” task and “day” task were more than 90% (“year”: sensitivity 92.5%, specificity 96.3%; “day”: sensitivity 92.4%, specificity 91.7%). For the Alzheimer‐type dementia patients, the five‐factor solution was suggested by factor analysis and the MMSE also had unidimensionality in terms of level of difficulty. Conclusions: We found that the MMSE had multiple cognitive areas. We showed that the MMSE could be used as an essentially unidimensional measure of cognitive ability and the question about orientation to time might be useful in the simplest assessment to identify cognitive dysfunction. Geriatr Gerontol Int 2012; 12: 310–316.     

Identifying cognitive dysfunction using the nurses’ rapidly clinical judgment in elderly inpatients

Background/PurposeThe aim of this study was to examine the relationship between nurses’ clinical judgment on cognitive function by fall risk assessment and mini-mental state examination (MMSE) scores in elderly inpatients.MethodsWe studied 61 consecutive hospitalized patients who received both comprehensive geriatric assessment (CGA) and fall risk assessment at the Department of Geriatric Medicine in Kyoto University Hospital from January 2006 to June 2010. During the fall risk assessment at admission, primary nurses evaluated the cognitive function by four items (with or without disorientation, impaired judgment, lack of comprehension, and memory loss), while a trained clinical assistant performed CGA including MMSE. Patients were divided into three groups according to the MMSE scores. The association between the four items of judgment by nurses and MMSE scores was then studied.ResultsThe mean age was 80.1 years and 55.7% of the patients were female. The percentage of patients judged to have impaired judgment, lack of comprehension, and memory loss was higher in patients with lower MMSE scores (impaired judgment, p for trend = 0.001; lack of comprehension, p for trend = 0.043; memory loss, p for trend = 0.001). The percentage of patients judged to have at least one of the four abnormalities was also significantly higher in patients with lower MMSE scores (p for trend <0.001). However, no significant relationship was found between disorientation and the MMSE scores. Further, nurses could not detect impaired cognition by the four items in one-third of the patients with mild impairment determined by MMSE.ConclusionThese data indicate that a comprehensive evaluation using all the four items on cognitive impairment is more effective in detecting cognitive impairment in elderly than using individual items, although one-third of cognitively impaired elderly patients may miss detection despite the use of the four items. Better approaches should be developed to identify cognitively impaired elderly patients by nurses.     

Goal Attainment Scaling for haemophilia (GAS‐Hēm): testing the feasibility of a new patient‐centric outcome measure in people with haemophilia

Introduction

To address the need for a patient‐reported outcome that can measure clinically and personally meaningful change in people with haemophilia (PwH) on prophylaxis, an approach based on Goal Attainment Scaling (GAS) was developed: the GAS‐Hēm.

Aim

To establish real‐world feasibility of GAS‐Hēm in PwH.

Methods

Patients aged 5‐65 years were enroled from four North American centres for a 12‐week study. The primary outcome was the proportion of participants who completed GAS‐Hēm interviews at baseline, 6 and 12 weeks. GAS‐Hēm scores were obtained by subject‐ and clinician‐rated goal attainment at Weeks 6 and 12, and compared with quality of life (QoL) measures and annualized bleed rate (ABR) for construct validity. Goals were evaluated qualitatively for content validity. Responsiveness was calculated using standardized response means (SRM).

Results

Forty‐two participants set 63 goals. Participants preferred to define (37/63) their own goals or further individualize (23/63) from the GAS‐Hēm menu. Thirty of the 37 self‐defined goals were matched to goals on the GAS‐Hēm menu. The most common goal areas were: weight, exercise and nutrition (n = 17); leisure activities (n = 8); and joint problems (n = 7). Both participant‐ and clinician‐rated GAS‐Hēm scores at 6 weeks (n = 40) and 12 weeks (n = 41) demonstrated satisfactory goal attainment (SRM [subject‐rated] at 12 weeks for adult and paediatric groups was 1.25 and 1.16, respectively). Correlations of GAS‐Hēm scores with QoL measures and ABR were uniformly small.

Conclusion

GAS‐Hēm was feasible and tapped constructs not captured by ABR or QoL measures.     

Increased Serum Level of IGF-1 Correlates With Better Cognitive Status in End-Stage Renal Disease Patients Undergoing Hemodialysis

Prevalence of cognitive function decline in end stage renal disease (ESRD) patients undergoing hemodialysis is higher than in the general population. We analyzed risk factors for cognitive function decline in those patients. This study included 93 ESRD patients undergoing hemodialysis two or three times a week in three centers for hemodialysis in Montenegro. The cognitive status of patients was assessed using the mini mental score examination (MMSE) test. All 93 patients have been divided into three groups according to the results of MMSE. Patients in the first group had severe cognitive impairment and MMSE score below 17 (26.88%), patients in the second group with MMSE score 18–23 had moderate cognitive impairment (40.86%) and third group of patients have MMSE >24 and no cognitive impairment (32.26%). There were no significant differences between groups for gender, smoking habits and level of parathyroid hormone. Level of schooling was significantly different between groups of patients (P < 0.001). Laboratory markers observed in this study with significant differences between groups were: IGF 1, IGFBP 3, erythrocytes and hemoglobin (P < 0.001, P = 0.004, P < 0.001, P = 0.002, respectively). IGF 1 proved to be of great importance for evaluating cognitive status in our study. This marker was statistically different between groups (P < 0.001) and Tukey post hoc analysis showed significant differences between all three groups (first and second group P = 0.045, second and third group P = 0.015, first and third group P < 0.001). Our data suggest that IGF 1 can be considered as novel biomarker for assessment of cognitive functioning in CKD patients, which can be of huge clinical importance.     

Salvage chemotherapy followed by granulocyte colony‐stimulating factor‐primed donor leukocyte infusion with graft‐vs.‐host disease control for minimal residual disease in acute leukemia/myelodysplastic syndrome after allogeneic hematopoietic stem cell transplantation: prognostic factors and clinical outcomes

This study investigated the prognostic factors and clinical outcomes of preemptive chemotherapy followed by granulocyte colony‐stimulating factor‐primed donor leukocyte infusion (Chemo‐DLI) according to minimal residual disease (MRD) status in patients with acute leukemia and myelodysplastic syndromes who received allogeneic hematopoietic stem cell transplantation (HSCT) (n = 101). Patients received immunosuppressive drugs to prevent graft‐vs.‐host disease (GVHD) after Chemo‐DLI. The 3‐yr cumulative incidences of relapse, non‐relapse mortality, and disease‐free survival (DFS) after HSCT were 39.5%, 9.6%, and 51.7%, respectively. The cumulative incidences of relapse and DFS were significantly poorer in patients who exhibited early‐onset MRD. Forty‐four patients turned MRD negative 1 month after Chemo‐DLI; their cumulative incidences of relapse and DFS were significantly better than those with persistent MRD 1 month after preemptive Chemo‐DLI (relapse: 19.8% vs. 46.8%, P = 0.001; DFS: 69.6% vs. 46.4%, P = 0.004). The cumulative incidences of relapse and DFS after HSCT were significantly better in patients with chronic GVHD (cGVHD) than those without cGVHD (relapse: 19.6% vs. 63.7%, P < 0.001; DFS: 74.4% vs. 23.8%, P < 0.001). Early‐onset MRD, persistent MRD after Chemo‐DLI, and non‐cGVHD after Chemo‐DLI, which were associated with increased relapse and impaired DFS, suggest unsatisfactory response to preemptive Chemo‐DLI.     

An exploratory study of long‐term health outcomes following an in‐patient multidisciplinary program for people with fibromyalgia syndrome

Objective: To examine the health status of people with fibromyalgia syndrome approximately 10 years after an intensive rehabilitation intervention to identify biopsychosocial factors for further research. Methods: Baseline data, collected upon admission to the rehabilitation intervention was compared to follow‐up data collected by telephone interview. Data was evaluated for differences and relationships using the appropriate parametric or non‐parametric tests. Results: The 29 participants were interviewed an average of 9.4 years after their admissions. All participants reported the persistence of fibromyalgia and use of related medication. Differences between baseline and follow‐up were: increased paid employment (P < 0.001), social networks (P < 0.05) and decreased stress levels (P < 0.05). Correlations with paid employment were: younger age (r_s = –0.66, P < 0.01); larger social networks (r_s = –0.40, P < 0.05) and transformation rehabilitation intervention experience (r_s = .46, P < 0.05). Follow‐up stress and sleep status were also related (r_s = 0.46, P < 0.05). Conclusion: Fibromyalgia symptoms and medication use persist over time. The wider issues concerning social integration and participation appear to be worthy of further investigation.     

Arterial damage and cognitive decline in chronic kidney disease patients

In the general population aortic stiffening, assessed by carotid femoral pulse wave velocity (cf‐PWV), is associated with cognitive dysfunction (CO/DY). Data in chronic kidney disease (CKD) are limited. This study tests the hypothesis that large artery stiffness and microvascular damage in CKD patients are related to the damage of brain microcirculation reflected by impaired cognitive function. A cross‐sectional study enrolled 151 patients (mean age 58.4 years; 64.5% males; 44 patients with CKD stage 1; 47 with stage 2; 25 with stage 3; and 35 with stage 4). Cognitive impairment, assessed by the Mini Mental State Examination (MMSE), the Clock – drawing test (Clock‐test), and the Instrumental Activity of Daily Living (IADL), was considered as primary outcome. We measured systolic and pulse pressures at the brachial and aortic sites and cf‐PWV. Our patients revealed a significant linear deterioration in all the domains of cognitive function according to CKD stages. High values of cf‐PWV (P = 0.029) and aortic pulse pressure (aPP) (P < 0.026) were independent determinants of cognitive decline assessed by the MMSE. The present trial supports the hypothesis of an interaction between the kidney, large artery damage, central pressure pulsatility, and the injury of brain microcirculation. In clinical practice, cf‐PWV and aPP measurements may help to predict cognitive decline. Whether the reduction in aortic stiffness following an aggressive treatment translates into improved cognitive outcomes remains to be determined.     

Effects of sodium intake on postural lightheadedness: Results from the DASH‐sodium trial

Lightheadedness after standing contributes to adverse clinical events, including falls. Recommendations for higher sodium intake to treat postural lightheadedness have not been evaluated in a trial setting. The Dietary Approaches to Stop Hypertension (DASH)‐Sodium trial (1998‐1999) tested the effects of the DASH diet and sodium reduction on blood pressure (BP). Participants were randomly assigned to DASH or a typical Western diet (control). During either diet, participants ate three sodium levels (50, 100, 150 meq/d at 2100 kcal) in random order for 30‐days, separated by 5‐day breaks. Participants reported the presence and severity of postural lightheadedness at baseline and after each feeding period. There were 412 participants (mean age 48 years; 57% women; 57% black). Mean baseline SBP/DBP was 135/86 mm Hg; 9.5% reported baseline lightheadedness. Among those consuming the DASH diet, high vs low sodium increased lightheadedness (OR 1.71; 95% CI: 1.01, 2.90; P = 0.047) and severity of lightheadedness (P = 0.02), but did not affect lightheadedness in those consuming the control diet (OR 0.77; 95% CI: 0.46, 1.29; P = 0.32). Among those consuming high vs low sodium in the context of the DASH diet, adults <60 vs ≥60 years old experienced more lightheadedness (P‐interaction = 0.04), along with obese vs non‐obese adults (P‐interaction = 0.01). In the context of the DASH diet, higher sodium intake was associated with more frequent and severe lightheadedness. These findings challenge traditional recommendations to increase sodium intake to prevent lightheadedness.     

Single versus tandem high‐dose melphalan followed by autologous blood stem cell transplantation in multiple myeloma: long‐term results from the phase III GMMG‐HD2 trial

The prospective, randomized phase III trial GMMG‐HD2 aimed at demonstrating non‐inferiority of single (Arm A) versus tandem (Arm B) high‐dose melphalan followed by autologous transplantation (HDM/ASCT) with regard to 2‐year event‐free survival (EFS) in newly‐diagnosed multiple myeloma (MM) and included 358 evaluable patients [Intention‐to‐treat population, (ITT), single/tandem HDM/ASCT: n = 177/181]. After a median follow‐up of more than 11 years, non‐inferiority of single versus tandem HDM/ASCT was demonstrated using the planned non‐inferiority threshold of 15% of the 2‐year EFS rate. Neither EFS (P = 0·53) nor overall survival (OS) (P = 0·33) differences were observed in the ITT population. In the tandem arm, 26% (n = 47/181) of patients refused a second HDM/ASCT due to non‐medical reasons. A per‐protocol (PP) analysis, including patients who received the intervention (single/tandem HDM/ASCT: n = 156/93) and patients who did not receive a second HDM/ASCT due to medical reasons (12%, n = 22/181), did not yield differences in EFS (P = 0·61) or OS (P = 0·16). In the ITT and PP set of the tandem arm, the rates of complete responses increased from first to second HDM/ASCT (both P = 0·04). Ten‐year OS for the entire ITT was 34% (95% confidence interval: 29–40%). OS after first relapse was significantly shortened in the tandem arm (P = 0·04). In this study single HDM/ASCT was non‐inferior to tandem HDM/ASCT in MM.     

Role of Physical Activity in Reducing Cognitive Decline in Older Mexican‐American Adults

The effect of physical activity on cognitive function in older adults from minority and disadvantaged populations is not well understood. This study examined the longitudinal association between physical activity and cognition in older Mexican Americans. The study methodology included a prospective cohort with longitudinal analysis of data from the Hispanic Established Populations for the Epidemiologic Study of the Elderly. General linear mixed models were used to assess the associations and interactions between physical activity and cognitive function over 14 years. Community‐based assessments were performed in participants' homes. Physical activity was recorded for 1,669 older Mexican Americans using the Physical Activity Scale for the Elderly. Cognition was measured using the Mini‐Mental State Examination (MMSE) and separated into memory and nonmemory components. A statistically significant positive association was observed between levels of physical activity and cognitive function after adjusting for age, sex, marital status, education, and comorbid health conditions. There was a statistically significant difference in MMSE scores over time between participants in the third (β = 0.11, standard error (SE) = 0.05) and fourth (β = 0.10, SE = 0.2) quartiles of physical activity and those in the first. The protective effect of physical activity on cognitive decline was evident for the memory component of the MMSE but not the nonmemory component after adjusting for covariates. Greater physical activity at baseline was associated with less cognitive decline over 14 years in older Mexican Americans. The reduction in cognitive decline appeared to be related to the memory components of cognitive function.     

Diabetes and cognitive function in a population-based study of elderly women and men

OBJECTIVES: The aim of this study was to examine the association between diabetes and cognitive function in the elderly. RESEARCH DESIGN AND METHODS: From January to December 2003, all 740 participants, aged 70 years or more, of an ongoing population-based cohort study were eligible for a telephone interview on cognitive function. Cognitive function was assessed using validated instruments, including the Telephone Interview of Cognitive Status (TICS) and the East Boston Memory Test (EBMT). Information on diabetes was available from prior questionnaires and was validated in 2002. We used multivariable logistic regression to estimate odds ratios (OR) of an impaired cognitive function (below 25th percentile) and their 95% confidence intervals (CI) adjusting for age, gender, smoking, alcohol consumption, body mass index (BMI), physical exercise, educational level, and depressive symptoms. RESULTS: Out of 473 participants interviewed (64.9%), 66 had diabetes (14.1%). The adjusted OR for diabetes and impaired cognitive function assessed by TICS was 2.3 (95% CI: 1.2-4.3). Diabetes was also associated with performance on delayed recall EBMT (adjusted OR=2.0; 95% CI: 1.0-4.1), but not immediate EBMT recall (adjusted OR=1.0; 95% CI: 0.5-2.1). The association between diabetes and cognitive function was a bit more pronounced in participants in whom diabetes was diagnosed 12 (median) or more years prior (adjusted OR with TICS=2.4; 95% CI: 1.0-5.8) and in those without antidiabetic treatment (age- and sex-adjusted OR=3.4; 95% CI: 1.7-6.5). CONCLUSION: Diabetes should be considered to be a risk factor for cognitive impairment in the elderly, which might be attenuated by antidiabetic treatment.     

Over‐the‐scope clip system: A review of 1517 cases over 9 years

Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over‐the‐scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC‐associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.     

Treatment of Epstein Barr virus‐induced haemophagocytic lymphohistiocytosis with rituximab‐containing chemo‐immunotherapeutic regimens

Haemophagocytic lymphohistiocytosis (HLH) is a life threatening complication of Epstein–Barr virus (EBV) infection. The anti‐CD20 antibody rituximab depletes B cells, leading to improved outcomes for patients with EBV‐associated B‐lymphoproliferative disorders. To gather data on the use of rituximab in EBV‐HLH, we performed a retrospective investigation involving 42 EBV‐HLH patients who had received treatment with rituximab‐containing regimens. On average, patients received 3 rituximab infusions (range 1–10) at a median dose of 375 mg/m². In all patients, rituximab was administered with other HLH‐directed medications, including steroids, etoposide and/or ciclosporin. Rituximab‐containing regimens appeared well tolerated and improved clinical status in 43% of patients. Examination of laboratory data obtained prior to and within 2–4 weeks after the first rituximab dose revealed significant reductions in EBV load (median load pre‐rituximab: 114 200 copies/ml, median post‐rituximab: 225 copies/ml, P = 0·0001) and serum ferritin levels (median ferritin pre‐rituximab: 4260 μg/l, median post‐rituximab: 1149 μg/l, P = 0·001). Thus, when combined with conventional HLH‐directed therapies, rituximab improves symptoms, reduces viral load and diminishes inflammation. These data support the incorporation of rituximab into future prospective clinical trials for patients with EBV‐HLH.