Prognosis of Mild Cognitive Impairment in General Practice: Results of the German AgeCoDe Study

PURPOSE

The concept of mild cognitive impairment (MCI) has recently been introduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as mild neurocognitive disorder, making it a formal diagnosis. We investigated the prognostic value of such a diagnosis and analyzed the determinants of the future course of MCI in the AgeCoDe study (German Study on Ageing, Cognition, and Dementia in Primary Care Patients).

METHODS

We recruited 357 patients with MCI aged 75 years or older from primary care practices and conducted follow-up with interviews for 3 years. Depending on the course of impairment over time, the patients were retrospectively split into 4 groups representing remittent, fluctuating, stable, and progressive courses of MCI. We performed ordinal logistic regression analysis and classification and regression tree (CART) analysis.

RESULTS

Overall, 41.5% of the patients had remission of symptoms with normal cognitive function 1.5 and 3 years later, 21.3% showed a fluctuating course, 14.8% had stable symptoms, and 22.4% had progression to dementia. Patients were at higher risk for advancing from one course to the next along this spectrum if they had symptoms of depression, impairment in more than 1 cognitive domain, or more severe cognitive impairment, or were older. The result on a test of the ability to learn and reproduce new material 10 minutes later was the best indicator at baseline for differentiating between remittent and progressive MCI. Symptoms of depression modified the prognosis.

CONCLUSIONS

In primary care, about one-quarter of patients with MCI have progression to dementia within the next 3 years. Assessments of memory function and depressive symptoms are helpful in predicting a progressive vs a remittent course. When transferring the concept of MCI into clinical diagnostic algorithms (eg, DSM-5), however, we should not forget that three-quarters of patients with MCI stayed cognitively stable or even improved within 3 years. They should not be alarmed unnecessarily by receiving such a diagnosis.     

Reservoir and excess pressures predict cardiovascular events in high-risk patients

Background

Analysis of the arterial pressure curve plays an increasing role in cardiovascular risk stratification. Measures of wave reflection and aortic stiffness have been identified as independent predictors of risk. Their determination is usually based on wave propagation models of the circulation. Another modeling approach relies on modified Windkessel models, where pressure curves can be divided into reservoir and excess pressure. Little is known of their prognostic value.

Methods and results

The aim of this study is to evaluate the predictive value of parameters gained from reservoir theory applied to aortic pressure curves in a cohort of high-risk patients. Furthermore the relation of these parameters to those from wave separation analysis is investigated.Central pressure curves from 674 patients with preserved ejection fraction, measured by radial tonometry and a validated transfer function, were analyzed. A high correlation between the amplitudes of backward traveling pressure waves and reservoir pressures was found (R = 0.97). Various parameters calculated from the reservoir and excess pressure waveforms predicted cardiovascular events in univariate Cox proportional hazards modeling. In a multivariate model including several other risk factors such as brachial blood pressure, the amplitude of reservoir pressure remained a significant predictor (HR = 1.37 per SD, p = 0.016).

Conclusions

Based on very different models, parameters from reservoir theory and wave separation analysis are closely related and can predict cardiovascular events to a similar extent. Although Windkessel models cannot describe all of the physiological properties of the arterial system, they can be useful to analyze its behavior and to predict cardiovascular events.     

Associations Between Macrolevel Economic Factors and Weight Distributions in Low- and Middle-Income Countries: A Multilevel Analysis of 200?000 Adults in 40 Countries

Objectives. We examined associations between macrolevel economic factors hypothesized to drive changes in distributions of weight and body mass index (BMI) in a representative sample of 200 796 men and women from 40 low- and middle-income countries.Methods. We used meta-regressions to describe ecological associations between macrolevel factors and mean BMIs across countries. Multilevel regression was used to assess the relation between macrolevel economic characteristics and individual odds of underweight and overweight relative to normal weight.Results. In multilevel analyses adjusting for individual-level characteristics, a 1–standard-deviation increase in trade liberalization was associated with 13% (95% confidence interval [CI] = 0.76, 0.99), 17% (95% CI = 0.71, 0.96), 13% (95% CI = 0.76, 1.00), and 14% (95% CI = 0.75, 0.99) lower odds of underweight relative to normal weight among rural men, rural women, urban men, and urban women, respectively. Economic development was consistently associated with higher odds of overweight relative to normal weight. Among rural men, a 1–standard-deviation increase in foreign direct investment was associated with 17% (95% CI = 1.02, 1.35) higher odds of overweight relative to normal weight.Conclusions. Macrolevel economic factors may be implicated in global shifts in epidemiological patterns of weight.Cardiovascular diseases are among the leading causes of death in low- and middle-income countries (LMICs),1 where mortality from such diseases has been increasing and is expected to continue doing so until 2030.2 In parallel to this trend, there has been an increase in average body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) in most regions of the world.3 With population-based studies indicating a U- or J-shaped relation between BMI and cardiovascular disease mortality,4,5 these shifts in BMI may increase the proportion of the population at greatest risk for cardiovascular diseases. As such, increases in BMI may contribute to escalating cardiovascular disease mortality in LMICs,6 highlighting the need for understanding BMI patterns and predictors.Comparative longitudinal data that can be used to monitor BMI changes (often expressed according to prevalence of underweight, overweight, and obesity) across LMICs are scant; however, existing data suggest that the prevalence of underweight has decreased, the prevalence of overweight and obesity has increased, and, in general, there is a greater burden of overweight than underweight in most LMICs, particularly in urban areas.7–9 Shifts in the key determinants of weight, including diet and physical activity, are hypothesized to influence these patterns.3 Major changes in global dietary consumption have increased per capita food intake in LMICs, as well as the proportion of people’s daily diet derived from energy-dense and fatty foods.3,10–12 Although cross-national and longitudinal data on physical activity are limited, available evidence suggests that forms of transportation, employment, and leisure activities have become more sedentary and may contribute to changing patterns of weight at the population level.13,14Macrolevel economic factors, including economic development, urbanization, foreign investment, and trade liberalization, are hypothesized to drive shifting patterns of dietary composition, physical activity, and other determinants of nutritional outcomes.3,15 Economic growth and attendant increases in per capita income, for example, are associated with increased consumption of energy-dense foods,16 and recent cross-national analyses suggest that economic development is associated with a faster rate of growth in the prevalence of overweight among lower-income groups in LMICs.17,18 Urbanization is hypothesized to increase access to processed diets, reduce opportunities for physical activity, and expose residents to food marketing, thereby promoting a more sedentary lifestyle associated with less energy expenditure and greater caloric intake.15The influx of foreign direct investment (FDI), defined as investments by an enterprise in one country intended to acquire a lasting management interest in an enterprise operating in a foreign economy, represents one mechanism through which transnational corporations enter into new markets. FDI inflows are, along with greater openness to trade,19 hypothesized to be a key element in reshaping the global market for food, particularly in LMICs, by threatening traditional modes of agricultural production and facilitating the processing, distribution, and marketing of lower-cost, energy-dense food.20,21Despite the potential role that these macrolevel economic factors may play in shaping the epidemiological pattern of diet, behavior, and weight in LMICs, few empirical studies have investigated the relation between contextual factors and individual weight. A limited number of ecological studies have been conducted,9,22 but their results cannot be used to draw inferences about health at the individual level. Furthermore, the social patterning of diet and physical activity according to area of residence (urban or rural) and gender suggests that the macrolevel factors posited to drive changes in weight may have distinct implications for particular groups of individuals,23,24 and ecological studies cannot assess whether associations between macrolevel economic characteristics and weight vary according to such individual-level characteristics.We used data from a sample of approximately 200 000 adults from 40 LMICs to describe the ecological associations between macrolevel economic factors hypothesized to drive changes in determinants of weight (i.e., economic development, urbanization, FDI, trade liberalization) and average BMIs across countries and examine the association between macrolevel characteristics and the probability at the individual level of underweight and overweight or obesity relative to normal weight. We also assessed cross-level interactions of macrolevel factors with gender and area of residence.     

High resolution ultrasound in posterior interosseous nerve syndrome

Introduction: Posterior interosseous nerve (PIN) syndrome is a rare compression neuropathy of the PIN in the region of the supinator muscle, most common by the arcade of Frohse. We aimed to specify ultrasonographic findings in patients with PIN syndrome in comparison to healthy volunteers. Methods: Ultrasound images and clinical data of 13 patients with PIN syndrome confirmed by neurological examination and electrophysiological testing were evaluated retrospectively. Anteroposterior nerve diameters measured at the arcade of Frohse were compared with those of 20 healthy volunteers. The echotexture and the presence of a caliber change of the PIN were additionally assessed. Results: Enlargement of the PIN was seen in all patients with PIN syndrome, but not in volunteers (statistically significant difference in mean diameter P < 0.05). Furthermore, edema and caliber change of the PIN were present in all patients. Conclusions: High‐resolution ultrasound allows for differentiation between patients with PIN syndrome and healthy volunteers. Muscle Nerve 49 : 35–39, 2014