A study led by the National Institute for Health Research (NIHR) BRACE and RSET Rapid Evaluation Centres and undertaken by researchers at UCL, Nuffield Trust, RAND Europe and the University of Birmingham suggests that effective coordination between primary and secondary care to set up and deliver remote home monitoring models can help patients and reduce demand on hospital services during the period of COVID-19.
25 jun 2021--The study, which is a systematic review of remotehomemonitoring models (including 'virtual wards') set up internationally, for confirmed or suspected COVID-19 cases shows thatprimary care-led models could be more adaptable to evolving patient and system needs and easier to replicate in contexts with limited access and capacity forhospital care.
The study, titled "Remote home monitoring (virtual wards) for confirmed or suspected COVID-19 patients: a rapid systematic review," and published in EClinicalMedicine, looks at COVID-19 remote monitoring models led by primary and secondary care across seven countries—US, Australia, Canada, the Netherlands, Ireland, China and the UK—where the models have been developed to:
Avoid unnecessary hospital admissions (providing appropriate care in the appropriate place).
Escalate cases of deterioration at an earlier stage to avoid invasive ventilation and ICU admission.
Facilitate early discharge from hospital so patients can be followed up safely in the community.
Using digital apps to monitor patients' blood oxygen levels allowed a higher number of patients to be followed up compared to paper-only models, while some studies indicated that models based on telephone calls were more inclusive of people without internet access or with limited digital literacy.
Dr. Manbinder Sidhu from the University of Birmingham (BRACE team) and a co-author of the study said: "Our review shows that primary care can play a central role in the coordination of remote patient monitoring models, providing more holistic care for patients and reducing the demand on hospital services. Yet, further research needs to explore the processes used to implement these models and how these might vary based on the healthcare sector, patient population, size, and approaches used for triage, monitoring and escalation."
These findings complement those from the teams' phase 1 empirical study of remote home monitoring during the first wave of the pandemic in England which concluded home monitoring methods can help reduce the risk of contracting COVID-19 for NHS patients and staff.
"Remote home monitoring (virtual wards) for confirmed or suspected COVID-19 patients: a rapid systematic review" is published in EClinicalMedicine.
More information: Cecilia Vindrola-Padros et al, Remote home monitoring (virtual wards) for confirmed or suspected COVID-19 patients: a rapid systematic review, EClinicalMedicine (2021). DOI: 10.1016/j.eclinm.2021.100965
Provided by University of Birmingham
Mental confusion an early warning sign of severe COVID-19
COVID-19 patients with mental confusion are at increased risk for a severe form of the illness, a new study finds.
25 jun 2021--Researchers analyzed theelectronic health recordsof more than 36,000 COVID-19 patients at five Florida hospitals. Of those, 12% developed severe COVID-19.
Patients with mental confusion were three times more likely to develop severe illness than those without such symptoms, according to the study published in the June issue of Critical Care Explorations.
"One of the key things in treating COVID-19 is looking for signs that you might have an aggressive or severe disease course," said lead study author David Marra. He is a postdoctoral researcher in the department of clinical and health psychology at the University of Florida's (UF) College of Public Health and Health Professions.
"What we found was that certain brain symptoms, specifically a condition known as encephalopathy, may be an early marker of more severe COVID-19," Marra said in a university news release. "We hope this might equip front-line workers and other health care providers with information to help them be on the lookout for a more severe disease course."
Encephalopathy is characterized by general disorientation and confusion, and "the person just doesn't seem right," Marra explained.
"They might not know where they are or be confused about the people around them," he said. "They might not know the date or recent events. If there is a lot of general confusion that's atypical for that person, that would be suggestive of some type of acute brain dysfunction."
Encephalopathy symptoms typically appeared a few days before or concurrent with the progression of COVID-19 to a serious stage requiring intensive treatment, such as admission to the intensive care unit or ventilation, the study found.
Watching for signs of encephalopathy in patients with COVID-19 could help doctors begin treatment much earlier and potentially prevent severe disease, the researchers said.
Consistent with previous research, the study found that COVID-19 patients with loss of smell and loss of taste were less likely to develop severe illness.
Study co-author Chris Robinson said, "I know we're starting to open up and we're getting vaccinated, but COVID will be with us for a while, so we need to be smarter than the virus and try to find things that we as physicians and families can identify early on to allow patients to combat the illness much more effectively."
Robinson, who is a neurointensivist and an assistant professor of neurology at the UF College of Medicine, added, "If we become complacent with what we know at this point, we'll still continue to lose people."
Monday, June 21, 2021
Chatbots for dementia patients and caregivers need more work
Chatbots hold promise for dementia patient or caregiver support, but are still in their infancy, finds a paper published in the Journal of Medical Internet Research. None of the interactive digital apps tested by medical researchers and a computer scientist performed well on all testing criteria, and all the apps contained linguistic biases and usability challenges. The authors conclude that until developers produce evidence-based chatbots that have undergone end user evaluation it will be hard to evaluate their potential to adequately educate and support dementia patients and their caregivers.
21 jun 2021--"Dementia care is complex and no two cases ofdementiaare alike. Chatbots have the potential of providing caregivers with instant support that is evidence-based and personalized. While it was promising to find some advancements in this area, it was disappointing to learn that more hasn't been done," said first author Nicole Ruggiano, a professor of social work at the University of Alabama.
Chatbots have become a familiar presence in online customer service settings, and millions of people use personal digital assistants like Amazon's Alexa or Apple's Siri to perform tasks and retrieve information every day. Chatbots combine text or voice recognition, machine learning, and pre-programmed responses to afford users relatively seamless conversation with a human-like machine.
Healthcare chatbots can interpret symptoms, suggest resources, or offer emotional support.
"Artificial intelligence chatbots have great potential to improve the communication between patients and the healthcare system, given the shortage of healthcare staff and the complexity of the patient needs. This is especially important for dementia patients and caregivers, who keep increasing as the population ages, and face care challenges daily," said corresponding author Vagelis Hristidis, a professor of computer science in UC Riverside's Marlan and Rosemary Bourns College of Engineering, and founder of SmartBot360, a healthcare chatbot company.
Chatbots can provide memory training or stimulate fond recollections for dementia patients. Dementia patient caregivers, who often feel isolated and insufficient, can receive advice and emotional support from chatbots. The effectiveness of chatbot interventions, however, is only as good as the medical knowledge used in their programming and the quality of the user's interactions with the bot.
"In regards to the use of a chatbot by dementia caregivers, there are many content areas family caregivers may find helpful. Caregivers are confronted by increasing care coordination challenges, and a decline in function and overall well-being of the person living with dementia," said co-first author Ellen Brown, Erica Wertheim Zohar Endowed Chair in Community Mental Health at Florida International University. "Additionally, a new caregiver may look for very different resources and information than a more experienced caregiver."
To assess the potential for chatbots to assist withdementia care, a team of researchers from the University of Alabama, Florida International University, and UC Riverside identified 501 chatbot apps available for download on several popular platforms. After eliminating apps that had no chat feature, offered a chat with live humans, were not actually focused on dementia, were unavailable, or were a game, they ended up with 27 apps, only six of which fit all evaluation criteria. The apps that made the cut were: CogniCare mobile app; CogniCare (Alexa Skills version); My Life Story; Dementia Types; Build Your Brain Power; and Everything Memory.
The authors assessed the productivity, effectiveness, functionality and humanity, and overall satisfaction, including affect, ethics and behavior.
The apps were generally focused on the epidemiology and symptoms of dementia and less on caregiving skills and activities. It was difficult to start using all the apps, which would present a big hurdle for people without experience using computers or for people with dementia. The voice chatbot apps only responded to very specific pronunciations and vocabulary terms, limiting their use to certain speech styles and dialects. All six of the apps were only available in English, further limiting their usefulness.
However, once the researchers were able to get the programs started, they worked fairly well. Of the five chatbots designed to educate about dementia, three had a breadth of knowledge and flexibility in interpreting information. Users were able to interact with the apps in a human-like way, though only one, My Life Story, passed the Turing test, in which a person interacting with a computer cannot tell if it is a computer or real person. Some of the apps had features that increased the user's enjoyment, such as soft background music, and one app elicited interaction with comments such as, "Tell me more."
On ethics and privacy, only the two CogniCare apps, both produced by the same organization, fared well. All the other apps had various limitations that the researchers recommended should be improved to increase user confidence.
In general, the apps' limited program content made it hard to have extended or varied conversations between users and chatbots. Because dementia is complex and the symptoms varied, this could limit the education and support the apps provide. It also was not clear if information programmed into the apps came from evidence-based medical literature or professional practice, or more questionable Internet sources.
The authors conclude that although all the chatbots tested had attractive and useful features, none of them were likely to be effective providers of reliable, evidence-based information and advice or emotional support. Because chatbots have the potential to ease the burden for caregivers as well as to help dementia patients manage their own care, the authors recommend continued development and further research into chatbot apps for dementia.
More information: Nicole Ruggiano et al, Chatbots to Support People With Dementia and Their Caregivers: Systematic Review of Functions and Quality, Journal of Medical Internet Research (2021). DOI: 10.2196/25006
Provided by University of California - Riverside
FDA advisory panelist outlines issues with aducanumab's approval for Alzheimer's disease
PET scan of a human brain with Alzheimer's disease. Credit: public domain
Despite near unanimous objection from its advisory panel, the U.S. Food and Drug Administration (FDA) granted aducanumab approval to treat Alzheimer's disease on June 7, 2021. In a commentary published in Annals of Internal Medicine, a member and former Chair of the advisory panel and an aducanumab site investigator explain why this unprecedented "accelerated approval" is problematic for clinical research and patient care.
21 jun 2021--Under accelerated approval, a drug is approved based on its effect on a surrogate marker of a disease rather than clinical outcomes. The product is expected to provide a meaningful advantage over other available therapies for a serious disease. Aducanumab's phase 1 study indicates the drug reduces beta-amyloid (the surrogate marker of disease), but whether beta-amyloid alone is a valid surrogate for the treatment of Alzheimer's is notably unclear and still a topic of ongoing important study. With the surprising approval, treating an amyloid level becomesclinical practice.
The authors express grave concern that aducanumab's approval will have important consequences for drug development, regulation, and patient care. While the world waits for the results of randomized and controlled clinical trials required to confirm aducanumab's clinical benefits (or not), insurers and payers will have to use the scant information available to determine which patients should take it and how to cover it. The copays for aducanumab, which may be as much as 20% of the total cost, will be added to the already substantial financial burden many American families face due to Alzheimer's disease. Also, clinicians will have to address with patients, uncertainty regarding whether the drug is even beneficial or safe.
According to the authors, the effect of aducanumab's approval will reverberate for years. Patients, caregivers, providers, and scientists must navigate treatment of Alzheimer's disease with an uncertain treatment. Time will tell whether or not it is safe and effective.
It is now clear that the lingering effects of COVID-19 can affect your health in many ways—including how your body reacts to surgery. In this case, the changes are significant. A growing number of studies have shown a substantial increased risk in post-operative death and pulmonary complications for at least six weeks after symptomatic and asymptomatic COVID-19 infection.
17 jun 2021 --Nosurgeryis without risk, and surgeons always weigh the risks versus benefits of performing a specific procedure on a particular patient. These findings about the connection between COVID-19 infection and surgical complications and mortality add new variables to the equation, and hospitals andhealth systemsaround the country are adopting new policies to keep patients as safe as possible.
A new policy at Yale New Haven Health now stipulates that elective surgeries for adult patients that require general or neuroaxial (anesthesia placed around the nerves, such as an epidural) anesthesia should be deferred seven weeks from the time of a known COVID-19 diagnosis.
Additionally, elective surgeries for adults who are immuno-compromised, diabetic, or have a history of hospitalization should be deferred eight to 10 weeks after diagnosis. Those with a history of intensive care hospitalization should be deferred 12 weeks.
Surgeons are advised to discuss the risks of proceeding with surgery with a patient ahead of time, says Nita Ahuja, MD, MBA, chair of surgery for Yale Medicine and chief of surgery for Yale New Haven Hospital. These guidelines do not apply to urgent and emergency surgery, she adds.
A snapshot of the studies
Several small studies, including one published in The Lancet, have suggested patients with positive COVID-19 test results may experience worse outcomes and increased chance of dying after surgery. A large international study, published in Anaesthesia, showed that keeping surgery on hold for at least seven weeks after a positive coronavirus test was associated with lower mortality risk compared with no delay.
The most recent study on this topic was published in JAMA Network Open in April and compared 5,470 surgical patients with positive COVID-19 test results (within six weeks) to 5,470 patients with negative results. There were more than double the number of deaths reported in the COVID-19-positive group versus the group with negative results.
An evolving landscape
Though surgeons are well aware of these guidelines, it's important for patients and their family members to understand the reasoning behind a decision to delay a surgery, even for a person who feels perfectly well. "We want to provide this information to patients so they can have a discussion with their surgeons and providers," says Roberta Hines, MD, chair of Yale Medicine's Department of Anesthesiology. "Each decision should be made at the individual level, and we want to stress that the patient is an active participant in their care."
For example, a patient who has cancer that requires surgery may want surgery as quickly as possible. For some, the risks of waiting to have the surgery may be greater than delaying it, while for others it may be smarter to wait. Every situation is different and what to do in a particular case is a decision that should be made jointly by patient and surgeon.
Emergency surgeries to "save life or limb" will still be done as needed. However, says Dr. Ahuja, "Semi-elective surgery accounts for the majority of our cases, especially with cancer care. These are surgeries that don't need to be done tonight, but there is a certain window of time. However, if someone comes to the hospital after a car accident, we won't delay surgery because they had COVID."
All patients must take a PCR (polymerase chain reaction, which is the most reliable of the various types of available tests) COVID-19 test before surgery. That will not change, and is key to picking up active infections [not prior ones] patients never knew they had, Dr. Ahuja adds.
The connection between COVID-19 infection and surgical complications seems logical given how research suggests a link between COVID-19 infection and inflammation. "Plus, an infection creates an inflammatory state in the body, and that can perpetuate for at least six weeks," Dr. Ahuja explains. "So that is why we recommend delaying surgery at least six weeks, so that your body is not still dealing with the effects of the virus."
It's not only the surgical procedure but the anesthesia as well that can exacerbate inflammation in the body, Dr. Hines notes.
"COVID-19 is an emerging disease and we are still learning about its acute and chronic repercussions. We initially thought it was a respiratory disease, but now we have learned about blood clots and a complex inflammatory process," Dr. Hines adds. "Six months from now, we may have different guidelines as the data is evolving."
More information: Max R. Haffner et al, Postoperative In-Hospital Morbidity and Mortality of Patients With COVID-19 Infection Compared With Patients Without COVID-19 Infection, JAMA Network Open (2021). DOI: 10.1001/jamanetworkopen.2021.5697
Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study, Anaesthesia (2021). DOI: 10.1111/anae.15458
Provided by Yale University
Wednesday, June 16, 2021
FDA approval of controversial Alzheimer's drug could delay discovery of more promising treatments
Alzheimer’s disease is characterized by progressive memory loss, spatial disorientation and many other cognitive and behavioural disorders that ultimately lead to a state of total dependence. Credit: Shutterstock
16 jun 2021--Alzheimer's disease is characterized by progressive memory loss, spatial disorientation and many other cognitive and behavioral disorders that ultimately lead to a state of total dependence.
As researchers who study Alzheimer's biomarkers—objective biological measures used to identify the disease, measure its progression and determine the effectiveness of treatments—we're very interested in the discovery of new treatments for this disease.
Aducanumab, which will be marketed under the name Aduhelm, was jointly developed by Biogen and Eisai. It is a monoclonal antibody administered by injection that binds to brain aggregates of amyloid and allows our bodies to dispose of them. The treatment is based on the idea that amyloid, a small protein that accumulates in the brains of people with Alzheimer's disease, is at the origin of a cascade of events that leads to the disease.
Questionable results
The FDA approval is based on two 18-month clinical trials that were conducted with aducanumab. One showed a slowing of the progression of cognitive impairment by about 22 percent in people who received the high-dose treatment. The other showed no difference between those who were given aducanumab and those given the placebo.
Typically, regulatory authorities require two Phase 3 trials with positive results to approve a drug. Biogen and Eisai terminated both trials after an independent panel of experts concluded that based on preliminary results, aducanumab was unlikely to be effective in slowing the cognitive decline of the disease despite showing some effectiveness in reducing brain amyloid levels.
In addition, aducanumab has been associated with cerebral edema in 40 percent of those treated. Edema is a fluid mass that produces pressure in the skull and requires medical monitoring or surgery.
After further review of the results from the two clinical trials, Biogen and Eisai announced in October 2019 that aducanumab administered in high doses showed efficacy on cognitive symptoms in patients with early Alzheimer's. This way of analyzing the results was strongly criticized by the scientific community, including some of the investigators who had participated in the clinical trials.
Neurons with amyloid plaques. Credit: Shutterstock
Amyloid may have little influence
The amyloid cascade, the idea behind how aducanumab works, is the subject ofgreat controversy in the scientific community. This hypothesis has dominated for nearly 30 years and guided the search for treatments that aim to remove amyloid from the brain. Yet every clinical trial using this approach has failed, representing dozens of products and hundreds of billions of dollars in investment.
More and more, we are realizing that the problems with Alzheimer's may not involve amyloid either directly or solely. For example, a person who is genetically predisposed to accumulate amyloid may develop Alzheimer's earlier, but may not progress more rapidly than a person who is not predisposed. This means that amyloid may have little influence on disease progression.
Even advocates of the amyloid hypothesis have become more measured about its possible influence, proposing that it may only have an indirect impact on brain dysfunction in Alzheimer's disease. This would occur through a process of brain inflammation, which is one of the possible causes of neuronal death in this disease.
So how can one explain the FDA's decision, which runs contrary to the recommendation of its own expert panel and is based on evidence that shows that amyloid only makes a small contribution to the progression of the disease?
Aducanumab reduced the amount of amyloid accumulated in the brain by nearly two-thirds in treated individuals. While this is a dramatic result, their symptoms persisted, meaning that amyloid is not a good biomarker of the disease.
The discovery and validation of reliable biomarkers to detect diseases and assess the efficacy of treatments only comes about after a long and rigorous process. The use of amyloid has never really gone through this process, yet the FDA approved a treatment based on this. Bypassing this process sets a risky precedent.
No curative treatment targeting Alzheimer's symptoms has emerged since the first treatments came to market in 1997. Aducanumab is the first approved treatment aimed at slowing the progression of the disease. The surprise and excitement generated by the first success in a journey that has included hundreds of failed clinical trials may explain why the FDA granted the drug conditional approval.
The approval also satisfies the financial interests of Biogen, Eisai and its investors. The most modest estimates put annual revenues from the sale of aducanumab at more than US$50 billion. Expectation of new revenue for Eisai and Biogen pushed the stock values of these companies up by 75 percent and 40 percent respectively the day the announcement was made.
New evidence collected after the launch of aducanumab will be critical to the future of the amyloid hypothesis and our understanding of Alzheimer's disease. With such a complex disease, it is likely that we will need to develop multiple approaches to stop its progression, much like triple therapy for HIV/AIDS. That's why we must not interrupt research on biomarkers and new therapeutic approaches.
Saturday, June 12, 2021
Study identifies how COVID-19 linked to Alzheimer's disease-like cognitive impairment
PET scan of a human brain with Alzheimer's disease. Credit: public domain
A new Cleveland Clinic-led study has identified mechanisms by which COVID-19 can lead to Alzheimer's disease-like dementia. The findings, published in Alzheimer's Research & Therapy, indicate an overlap between COVID-19 and brain changes common in Alzheimer's, and may help inform risk management and therapeutic strategies for COVID-19-associated cognitive impairment.
12 junho 2021--Reports of neurological complications in COVID-19 patients and "long-hauler" patients whose symptoms persist after the infection clears are becoming more common, suggesting that SARS-CoV-2 (the virus that causes COVID-19) may have lasting effects onbrain function. However, it is not yet well understood how the virus leads to neurological issues.
"While some studies suggest that SARS-CoV-2 infects brain cells directly, others found no evidence of the virus in the brain," says Feixiong Cheng, Ph.D., assistant staff in Cleveland Clinic's Genomic Medicine Institute and lead author on the study. "Identifying how COVID-19 and neurological problems are linked will be critical for developing effective preventive and therapeutic strategies to address the surge in neurocognitive impairments that we expect to see in the near future."
In the study, the researchers harnessed artificial intelligence using existing datasets of patients with Alzheimer's and COVID-19. They measured the proximity between SARS-CoV-2 host genes/proteins and those associated with several neurological diseases where closer proximity suggests related or shared disease pathways. The researchers also analyzed the genetic factors that enabled SARS-COV-2 to infect brain tissues and cells.
While researchers found little evidence that the virus targets the brain directly, they discovered close network relationships between the virus and genes/proteins associated with several neurological diseases, most notably Alzheimer's, pointing to pathways by which COVID-19 could lead to AD-like dementia. To explore this further, they investigated potential associations between COVID-19 and neuroinflammation and brain microvascular injury, which are both hallmarks of Alzheimer's.
"We discovered that SARS-CoV-2 infection significantly altered Alzheimer's markers implicated in brain inflammation and that certain viral entry factors are highly expressed in cells in the blood-brain barrier," explained Dr. Cheng. "These findings indicate that the virus may impact several genes or pathways involved in neuroinflammation and brain microvascular injury, which could lead to Alzheimer's disease-like cognitive impairment."
The researchers also found that individuals with the allele APOE E4/E4, the greatest genetic risk factor for Alzheimer's, had decreased expression of antiviral defense genes, which could make these patients more susceptible to COVID-19.
"Ultimately, we hope to have paved the way for research that leads to testable and measurable biomarkers that can identify patients at the highest risk for neurological complications with COVID-19," said Dr. Cheng.
Dr. Cheng and his team are now working to identify actionable biomarkers and new therapeutic targets for COVID-19-associated neurological issues in COVID long-haulers using cutting-edge network medicine and artificial intelligence technologies.
More information: Yadi Zhou et al, Network medicine links SARS-CoV-2/COVID-19 infection to brain microvascular injury and neuroinflammation in dementia-like cognitive impairment, Alzheimer's Research & Therapy (2021). DOI: 10.1186/s13195-021-00850-3
Provided by Cleveland Clinic
Central retinal artery occlusion may indicate a cardiovascular problem, say researchers
Acute central retinal artery occlusion (CRAO) is a medical emergency, and patients should be immediately triaged to an emergency department for appropriate management, according to a scientific statement issued by the American Heart Association and published online March 8 in Stroke.
12 jun 2021--Brian Mac Grory, M.B., B.Ch., from the Duke Comprehensive Stroke Center at the Duke University School of Medicine in Durham, North Carolina, and colleagues conducted a review of the literature relating to management of CRAO. A panel of experts synthesized the data, submitted considerations for practice, and revised the drafts until consensus was achieved.
In the setting of CRAO, two additions to the stroke code process are needed: A funduscopic examination to confirm diagnosis and exclude alternative causes, and a screening for arteritis. Sudden, painless, monocular vision loss most often results from CRAO and should be emphasized in public outreach campaigns as a symptom of potential stroke. Treatment with intravenous tissue plasminogen activator is suggested and may be considered for patients who have disabling visual deficits and who meet criteria after a thorough risk-benefit discussion. Secondary prevention should include collaboration between neurology, ophthalmology, and primary care medicine; risk factor modification is recommended for secondary prevention.
"Central retinal artery occlusion is a cardiovascular problem disguised as an eye problem," Mac Grory said in a statement. "Unfortunately, a CRAO is a warning sign of other vascular issues, so ongoing follow-up is critical to prevent a future stroke or heart attack."
Several authors disclosed financial ties to the pharmaceutical industry.
Macular degeneration can result in blurred or no vision in the center of the visual field. Credit: Shutterstock
Jacques was a very active retiree. That ended one November morning as his life was suddenly turned upside down. When he woke that day, he could not see out of one eye. Panicked, he came to see me right away.
12 jun 2021--Jacques had been diagnosed withage-related macular degeneration(AMD) a few years earlier. His condition had been stable, but now it suddenly progressed to the most severe form of the disease, "wet degeneration." This stage is characterized by the sudden development of a network of new blood vessels that ooze into the deep layers of the retina, causing a rapid loss of functional vision in the affected eye.
An urgent referral to ophthalmology is made in cases like these because the window of opportunity for treatment is narrow. Immediate treatment usually results in the best prognosis. Jacques managed to get treatment within a few days.
The ophthalmologist gave him interocular injections of medication, but this only improved his vision slightly. Jacques was depressed and his anxiety was increasing. He felt useless and had lost considerable autonomy.
The loss of an eye is a traumatic event, regardless of the patient's age. While the significant negative psychological effects are well documented for older patients, recent publications also report the same adverse consequences in younger populations.
For example, the rate of depression is six times greater in those with significant vision loss than in the general population (25 percent versus four percent).
Hope for patients
So what can we do to help Jacques? We can't promise that his vision will be fully restored. Although injection treatments can be effective, the basic degeneration will not go away. The best option for Jacques is to refer him to a visual impairment rehabilitation centre where he will receive help from a variety of professionals.
At this centre, he will be seen by specialists trained to treat visual impairment and its repercussions on the lives of people who suffer from it, and on the people around them. Understanding this reality is the first step toward helping patients address their needs.
The next step, after providing psychological support to Jacques, is to optimize his visual condition. Optometrists who specialize in low vision can prescribe optical aids to help Jacques regain some of his visual function, including magnifiers, vision aids and specialized glasses that can be provided through a government program designed for this purpose.
Age-related macular degeneration (AMD) can result in blurred or no vision in the centre of the visual field. Credit: Shutterstock
A social worker, aware that the impacts of a visual handicap go far beyond the person experiencing it, will accompany Jacques during his rehabilitation process and communicate with his family. In short, Jacques will have a good support system and will be able to regain a certain level of autonomy in his life, which, in turn, will have a positive impact on his morale. Support groups can also help him in his efforts and if, thanks to effective injections, his visual acuity improves, he will be in a win-win situation.
However, Jacques still has other concerns about his disease. He is worried that his children will develop similar conditions, especially one of his sons.
In addition to aging, other risk factors associated with the development of the disease include family history, ethnic origin (Caucasians and Northern Europeans are more affected), gender (women are more affected), atherosclerotic and vascular diseases, obesity and sun exposure (phototoxicity of the retinal cells).
For Jacques' son, the risk of developing AMD is clear but so are his options. He will not be able to change his genes, prevent himself from aging or change his ethnicity or chromosomes. However, he can control the modifiable factors: he can quit smoking, control his weight and stay physically active.
Diet can play a preventive role. Reducing fat intake in the diet and ensuring adequate omega-3 consumption (forms of triglyceride, 800 mg DHA/EPA per day) are important. However, adding vitamins formulated for eye health to the mix is not recommended in Jacques' case. Vitamins are only effective in treating dry AMD in its middle stages, not for preventing it. However, they are one of the few ways Jacques can reduce the risk of having his other eye affected and losing all his functional vision.
It is imperative for both Jacques and his son to follow the doctor's recommendations on managing vascular problems (hypertension, cholesterol, diabetes). When poorly controlled, these conditions significantly increase the risk of developing wet AMD.
Remember, macular degeneration is first and foremost a vascular disease: the blood vessels are no longer able to nourish the retinal cells and no longer get rid of their metabolic waste efficiently. As a result, the cells die. New blood vessels develop, but they are fragile and, when they break, flood the retina with fluid.
Finally, both father and son will need to protect themselves from the sun's harmful rays, either with a transparent filter (UV400) in their regular prescription glasses or by wearing good quality sunglasses when they are outdoors. Their eye care professionals will be able to advise them about this.
Jacques' spirits are not high, but I have given him some hope that better days lie ahead. He knows he can count on a team of professionals to support him and that he will not be dealing with his condition alone. There is hope. And hope is the first thing that makes it possible to overcome the impacts of any disease.
Provided by The Conversation
Wearable accelerometer and vibrator 'thimble' could reduce falls amongst seniors
by Yokohama National University
Overview of the proposed wearable light-touch device for human balance support. Credit: Yokohama National University
Japanese researchers have developed and tested a prototype device—wearable on the fingertips—that incorporates the concept of 'light touch' to enhance the sense of balance. If widely implemented, the device should significantly reduce incidence of falls amongst seniors. The findings are published in the journal Scientific Reports on April 1.
As we age, our sense of balance can become impaired. The resulting increase in postural sway in turn increases the risk of falls and consequent injuries. Meanwhile, older people make up a large and increasing proportion of the population in highly developed countries. This makes efforts to reduce the effects of postural sway ever more imperative.
Aids such as canes and walking frames help a great deal, but research suggests their use or misuse in certain circumstances such as on stairs or stepping into or out of vehicles can actually exacerbate the problem with sense of balance and increase the risk of injury.
In order to address the challenge of human balance in the elderly, in recent years a great deal of research has focussed on the phenomenon known as 'light touch.' Even with eyes closed, a subject that lightly touches a curtain or piece of paper draped in front of them with just their fingertips is given enough of a stimulus cue to reduce their swaying. This happens even though a curtain or piece of paper cannot deliver any postural support in the way that a cane or walking frame can.
Researchers with Yokohama National University (YNU) and the Prefectural University of Hiroshima wanted to test a way to create a 'virtual light touch' (VLT) system to achieve the same result—in effect creating a virtual curtain.
The first step was a basic VLT system that incorporated a small device that fits over a fingertip of a subject—much like wearing a thimble—and delivers a vibrotactile 'nudge' when they begin to sway. Assessment of swaying in this first attempt at a VLT was performed by a 3-D motion capture system akin to what is used by special effects professionals in the movie industry.
Initial tests on subjects with this proof-of-concept system showed results equivalent to the use of a physical curtain.
"The use of such a large and complex motion capture system is no more practical in daily life than a curtain," said Keisuke Shima, Associate Professor at faculty of engineering of YNU and lead author of the study.
"But the tests on live subjects showed that the concept worked," added YNU researcher Mami Sakata, a co-author of the paper. "The next step was to transform the VLT into a system that could be used in everyday life."
The researchers swapped out the motion capture system for an accelerometer—an electromechanical device that measures acceleration forces—similar to what is found in most smartphones. The vibrotactile nudges were still delivered by the vibrotactile thimble device.
The accelerometer-and-vibrotactile-thimble VLT system was then tested on 150 volunteers ranging in age from their sixties to their nineties and again found that postural sway was reduced as significantly as a physical curtain.
The acceleration-based VLT set-up is immediately practical as a balance aid in everyday life as it involves a simple, lightweight and compact sensor and motor. It should enjoy widespread adoption amongst elderly people.
However, the researchers want to improve their system further by making the device even more lightweight and compact, and to enhance its reduction of postural sway. For this latter enhancement, they will need to explore precisely how the still poorly understood light-touch effect works to support human balance.
More information: Keisuke Shima et al, A wearable light-touch contact device for human balance support, Scientific Reports (2021). DOI: 10.1038/s41598-021-85687-4
Provided by Yokohama National University
To prevent delirium, increase mobility, connection and sleep
Accelerated cognitive decline in patients with and without existing dementia is one of the most disturbing outcomes of hospitalizations for older adults, affecting at least 2.6 million Americans every year.
12 jun 2021--But the condition, known asdelirium, is believed to be preventable in up to 40 percent of hospital-acquired cases, and researchers at UC San Franciso wanted to see if simple tweaks, like avoiding nighttime interruptions to promote sleep, nixing certain prescription drugs, and promoting exercise and social engagement, could decrease its incidence.
In a June 8, 2021, study in the Journal of Hospital Medicine, the researchers followed approximately 22,700 inpatients aged 50 and over who had been admitted to and discharged from the same non-intensive care unit at UCSF Medical Center. Half of the patients were admitted after the hospital had implemented a comprehensive delirium prevention and treatment care pathway, which included screening on admission as well as during each 12-hour nursing shift.
Since the screening did not take place prior to the study, the researchers could not confirm the interventions' impact on delirium prevention. However, data comparing outcomes pre- and post-intervention showed an overall 2 percent drop in length of hospital stay. Remarkably, for the approximate 20 percent of study participants in the medicine unit, where patients require less specialized care, the researchers found a 9 percent drop in length of stay, together with a 7 percent reduction in cost savings, for an average of $1,237 less per hospitalization.
Some specialty patients less likely to respond to interventions
The difference in impact between patients in the medicine unit and those in specialty care can be explained by the fact that the former are more likely to be elderly patients who develop delirium due to sleep deprivation, restraints and certain drugs, said senior author Vanja Douglas, MD, of the UCSF Department of Neurology and the Weill Institute for Neurosciences. "Other patients, such as neurology and neurosurgery patients, are delirious due to factors like recent brain surgery, seizures or encephalitis, and are less likely to respond to the non-pharmacologic interventions that were part of the delirium care pathway."
Interventions for patients of all specialties also led to a 14 percent reduction in the number of 30-day readmissions, a sign that "patients at risk of delirium may not have developed delirium or that interventions reduced its duration," said first author Sara LaHue, MD, also from the UCSF Department of Neurology and the Weill Institute for Neurosciences.
The hallmarks of delirium include confused thinking, restlessness and agitation, together with reduced awareness of the environment and changes in attention ranging from confusion to withdrawal. Unlike dementia, which develops gradually, delirium starts rapidly and may be triggered by acute illness, as well as by hospitalization. Patients over 75 with hearing or vision impairments, who have been living in a nursing home or assisted living facility are at higher risk.
"Compared with non-delirious patients, delirious patients are more likely to consume more hospital staff time and life-support resources, stay longer and develop in-hospital complications," said LaHue.
The researchers found that 12.6 percent of the patients, whose average age was 67, had delirium on admission, and 5.6 percent developed the condition during their stay. The patients' risk for delirium was gauged by age, illness severity, orientation and ability to perform a simple word or math test. For patients at high risk, the researchers reviewed their medications and eliminated or substituted those that were "deliriogenic." They also revised nighttime routines to avoid interruptions, prescribed melatonin as a sleep aid, and in some cases scheduled consults with occupational and speech/language therapists to help with mobility and cognitive stimulation.
Bladder catheters, restraints linked to more delirium
Of note, bladder catheters were removed, an initiative that is a cornerstone of delirium prevention, according to LaHue. "Any kind of tether, like a bladder catheter or physical restraint, limits mobility and adds to the risk of disorientation," she said.
Similarly, the use of physical restraints was decreased in all study patients, from 17.1 restraint days per 1,000 patient days in the first three months of the intervention to 11 restraint days per 1,000 patient days in the last three months of the 12-month intervention. "As a result, one might expect a need for more frequent safety attendant use and an associated cost increase," said Douglas. "However, we found that safety attendant use decreased significantly with the intervention, in parallel to reduced restraint use."
Additionally, they recommended that nursing staff walk with higher-risk patients three times a day and engage in conversation, assist them with getting out of bed to eat their meals, ensure water was within reach at all times, and reinforce awareness of time by writing the date on the board in their room, and by lowering shades at night and opening them in the day.
COVID safety measures may mean future 'epidemic of cognitive impairment'
While the study was conducted prior to the pandemic, LaHue has since noted that patients hospitalized with COVID-19 join the ranks of those at high risk for delirium. In her perspective published last year, LaHue states that not only does COVID-19 lead to a "heightened inflammatory state" that raises risk, but aggressive efforts to prevent transmission of the virus in hospitals exacerbate those risks. These include less engagement with PPE-clad clinicians and bans on visitors, who may have played an essential role in reducing delirium risk by "encouraging physical and cognitive stimulation, protecting their loved ones from falls and advocating for their basic needs."
LaHue points to a study that found 9.5 percent of cognitively normal adults who developed delirium following surgery were diagnosed with mild cognitive impairment or dementia within one year, indicating that long-term effects may be at least partially irreversible even in those without existing dementia. For hospitals, efforts to curtail the spread of the virus may have resulted in collateral damage: an epidemic of a different nature.
"In addition to the physical and psychological challenges that COVID-19 survivors face," she said, "a surge in delirium during this pandemic may lead to a delayed epidemic of cognitive impairment."
More information: Andrea Yevchak Sillner et al, Ultrabrief Screens for Detecting Delirium in Postoperative Cognitively Intact Older Adults, Journal of Hospital Medicine (2020). DOI: 10.12788/jhm.3410
Provided by University of California, San Francisco
