Quick Administration Research Articles

Psychometric Properties of the Neuropsychiatric Inventory: A Review.

Neuropsychiatric symptoms cause a significant burden to individuals with neurocognitive disorders and their families. Insights into the clinical associations, neurobiology, and treatment of these symptoms depend on informant questionnaires, such as the commonly used Neuropsychiatric Inventory (NPI). As with any scale, the utility of the NPI relies on its psychometric properties, but the NPI faces unique challenges related to its skip-question and scoring formats. In this narrative review, we examined the psychometric properties of the NPI in a framework including properties pertinent to construct validation, and health-related outcome measurement in general. We found that aspects such as test-retest and inter-rater reliability are major strengths of the NPI in addition to its flexible and relatively quick administration. These properties are desired in clinical trials. However, the reported properties appear to cover only some of the generally examined psychometric properties, representing perhaps necessary but insufficient reliability and validity evidence for the NPI. The psychometric data seem to have significant gaps, in part because small sample sizes in the relevant studies have precluded more comprehensive analyses. Regarding construct validity, only one study has examined structural validity with the NPI subquestions. Measurement error was not assessed in the reviewed studies. For future validation, we recommend using data from all subquestions, collecting larger samples, paying specific attention to construct validity and formulating hypotheses a priori. Because the NPI is an outcome measure of interest in clinical trials, examining measurement error could be of practical importance.

Bloodstream Bacterial Infection in Neutropenic Acute Leukemia Patients

Objective: The rapid detection of blood stream infection has the potential to not only improve patient outcomes due to quicker administration of appropriate antibiotics but also improve antibiotic stewardship by reducing patient exposures to ineffective or unnecessary broad-spectrum antibiotics. Methods: In this study blood samples from acute leukemia neutropenic patients (samples under study) and non neutropenic patients (control) were tested using cultural and non-cultural based techniques via blood culture, C-reactive protein (CRP), Erythrocyte sedimentation rate (ESR) and Molecular techniques (bacterial 16S rDNA analysis). Results: About 22% & 15% were shown positive in blood culturing; 94% & 85% were positive for CRP; 86% and 75% were presented by elevation in ESR rate for the first hour; 94% and 80% were presented by elevation in ESR rate for second hour. Treatment response of the positive cases by blood culture only was found to be 72.7% and 100% not in remission for samples under study and control respectively. In cases under study there is statistically significant correlation between culture growth sensitivity and PCR technique with P value 0.005.

When Time is of the Essence: Preliminary Findings for a Quick Administration of the Dot Counting Test.

Performance validity research has emphasized the need for briefer measures and, more recently, abbreviated versions of established free-standing tests to minimize neuropsychological evaluation costs/time burden. This study examined the accuracy of multiple abbreviated versions of the Dot Counting Test ("quick" DCT) for detecting invalid performance in isolation and in combination with the Test of Memory Malingering Trial 1 (TOMMT1). Data from a mixed clinical sample of 107 veterans (80 valid/27 invalid per independent validity measures and structured criteria) were included in this cross-sectional study; 47% of valid participants were cognitively impaired. Sensitivities/specificities of various 6- and 4-card DCT combinations were calculated and compared to the full, 12-card DCT. Combined models with the most accurate 6- and 4-card combinations and TOMMT1 were then examined. Receiver operator characteristic curve analyses were significant for all 6- and 4-card DCT combinations with areas under the curve of .868-.897. The best 6-card combination (cards, 1-3-5-8-11-12) had 56% sensitivity/90% specificity (E-score cut-off, ≥14.5), and the best 4-card combination (cards, 3-4-8-11) had 63% sensitivity/94% specificity (cut-off, ≥16.75). The full DCT had 70% sensitivity/90% specificity (cut-off, ≥16.00). Logistic regression revealed 95% classification accuracy when 6-card or 4-card "quick" combinations were combined with TOMMT1, with the DCT combinations and TOMMT1 both emerging as significant predictors. Abbreviated DCT versions utilizing 6- and 4-card combinations yielded comparable sensitivity/specificity as the full DCT. When these "quick" DCT combinations were further combined with an abbreviated memory-based performance validity test (i.e., TOMMT1), overall classification accuracy for identifying invalid performance was 95%.

Microbiological profile in keratoconjuctivits

Microbiological profile in keratoconjuctivits - IJCEO- Print ISSN No: - 2395-1443 Online ISSN No:- 2395-1451 Article DOI No:- 10.18231/j.ijceo.2019.122, Indian Journal of Clinical and Experimental Ophthalmology-Indian J Clin Exp Ophthalmol

The reliability and validity of a digital version of the Cumberland Ankle Instability Tool

Purpose The Cumberland Ankle Instability Tool is a common patient reported outcome used to assess those with Chronic Ankle Instability. However, paper versions of the Cumberland Ankle Instability Tool have only been assessed for reliability purposes. The purpose of this study was to assess the agreement and reliability of a digital version of the Cumberland Ankle Instability Tool-Digital. Materials and methods Sixty-eight participants with a history of ankle sprain(s) were recruited to participate in this study. Participants completed a paper version of the Cumberland Ankle Instability Tool and a digital version then returned one week later and completed them again. Intraclass correlation coefficients (ICC) and Kappa coefficients were used to determine the agreement between the paper and digital versions as well as test-retest reliability between the two time periods. Results The digital version showed excellent reliability (ICC = 0.93, 95% CI: 0.89–0.96) with the paper version. The test-retest reliability between testing sessions was considered good (ICC = 0.86, 95% CI: 0.77–0.92). A majority of individual items on the digital version demonstrated substantial agreement (κ = 0.60–0.81) with the paper version. Conclusions A digital version of the Cumberland Ankle Instability Tool demonstrated good to excellent psychometric properties. Clinicians who utilize a digital version as part of an electronic medical record system can utilize them confidently to accurately assess patients with Chronic Ankle Instability. Future studies may want to consider assessing a digital version with expanded clinical and research populations. Implications for rehabilitation The digital version of the Cumberland Ankle Instability Tool demonstrated adequate psychometric properties. The digital version of the Cumberland Ankle Instability Tool can be considered a reliable instrument for the assessment of Chronic Ankle Instability. A digital version of the Cumberland Ankle Instability Tool can provide automated scoring and quick administration for clinicians in a rehabilitation setting.

Abstract TP288: Emergency Department Nursing Stroke Champions Improve Door to Needle Times at a Comprehensive Stroke Center

Introduction: Intravenous tissue plasminogen activator (IV tPA), for acute ischemic stroke, has a more robust effect if given early. Improving Door-to-Needle (DTN) times in order to allow quicker administration of IV tPA continues to be the primary aim of TARGET:STROKE. The Stroke Champion (SC) Program, an American Heart Association’s Get with the Guidelines recommendation, was implemented in our emergency department (ED) in 2018. Purpose: The purpose of this study was assess if an ED Nurse SC would help to improve DTN, with a specific goal to increase the percentage of patient’s receiving IV tPA ≤30 minutes. Methods: The SC program was initiated in our ED in January 2018. The ED Nurse SC carries the following responsibilities: respond to all stroke alerts, weekly audit of all stroke alert charts, peer to peer follow up for any fallouts to determine if there was a system error or if there was an educational opportunity, weekly update of ED staff virtual communication board, weekly meeting with ED director for any challenges or expected changes, development of a relevant stroke education topic to be delivered at the biweekly ED nursing huddle, participate at the weekly code stroke huddle to collaborate with the stroke team, and attend relevant stroke conferences or stroke-related educational opportunities. A weekly “Stroke Shout Out” was also initiated by the ED Nurse SC to recognize a high performing member of the ED team. Data was compared 6 months pre and post-intervention, and analyzed using a Wilcoxon Rank Sum Test. Results: More patients received IV tPA after the initiation of the ED Nursing SC program than before (38 vs. 23 p=0.03). The median DTN was 36 (IQR 23-49) mins after implementation vs. 47 (IQR 40-56) mins before implementation (p=0.004). A higher percentage of patients received IV tPA less than 30 minutes post intervention vs. pre-intervention (42.1% vs. 17.4% , p <0.001) Conclusion: Implementation of an ED Nurse SC can increase the number of patients who receive IV tPA, improve DTN, and increase the percentage of patients who receive IV tPA less than 30 minutes from door time.

The Questionnaire for Psychotic Experiences: An Examination of the Validity and Reliability

Psychotic experiences are prevalent across a wide variety of psychiatric, neurological, and medical conditions. Yet current assessments are often designed for one disorder, or are limited in their examination of phenomenological features; this has hindered transdiagnostic research. This article describes an examination of the validity and reliability of the English version of a new assessment, the Questionnaire for Psychotic Experiences (QPE). This study aimed to use the QPE to examine hallucinations and delusions across a number of different conditions, and to ensure that the QPE had acceptable psychometric properties. An International Consortium on Hallucination Research working group, along with consumer groups, developed the 50-item QPE to assess the presence, severity, and phenomenology of hallucinations and delusions. Participants in the study who reported psychotic experiences included those with schizophrenia, schizoaffective disorder, bipolar affective disorder, and major depressive disorder, and those without a need for care (ie, nonclinical participants). There were 173 participants in total. Convergent and discriminant validity were assessed. Reliability was examined in terms of stability, equivalence, and internal consistency. The data confirmed that the QPE had good psychometric properties and could be put forward as an accepted measure of the transdiagnostic evaluation of psychotic experiences. Further validation is recommended with neurological and medical populations. Given its validity and reliability, comprehensive evaluation of psychotic phenomena, and relatively quick administration time, we propose that the QPE is a valuable instrument for both clinical and research settings.

Evaluation of in vitro antimicrobial susceptibility of Bacillus anthracis strains isolated during anthrax outbreaks in Italy from 1984 to 2017.

Anthrax, caused by Bacillus anthracis, is a non-contagious infectious disease that affects a wide range of animal species (primarily ruminants) including humans. Due to the often-fatal outcome in humans, quick administration of definitely effective antimicrobials is crucial either as prophylaxis or as a clinical case therapy. In this study, 110 B. anthracis strains, temporally, geographically, and genetically different, isolated during anthrax outbreaks in Italy from 1984 to 2017, were screened using a broth microdilution method to determine their susceptibility to 16 clinically relevant antimicrobial agents. The strains were isolated from various matrices (human, animal, and environmental samples) and were representative of thirty distinct genotypes previously identified by 15-loci multiple-locus variable-number of tandem repeats analysis. The antimicrobials tested were gentamicin, ceftriaxone, streptomycin, penicillin G, clindamycin, chloramphenicol, vancomycin, linezolid, cefotaxime, tetracycline, erythromycin, rifampin, amoxicillin, ciprofloxacin, doxycycline, and trimethoprim. All isolates were susceptible to most of the tested antimicrobials, with the exception of trimethoprim for which all of them showed high minimal inhibitory concentration values. An intermediate level of susceptibility was recorded for ceftriaxone and cefotaxime. Although the Centers for Disease Control and Prevention recommend the use of doxycycline, ciprofloxacin, penicillin G, and amoxicillin for treatment of human cases and for post-exposure prophylaxis to anthrax spores, this study shows a high degree of in vitro susceptibility of B. anthracis to many other antimicrobials, suggesting the possibility of an alternative choice for prophylaxis and therapy.

Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department.

Delirium is very frequent in older patients presenting to the emergency department (ED), but is often undetected. The purpose of this study was to evaluate the performance of the French version of the 4 A’s Test (4AT-F) for the detection of delirium and cognitive impairment in older patients. The study was conducted in four Canadian ED. Participants (n= 320) were independent or semi-independent patients (able to perform ≥5 activities of daily living) aged 65 and older and had an 8-hour exposure to the ED environment. The Telephone Interview for Cognitive Status (TICS-m), the Confusion Assessment Method (CAM) as well as the 4AT-F were administered to patients at the initial interview. The CAM and 4AT-F were then administered twice a day during the patients’ ED or hospital stay. The 4AT-F’s sensitivity and specificity were compared to those of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Our results suggest that the 4AT-F has a sensitivity of 84% (95% CI: [76, 93]) and a specificity of 74% (95% CI: [70, 78]) for delirium, as well as a sensitivity of 49% (95% CI: [34, 64]) and a specificity of 87% (95% CI: [82, 92]) for cognitive impairment. The 4AT-F is a fast and reliable screening tool for delirium and cognitive impairment in ED. Due to its quick administration time, it allows a systematic screening of patients at risk of delirium, without significantly increasing the workload of the ED staff.

Léčba k cíli u dnavé artritidy

Gout is a crystal-induced, metabolically determined inflammatory rheumatic disease with increasing prevalence. In clinical practice, gout causes frequent diagnostic as well as therapeutic problems. The golden diagnostic standard is crystalographic analysis and evidence of monosodium urate crystals in the polarization microscope; if this is not available, the diagnosis can be established through a combination of clinical, laboratory and imaging techniques. The acute gouty attack must be treated by quick administration of anti-inflammatory medicines, with available alternatives being nonsteroidal antirheumatic drugs (NSA), colchicine and glucocorticoids. When the attack subsides, hypouricemic therapy is initiated which should combine the regimen and diet measures and pharmacological treatment. Recommendations for the treatment of gout were published by the EULAR and the Czech Society for Rheumatology. Recently a new strategy appeared known as Treat to target - T2T. This principle has been successfully used in the treatment of rheumatiod arthritis and spondyloarthritis. The publication is structured as four overarching principles and nine Recommendations. The recommendations emphasize long-term maintenance of serum levels of uric acid below 360 μmol/l as the basic gout-related target in all patients, and below 300 μmol/l for patients with tophies. It is recommended to administer prophylactic small doses of colchicine for at least 3-6 months on the commencement of hypouricemic therapy. The Recommendations further emphasize the need for regular monitoring of comorbidities and the kidney function. A separate recommendation is concerned with necessary education of patients and their motivation toward compliance with regimen measures and increased physical activity.Key words: colchicine - gouty arthritis - treat to target principle.

Sensitivity and Specificity of a Short Questionnaire to Screen Frailty in the Community-Dwelling Older Population

Introduction. Frailty represents a major risk factor for death and Use of Hospital Services (UHS) among older adults. A simple tool to detect frailty might permit stratification of the community-dwelling older population according to the risk of negative outcomes. The present study aims at determining the sensitivity and specificity in predicting mortality and UHS of the Short Functional Geriatric Evaluation (SFGE), a short questionnaire to screen for frailty in community-dwelling older citizens. Methods. The study is a secondary analysis of all the data collected through an observational longitudinal cohort study carried out in Lazio region (Italy). The SFGE is compared with the Functional Geriatric Evaluation (FGE) questionnaire to define sensitivity and specificity for mortality and for UHS during the first year following its administration. Results. The SFGE classifies 36.3% of the respondents as frail and shows a sensitivity of 90.4% and a specificity of 78.3% compared to the FGE (area under the ROC: 0.928; CL95%: 0.910 - 0.947; p-value < 0.001). Those respondents identified by the SFGE as frail also include some of those classified by the FGE as pre-frail, who also show a high rate of UHS. The results show that the SFGE score predicts the UHS more accurately than it does the mortality rate. Conclusion. The SFGE identifies as frail a larger portion of the enrolled population than the FGE. Those people so identified show a high rate of UHS. Because of its easy and quick administration, it can be considered a useful primary screening tool but it must be followed up with a more extensive assessment of those identified as frail. The small time needed to fill in the tool and the possibility of administering it by telephone makes the SFGE a useful tool to screen for frailty and to plan the provision of care services at both individual and population level.

Ozone therapy for diabetic foot.

Diabetic foot ulcers (DFU) are a burden to the diabetic community. With increasing medical bills, to unsuccessful treatment, those suffering from DFUs can use alternative therapeutics. First seen in the mid-1800s, ozone (O3) is thought to be unstable, due to inherent molecular nature. With the help of pharmaceutical science, various O3 treatments have flourished in the medical community to help those suffering from DFUs. Promising results are seen through numerous studies. Usually, a mixture of both O2 and O3 is seen in pressurized machines as administered to the foot ulcer. Foot ulcers, specifically DFUs, need to be assessed, cleaned, and treated as fast as possible for the fastest results. Results such as amputation can be seen if the foot is not attended to as soon as possible. With fast growing clinical trials in O3 therapy and quick administration of the O3, O3 therapy may be on the rise to be at the forefront of treating DFUs. Compelling evidence is seen in clinical trials, but more must be done to fully understand the role of O3 in DFUs.

An Italian validation of "meter", an easy-to-use Health Literacy (hl) screener.

Health Literacy (HL) is the degree to which individuals have the capability to obtain, understand and process basic health information needed to make appropriate health decisions. It affects persons' ability to access and use health care, to interact with providers, and to care for themselves. Established literacy screeners have practical limitations (such as practictioner's attendance, time to complete, etc.): to address these, a short, self-administered measure of HL, the Medical Term Recognition Test (METER) was introduced in USA. In this study an Italian version (IMETER) of this measure has been validated administering it to undergraduate students, attending Medicine, Arts and Engineering faculties. The results of this study show a high degree of reliability and validity of the test when comparing the skills of students educated in medical matters and those of non-biological faculties, indicating the potential capability of the tool to screen low HL levels in larger population. Despite the limits of this pilot study, IMETER's quick and easy administration method seems useful not only in clinical settings, but also to ease the implementation of future larger studies.

Quick epinephrine administration induces favorable neurological outcomes in out-of-hospital cardiac arrest patients

ObjectiveThis research is to study if quick administration of adrenaline on OHCA prior to hospitalization has an effect on improving CPC1-2 at one month. MethodologyA total 13,326 cases were extracted from 2011 to 2014 Utstein data for this retrospective cohort study, also, EMT reached the patients within 16min after 119 called and adrenaline was then administered within 22min of after contact. Patients divided into two groupsPatients were contacted within 8min of the 119 call (n=6956), and were contacted between 8 and 16min after the call (n=6370). Further divided into groups in which the adrenaline was administered within/without 10min after contact. Primary outcome was the rate of a good prognosis for cerebral performance (CPC1-2) at 1 month and secondary outcome was the return of spontaneous circulation (ROSC) rate. ResultsThe odds ratio of the CPC1-2 at 1month by the EMS reached within 8min after 119 call and then adrenaline administered within 10min was 2.12 (1.54–2.92).Those reached between 8 and 16min was 2.66 (1.97–3.59). However, the ROSC rate was 2.00 (1.79–2.25) for those reached within 8min and also 2.00 (1.79–2.25) for those reached between 8min and 16min. ConsiderationsIn cases of OHCA, it appears that the CPC1-2 rate after 1month can be improved even in cases where the victim is reached >8min after the 119 call, as long as the victim is reached within 16min and emergency responders administer the adrenaline as quickly as possible.

Fall risk screening in the elderly: A comparison of the minimal chair height standing ability test and 5-repetition sit-to-stand test

BackgroundSuccessfully identifying older adults with a high risk of falling can be complicated, time consuming and not feasible in daily medical practice. This study compared the effectiveness of the Minimal Chair Height Standing Ability Test (MCHSAT) and 5-repetition sit-to-stand tst (5R-STS) as fall risk-screening instruments for the elderly. Methods167 community-dwelling older adults (mean age=83.6±7.3years) were interviewed for demographics, fall history, cognition, and mobility status. MCHSAT performance was assessed using a chair whose seat height was modifiable by increments of 5cm, starting at 47cm and lowering after each successful attempt. 5R-STS performance was assessed by recording the time it took to rise and sit back down five consecutive times from a chair of 47cm high. Operating Receiving Characteristic (ROC) curves and Area under the Curve (AUC) were calculated for each test as well as for sub-groups of participants classified based on medical comorbidities (e.g. cardiac disease/stroke, lower limb arthritis). ResultsThe MCHSAT and 5R-STS were equally effective fall-risk screening instruments for the overall population (AUC (95% CI)=0.72 (0.63–0.82) and 0.73(0.64–0.81) respectively). The 5R-STS was more effective than the MCHSAT for participants suffering from lower limb arthritis (AUC (95% CI)=0.81(0.70–0.92) and 0.71(0.58–0.85) respectively) while the opposite was true for participants with a history of cardiac disease or stroke (AUC (95% CI)=0.59 (0.44–0.80) and 0.65 (0.47–0.84) respectively). ConclusionDue to their simplicity and quick administration time, the MCHSAT and 5R-STS are equally suitable for implementation in clinical settings.

Health Literacy in Obstetric Patients: A Pharmacist's Experience with The Newest Vital Sign.

Health literacy can greatly impact patients’ self-management of medical conditions and adherence to treatment recommendations. This study aimed to assess the health literacy of obstetric patients at a university-based women’s clinic using the Newest Vital Sign (NVS). A clinical pharmacist or student pharmacist utilized the instrument to interview women during a routine clinic visit. This project is a cross-sectional, retrospective study using the de-identified survey data. Descriptive statistics were used to provide a summary of the NVS scores in this population. The average age of the 140 participants was 27 years (SD = 6) with the range from 16 to 49 years old. The majority (78%) of the patients was ≤ 30 years old; 50% were white and 39% were black. The average NVS score was 3 (SD = 2.2). 49% had scores ≤ 3 which indicates limited literacy. This pilot study yielded preliminary data for future investigations of health literacy in this population while identifying a potential role for pharmacists. Due to its ease of use and quick administration, it is feasible to use the NVS instrument to routinely screen health literacy in an obstetric clinic setting.

Hepatology highlights

Hepatology highlights

Early Treatment of Ischemic Stroke With Intravenous tPA Reduces Disability Risk

Very early treatment with intravenous thrombolysis forpatientswith mild-to-moderate acute ischemic strokes was associated with decreased risk ofhavingpermanentdisability, according to a European study published August 22 in Stroke. The American Heart Association/ AmericanStrokeAssociation(AHA/ASA)recommends getting patients to a hospital as soon as possible after onset of acute ischemic stroke symptoms for treatmentwith intravenous tissue-type plasminogen activator (tPA) This thrombolytic agent allows reperfusionof thebrainandhasprovenbenefit for select patients. AHA/ASAguidelines recommend giving tPA to treat stroke up to 4.5 hours after onset of symptoms. But sooner is farbetter than laterbecausestroke rapidlycauses irreversibly injuredtissue,with 2 million additional neurons lost each minute until reperfusion is achieved. In the Stroke study (Strbian D et al. Stroke. doi:10.1161/STROKEAHA.111.000819 [published online August 22, 2013]), researchers collected data from 6856 consecutive patients treated at 10 European strokecentersbetween 1998and2012.The patients, all of whom received tPA treatment (somewithin90minutesof strokeonset, some more than 90 minutes after onset of stroke symptoms), were divided into groups based on stroke severity as determined by the National Institutes of Health Stroke Scale (0-6, 7-12, and more than 12, designatingmild,moderate, and severe, respectively). The researchers found that for those with moderate stroke, receiving tPA in 90 minutes or less was associated with a 37% increased chance of having an excellent outcome at 3 months after stroke compared with receiving tPA after more than 90 minutes. An excellent outcome was defined as a score of 0 or 1 on the modified Rankin scale, which measures the degrees of disabil ity or dependence in daily activities after a stroke; a 0 or 1 means no symptoms of stroke or no significant disability. For patients with severe or mild stroke, the quick administration of tPA was not associated with improved chances of an excellent outcome. The researchers speculated that for those with mild stroke, quick administration of tPA did not improve the chances of an excellent outcome because the likelihood of disability is already very low. Secondary analysis did find an association at 3 months after stroke between patients receiving tPA in 90 minutes or less and a chanceofscoringa0onthemodifiedRankin scale. “Ultra-earlytreatment increasesthe likelihoodofexcellentoutcomes inpatientswith moderately severe symptoms and, in secondary analysis, also in those with mild symptoms,” said leadauthorDaniel Strbian, MD, PhD, from the department of neurologyatHelsinkiUniversityCentralHospital in Finland, in a release. “All measures must be taken to reduceonset-to-treatment timeas much as possible.” The Stroke study adds to the scientific literaturesupportingquicker treatmentof ischemicstrokewith tPA.Forexample,astudy in June involving 58 353 patients treated with tPA within 4.5 hours of symptom onset found faster treatment (measured in 15minute increments)was associatedwith reductions in in-hospital death and symptomatic intracranial bleeding and increased ratesof independent ambulationat discharge and discharge to home (Saver JL et al. JAMA. 2013;309[23]:2480-2488). For Larry B. Goldstein, MD, director of the Duke Comprehensive Stroke Center in Durham,NorthCarolina, theStroke studyaffirms existing thinking on treating acute ischemic stroke. “The trial is consistentwith our current practice, which is to try to treat patients as quickly as possible,” said Goldstein, who is also a spokesperson for the AHA/ASA. He also cautioned against interpreting the study’s findings too broadly. “One has to be careful of overinterpreting the results with consideration of stroke severity,” said Goldstein. “It is not a prospective randomized trial. It is a comparison of patients treated earlier or later,with treatment earlier seeming to benefit compared to treating later.” news@JAMA

Febrile neutropenia studies in Brazil - treatment and cost management based on analyses of cases

The management of neutropenia is a challenge in the clinical practice. It is known since the 1960s that risk of infection is associated with the intensity and duration of neutropenia(1). Neutropenic patients with an infection usually present incomplete signs and symptoms considering the severity of the condition. Thus, rubor, erythema and pustules may not be seen in neutropenia associated with a cutaneous infection, just as pulmonary infections may fail to present classical signs and symptoms such as cough, dyspnea and characteristic physical examination findings(2). Sometimes the only sign found is fever. Studies published in the 1970s have taught us that the quick administration of broad-spectrum antimicrobial agents dramatically reduces mortality from 50-90% to 10-40% within the first 72 hours of treatment(3-5). It is also known that the microbial isolation rate is low, and that there is a predominance of gram-negative bacilli. The use of antibiotics for gram-positive cocci should be adopted in cases of clear-cut risk situations such as mucositis, evident infection of a central venous catheter, hemodynamic instability and cutaneous infections(6). As of the 1980s, several studies on febrile neutropenia were performed in an attempt to differentiate risk groups for severe complications and death. The studies started with Talcott et al., who showed that patients with neutropenia undergoing chemotherapy and fever at home, without comorbidities and with the oncological disease under control, presented a low risk(7,8). In 2000, a study that standardized the risk evaluation of patients with febrile neutropenia undergoing chemotherapy was published. The index of the Multinational Association for Supportive Care of Cancer (MASCC) standardized the risk evaluation in febrile neutropenia based on clinical parameters; this evaluation that took into account the intensity of symptoms, hypotension, presence of previous fungal infection, dehydration, age and home fever was widely tested and recognized as one of the best methods to screen patients with febrile neutropenia(9). In Brazil, there are few studies that applied the MASCC index(10,11), but the mortality rate among high- and low-risk febrile neutropenia groups is notorious (Table 1). Table 1 Mortality rate among high-risk and low-risk febrile neutropenia groups Differentiating the risk groups is important because it can lower the costs of the treatment of febrile neutropenia. Pharmacoeconomic studies have estimated that the cost of each febrile neutropenia event varies between US$ 2000 and US$ 11000. According to Canadian and British studies, 25.8% of this cost is related to antibiotics and 16.4% to complementary tests. It is further estimated that about US$ 5000 can be saved per febrile neutropenia episode when the patient can be discharged early and followed up as an outpatient. The use of orally instead of intravenously administered antibiotics reduces the cost by about 80%(15). The article published in this journal, Neutropenic patients and their infectious complications at a University Hospital(16), reports on a cross-sectional study of the universe of neutropenic inpatients with infections in a general hospital. This matter needs to be further studied, and Brazilian multicentric prospective studies need to be performed given the importance of studies like this in reconfirming the relevance of the MASCC index in respect to mortality. The profile of the microbial agents isolated and their sensitivity profile help our understanding of febrile neutropenia cases and improves treatment provided to patients and a better management of the costs.

Does the Clock Drawing Test predict dementia? Results of the Leipzig Longitudinal Study of the Aged (LEILA 75+)

Background/Objectives: Being diagnosed with dementia has an enormous impact on the patients themselves as well as on caregivers and the society. Therefore research aims to identify individuals at risk prior to a diagnosis of dementia in order to maximise preventive and treatment efficacy. In recent years, research on the preclinical detection of dementia focused on the concept of mild cognitive impairment (MCI), a transitional phase between normal aging and dementia. Patients diagnosed with MCI are more likely to develop dementia compared to normal control groups and therefore represent a high-risk group. However, establishing a diagnosis of MCI often is time consuming. The Clock Drawing-Test (CDT) has been widely used to screen for dementia, especially because of its easy, quick and simple administration and good acceptance among elderly patients. Nonetheless, it is still questionable whether the CDT is an appropriate instrument to identify persons at an early stage or at a high risk of onset of dementia. Methods: Data were derived from the Leipzig Longitudinal Study of the Aged (LEILA 75+), a population-based study of individuals aged 75 and over. In this study the CDT version of Shulman et al. was used. MCI was diagnosed according to the international consensus criteria of Winblad. The cognitive criteria for a dementia diagnosis were based on the „Structured Interview for the Diagnosis of Dementia of Alzheimer type, Multi-infarct Dementia and Dementia of other Etiology according to DSM-III-R, DSM-IV and ICD-10“ (SIDAM) or, with proxy interviews, on the „Clinical Dementia Rating Scale“ (CDR). The CDT scores and diagnosis of MCI between patients developing and patients not developing dementia were compared. Multivariate analyses (Cox proportional hazard models, Kaplan-Meier), receiver operating characteristic analyses, and sensitivity and specificity of the CDT were calculated. Results: A total of 7.3% subjects of the initial population were diagnosed with dementia at the following assessment, on average 1.4 years after the initial assessment. Individuals developing dementia at follow-up more often had an initial diagnosis of MCI (64.3% vs. 9.3%) and showed significantly higher CDT scores (2.64 vs. 1.82) compared to those not developing dementia during the study course. The results of the multivariate analysis also revealed that CDT and MCI had a significant effect on a future diagnosis of dementia after adjusting for different confounding variables. The area under the curve was 0.700 (p<0.001) for predicting dementia by using the CDT, and 0.775 (p<0.001) by using MCI-diagnosis. According to the best ratio of values of sensitivity and specificity, the best cut off point was at a CDT score of 3 points. However, the values of sensitivity (67.9%) and specificity (65.2%) were not adequate for predicting a diagnosis of dementia. Discussion/Conclusions: The Clock Drawing Test significantly differentiated between patients developing dementia and patients not developing dementia during the course of the study. Although our results indicate that a diagnosis of MCI is slightly better in predicting dementia than the CDT, the quality of prediction is insufficient for both. While diagnosing MCI is very time consuming, the CDT's major qualities are its quick application and scoring. Further research should therefore aim at improving the CDT scoring system which should focus in more detail on the placement and the size of the hands in order to increase predictive validity. Funding: German Federal Ministry of Education and Research (grant no. 01 ET 0728), and Interdisciplinary Research Cluster of Genetic Factors, Clinical Phenotypes and Environment (LIFE Centre, University of Leipzig). Keywords: Outcome assessment, Clock Drawing Test, dementia.