Background
During the current COVID-19 health crisis virtual geriatric clinics have become increasingly utilised to complete outpatient consultations, although concerns exist about feasibility of ...such virtual consultations for older people. The aim of this rapid review is to describe the satisfaction, clinic productivity, clinical benefit, and costs associated with the virtual geriatric clinic model of care.
Methods
A rapid review of PubMed, MEDLINE and CINAHL databases was conducted up to April 2020. Two independent reviewers extracted the information. Four subdomains were focused on: satisfaction with the virtual geriatric clinic, clinic productivity, clinical benefit to patients, costs and any challenges associated with the virtual clinic process.
Results
Nine studies with 975 patients met our inclusion criteria. All were observational studies. Seven studies reported patients were satisfied with the virtual geriatric clinic model of care. Productivity outcomes included reports of cost-effectiveness, savings on transport, and improved waiting list metrics. Clinical benefits included successful polypharmacy reviews, and reductions in acute hospitalisation rates. Varying challenges were reported for both clinicians and patients in eight of the nine studies. Hearing impairments and difficulty with technology added to anxieties experienced by patients. Physicians missed the added value of a thorough physical examination and had concerns about confidentiality.
Conclusion
Virtual geriatric clinics demonstrate evidence of productivity, benefit to patients, cost effectiveness and patient satisfaction with the treatment provided. In the current suboptimal pandemic climate, virtual geriatric clinics may allow Geriatricians to continue to provide an outpatient service, despite the encountered inherent challenges.
Guidelines recommend increased salt intake as a first-line recommendation in the management of symptomatic orthostatic hypotension and recurrent syncope. There have been no systematic reviews of this ...intervention. We sought to summarize the evidence for increased salt intake in patients with orthostatic intolerance syndromes.
We conducted a systematic review and meta-analysis of studies in PubMed, EMBASE, and CINAHL. Interventional studies that increased salt intake in individuals with orthostatic intolerance syndromes were included. Primary outcome measures included incidence of falls and injuries, and rates of syncope and presyncope. Secondary outcome measures included other orthostatic intolerance symptoms, blood pressure, and heart rate.
A total of 14 studies were eligible, including participants with orthostatic hypotension, syncope, postural orthostatic tachycardia syndrome, and idiopathic orthostatic tachycardia (n = 391). Mean age was 35.6 (± 15) years. All studies were small and short-term (<60 mins-90 days). No study reported on the effect of increased salt intake on falls or injuries. Meta-analysis demonstrated that during head-up tilt, mean time to presyncope with salt intake increased by 1.57 minutes (95% confidence interval CI, 1.26-1.88), mean systolic blood pressure increased by 12.27 mm Hg (95% CI, 10.86-13.68), and mean heart rate decreased by −3.97 beats per minute (95% CI, −4.08 to −3.86), compared with control. Increased salt increased supine blood pressure by 1.03 mm Hg (95% CI, 0.81 to 1.25). Increased salt intake resulted in an improvement or resolution of symptoms in 62.3% (95% CI, 51.6 to 72.6) of participants in short-term follow-up studies (mean follow-up of 44.3 days, 6 studies; n=91). Methodological quality of studies were low with high statistical heterogeneity in all meta-analyses.
Our meta-analysis provides low-quality evidence of a short-term improvement in orthostatic intolerance with increased salt intake. There were no clinical trials demonstrating the efficacy and safety of increased salt intake on long-term clinical outcomes. Overall, there is a paucity of clinical trial evidence to support a cornerstone recommendation in the management of orthostatic intolerance syndromes.
While lifestyle risk factors are implicated in the development and progression of cognitive impairment, interventional trials of individual participants have yielded unconvincing evidence. We sought ...to explore the development of lifestyle interventions targeting the household-unit.
Semi-structured interviews were carried out among eight households affected by cognitive impairment (i.e. member of the household had cognitive impairment). Interviews took place online using a secure, web-based video platform recommended for patient clinician interaction. Interview content was analysed, and important themes identified.
Eighteen participants were interviewed within households, of which eight (one per household) had cognitive impairment and others were spouses or first-degree relatives living in the same home. Several themes emerged; 1) household members without cognitive impairment were more likely to report poor sleep habits, and sleep was perceived to be the hardest behaviour to change; 2) diet generated most interest as a potential lifestyle intervention target as most participants believed there is a strong link with nutrition and cognition; 3) physical activity is challenging to adapt due to lack of motivation and focus when individuals are cognitively impaired. Barriers to study participation, including risk of harm, complexity of intervention and deviation from routine emerged during discussions.
This study identified beliefs and preferences of households towards lifestyle intervention trials. Findings from this study may be used to inform future clinical trial protocols and future qualitative studies should explore acceptability and feasibility of digital intervention applications.
Background: The association of lipid lowering therapy and intracerebral hemorrhage risk is controversial. Methods: We performed a cumulative meta-analysis of lipid lowering trials that reported ...intracerebral hemorrhage. Statin, fibrate, ezetimibe, PCSK9, and CETP trials were included. We explored whether the association of lipid lowering therapy and risk of intracerebral hemorrhage may vary by baseline low-density lipoprotein (LDL) level, mean change in LDL or baseline cardiovascular risk of population. Results: Among 39 trials (287,651 participants), lipid lowering therapy was not associated with a statistically significant increased risk of intracerebral hemorrhage (ICH) in primary and secondary prevention trials combined (odds ratio OR, 1.12; 95% confidence interval CI, .98-1.28). Lipid lowering was associated with an increased risk of ICH in secondary prevention trials (OR, 1.18; 95% CI, 1.00-1.38), but not in primary prevention trials (OR, 1.01; 95% CI, .78-1.30), but the test for interaction was not significant (P for interaction = .31). Meta-regression of baseline LDL or difference in LDL reduction between active and control did not explain significant heterogeneity between studies for ICH risk. Of 1000 individuals treated for 1 year for secondary prevention, we estimated 9.17 (95% CI, 5.78-12.66) fewer ischemic strokes and .48 (95% CI, .06-1.02) more ICH, and a net reduction of 8.69 in all stroke per 1000 person-years. Conclusions: The benefits of lipid lowering therapy in prevention of ischemic stroke greatly exceed the risk of ICH. Concern about ICH should not discourage stroke clinicians from prescribing lipid lowering therapy for secondary prevention of ischemic stroke.
•Frailty, cognitive impairment and residing in nursing homes were associated with an increased likelihood of developing delirium in older adults with COVID-19.•The presence of delirium significantly ...increases mortality risk in older adults with COVID-19.
Older adults with COVID-19 are more likely to present with atypical symptoms, notably delirium. The main objective of this meta-analysis is to identify risk factors for delirium and outcomes of delirium in hospitalized older adults (65 years or above) with COVID-19.
Comprehensive literature search of Embase, CINAHIL, Medline and Web of Science was performed for published literature until 31st August 2021. Two independent researchers evaluated study eligibility and assessed study quality using the Newcastle Ottawa Scale (NOS) for cohort studies and Joanna Briggs Institute (JBI) critical appraisal tools for case series. The association of various predisposing factors with delirium in this cohort was reported as odds ratio (OR) and its 95% confidence interval (CI).
A total of 31 studies from 11 countries were included in this review. Most of the included studies investigated patients from non-ICU settings (n = 24; 77.4%). Frailty (OR 3.52, 95% CI: 1.96–6.31, p<0.0001, I2=71.63%), cognitive impairment including dementia (OR 6.17, 95% CI: 2.92–13.07, p<0.00001, I2=88.63%) and being nursing home residents (OR 1.72, 95% CI: 1.31–2.24, p<0.0001, I2=0) were significantly associated with increased likelihood of developing delirium in older adults with COVID-19. The presence of delirium also significantly increases mortality risk in hospitalized older adults with COVID-19 (OR 2.51, 95% CI: 1.51–4.17, p<0.0001, I2=89.3%).
Our review identifies key factors associated with increased risk of developing delirium in hospitalized older adults with COVID-19. Identification of patients at risk of delirium and attention to these factors early during admission may improve outcomes for this vulnerable cohort.
•We identified no RCT where the household was the unit of randomisation. However, we identified 5 clinical trials that randomised the adjacent construct of dyads.•Amongst these trials (n = 1721), ...lifestyle-based interventions (diet and physical activity) were not significantly associated with change in cognitive or functional outcomes.•Our findings suggest a deficit in household-level lifestyle interventions for prevention of cognitive decline and related outcomes.•Given the importance of lifestyle factors in risk of dementia, simple lifestyle interventions which target households may have group-level health benefits for all members.
Lifestyle interventions targeting households may be an effective means of promoting healthier cognitive function in later life, with extended benefit to other household members. In this systematic review and meta-analysis, we sought to assess the effect of targeting lifestyle behaviours of households on cognitive outcomes
An electronic search strategy was designed to identify randomised controlled trials (RCTs) where households were randomised to receive a lifestyle intervention for the prevention of cognitive decline, from database inception until April 2020. Our initial search identified no eligible studies, so we revised our search strategy to include trials enroling dyads. We reported the cognitive outcomes, functional outcomes, caregiver outcomes and long-term care (LTC) admissions for eligible studies.
We identified no RCTs which randomised households to receive a lifestyle intervention for preventing cognitive decline. We identified five RCTs (n = 1721, with mean follow-up of 9.6 months) which randomised dyads, which evaluated diet (two trials) and physical activity (three trials).
Trials evaluating dietary and exercise interventions in dyads were identified. No trial demonstrated a significant association of interventions with change in cognitive testing, functional outcomes or long-term care admissions, although trials were small with short-term follow-up. Future studies should consider targeting lifestyle behaviours of households for prevention of dementia.
Background A run‐in period may increase adherence to intervention and reduce loss to follow‐up. Whether use of a run‐in period affects the magnitude of treatment effects is unknown. Methods and ...Results We conducted a meta‐analysis comparing treatment effects from 11 systematic reviews of cardiovascular prevention trials using a run‐in period with matched trials not using a run‐in period. We matched run‐in with non–run‐in trials by population, intervention, control, and outcome. We calculated a ratio of relative risks (RRRs) using a random‐effects meta‐analysis. Our primary outcome was a composite of cardiovascular events, and the primary analysis was a matched comparison of clinical trials using a run‐in period versus without a run‐in period. We identified 66 run‐in trials and 111 non–run‐in trials (n=668 901). On meta‐analysis there was no statistically significant difference in the magnitude of treatment effect between run‐in trials (relative risk RR, 0.83 95% CI, 0.80–0.87) compared with non–run‐in trials (RR, 0.88 95% CI, 0.84–0.91; RRR, 0.95 95% CI, 0.90–1.01). There was no significant difference in the RRR for secondary outcomes of all‐cause mortality (RRR, 0.97 95% CI, 0.91–1.03) or medication discontinuation because of adverse events (RRR, 1.05 95% CI, 0.85–1.21). Post hoc exploratory univariate meta‐regression showed that on average a run‐in period is associated with a statistically significant difference in treatment effect (RRR, 0.94 95% CI, 0.90–0.99) for cardiovascular composite outcome, but this was not statistically significant on multivariable meta‐regression analysis (RRR, 0.95 95% CI, 0.90–1.0). Conclusions The use of a run‐in period was not associated with a difference in the magnitude of treatment effect among cardiovascular prevention trials.
Cushing’s syndrome is a rare disorder of cortisol excess and is associated with significant morbidity and mortality. Hypercalcaemia due to hyperparathyroidism is a common condition; however, in 10% ...of young patients, it is associated with other endocrinopathies and occurs due to a genetic variant e.g. multiple endocrine neoplasia (MEN) type 1 (MEN1), MEN2 or MEN4. We report the case of a 31-year-old woman who was referred to the endocrinology out-patient service with an 8-month history of hirsutism, amenorrhoea and weight gain. Her biochemical work up was significant for adrenocorticotropic hormone (ACTH)-independent Cushing’s syndrome. Radiological investigations revealed an adrenal adenoma. During investigation she was also found to have primary hyperparathyroidism due to a parathyroid adenoma. Pre-operatively, the patient was commenced on metyrapone and both her adrenal and parathyroid lesions were resected successfully. There were several concerning findings on initial examination of the parathyroid tumour, including possible extension of the tumour through the capsule and vascular invasion; however, following extensive review, it was ultimately defined as an adenoma. Given the unusual presence of two endocrinopathies in a young patient, she subsequently underwent genetic testing. Analysis of multiple genes did not reveal any pathogenic variants. The patient is currently clinically well, with a normal adjusted calcium and no clinical features of cortisol excess. She will require long-term follow up for recurrence of both hypercalcaemia and hypercortisolaemia.
Introduction: Accreditation is often viewed as a benchmark of quality. The Intersocietal Accreditation Commission (IAC) has been evaluating and accrediting nuclear medicine and PET labs since 1997. ...As part of the accreditation process, the quality of staff credentials, equipment, protocols, study appropriateness, imaging, interpretation, reporting, and the quality improvement (QI) program are evaluated. Historically, deficiencies have been identified for approximately 70% of labs applying for IAC nuclear/PET accreditation. In 2016, to assist labs in self-evaluating and improving the quality of their diagnostic imaging studies, the IAC created a QI Self-Assessment Tool. The QI Self-Assessment Tool concentrates on four quality areas: test appropriateness, image quality/safety, interpretive quality, and report timeliness/completeness. The results of the self-assessment can be used to fulfill the annual QI accreditation requirements. The ability of IAC QI Tool to improve diagnostic imaging study quality is known. Using the IAC accreditation decision with its inherent identification of quality issues as an outcome variable, the aim of this study is to evaluate the effect of IAC QI Self-Assessment Tool utilization on subsequent accreditation decision by labs applying for IAC nuclear/PET accreditation. Methods: All facilities applying for IAC nuclear/PET accreditation from October 2016 through November 2017 were evaluated. Variables measured included: application date, accreditation area (myocardial perfusion imaging (MPI), equilibrium radionuclide angiography (ERNA), general nuclear medicine (GNM), and PET), accreditation decision (delay = issues identified, grant = no significant issues identified), date of first QI self-assessment, self-assessment completed before submission of application (yes/no), number of assessments per lab, cases per assessment, and reviewers per assessment. The number and percentage was reported for categorical variables, and the median and interquartile range was reported for continuous variables. Comparisons were made using Chi-square tests (X2) and logistic regression analysis with a p-value of <.05 significant. Results: Between October 2016 and November 2017, 784 labs applied for IAC nuclear/PET accreditation. Of those labs, 161 (20.5%) completed a QI self-assessment and 55 (7.0%) completed a self-assessment prior to submitting an accreditation application. The median number of assessments per lab was 2 (Q1=1, Q3=4). The median cases per assessment was 6.7 (Q1=2.6, Q3=13.1), and the median reviewers per assessment was 1.0 (Q1=1, Q3=2). Overall, quality issues (delayed accreditation), that must be corrected before accreditation is granted, were identified at 559 (71.3%) applicant labs. A smaller number of labs that utilized the QI Self-Assessment Tool had quality issues identified at the time of accreditation than those that did not use the tool (49.1% vs. 73.0, p<.0001). Controlling for the number of assessments, average cases per assessment, average reviewers per assessment, volume of studies, and type of lab, nuclear/PET labs that utilize the IAC QI Self-Assessment Tool are 3.46 times more likely to be granted accreditation. Conclusions: The IAC QI Self-Assessment Tool demonstrates a positive effect in identifying and correcting quality issues leading to positive accreditation outcomes.
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