Prevalence and Association of Sarcopenia with Mortality in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: The objective of this meta-analysis was to assess the association of sarcopenia defined on computed tomography (CT) head and neck with survival in head and neck cancer patients. METHODS: Following a PROSPERO-registered protocol, two blinded reviewers extracted data and evaluated the quality of the included studies using the Quality In Prognostic Studies (QUIPS) tool, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. A meta-analysis was conducted using maximally adjusted hazard ratios (HRs) with the random-effects model. Heterogeneity was measured using the I2 statistic and was investigated using meta-regression and subgroup analyses where appropriate. RESULTS: From 37 studies (11,181 participants), sarcopenia was associated with poorer overall survival (HR 2.11, 95% confidence interval [CI] 1.81-2.45; p < 0.01), disease-free survival (HR 1.76, 95% CI 1.38-2.24; p < 0.01), disease-specific survival (HR 2.65, 95% CI 1.80-3.90; p < 0.01), progression-free survival (HR 2.24, 95% CI 1.21-4.13; p < 0.01) and increased chemotherapy or radiotherapy toxicity (risk ratio 2.28, 95% CI 1.31-3.95; p < 0.01). The observed association between sarcopenia and overall survival remained significant across different locations of cancer, treatment modality, tumor stages and geographical region, and did not differ between univariate and multivariate HRs. Statistically significant correlations were observed between the C3 and L3 cross-sectional area, skeletal muscle mass, and skeletal muscle index. CONCLUSIONS: Among patients with head and neck cancers, CT-defined sarcopenia was consistently associated with poorer survival and greater toxicity.

Effect of sarcopenia and frailty on outcomes among patients with brain metastases.

PURPOSE: Sarcopenia and frailty have been associated with increased mortality and duration of hospitalization in cancer. However, data investigating these effects in patients with brain metastases remain limited. This study aimed to investigate the effects of sarcopenia and frailty on clinical outcomes in patients with surgically treated brain metastases. METHODS: Patients who underwent surgical resection of brain metastases from 2011 to 2019 were included. Psoas cross-sectional area and temporalis thickness were measured by two independent radiologists (Cronbach's alpha > 0.98). Frailty was assessed using the Clinical Frailty Scale (CFS) pre-operatively and post-operatively. Overall mortality, recurrence, and duration of hospitalization were collected. Cox regression was performed for mortality and recurrence, and multiple linear regression for duration of hospitalization. RESULTS: 145 patients were included, with median age 60.0 years and 52.4% female. Psoas cross-sectional area was an independent risk factor for overall mortality (HR = 2.68, 95% CI 1.64-4.38, p < 0.001) and recurrence (HR = 2.31, 95% CI 1.14-4.65, p = 0.020), while post-operative CFS was an independent risk factor for overall mortality (HR = 1.88, 95% CI 1.14-3.09, p = 0.013). Post-operative CFS (ß = 15.69, 95% CI 7.67-23.72, p < 0.001) and increase in CFS (ß = 11.71, 95% CI 3.91-19.51, p = 0.004) were independently associated with increased duration of hospitalization. CONCLUSION: In patients with surgically treated brain metastases, psoas cross-sectional area was an independent risk factor for mortality and recurrence, while post-operative CFS was an independent risk factor for mortality. Post-operative frailty and increase in CFS significantly increased duration of hospitalization. Measurement of psoas cross-sectional area and CFS may aid in risk stratification of surgical candidates for brain metastases.

Prevalence of tight glycemic control based on frailty status and associated factors in community-dwelling older adults.

BACKGROUND: Tight control of type 2 diabetes (T2DM) in frail older adults has shown to be associated with adverse outcomes. The objective of this study is to determine the prevalence of tight glycemic control based on underlying frailty status and its association with functional and cognitive measures in community-dwelling older adults. METHODOLOGY: Ancillary study of the Singapore Population Health Studies on older adults aged ≥65 years with T2DM. Tight glycemic control cut-offs were based on the 2019 Endocrine Society guideline using HbA1c target range based on a patient's overall health status measured by the FRAIL scale. Data on basic demographics, frailty, cognitive, and functional statuses were collected. Multivariable regression was used to assess potential factors associated with tight glycemic control. RESULTS: Of 172 community-dwelling older adults with diabetes mellitus and HbA1c done, frail (65%) and pre-frail (64.4%) participants were more likely to have tight glycemic control than robust participants (31.6%, P < 0.001). In multi-variate analysis, frailty (OR 6.43, 95% CI 1.08-38.1, P = 0.041), better cognition (OR 1.15, 95% CI 1.02-1.32, P = 0.028), and multi-morbidity (OR 7.36, 95% CI 1.07-50.4, P = 0.042) were found to be significantly associated with increased odds of tight glycemic control. CONCLUSION: Tight glycemic control was highly prevalent in frail and pre-frail older adults, especially in those with multi-morbidity and better cognition. Future prospective longitudinal studies are required to evaluate effectiveness of frailty screening in making treatment decisions and long-term outcomes. Key messages What is already known on this topic:  There is growing recognition that glycemic targets should be adjusted based on health or frailty status. However, there is no consensus on how health status or frailty should be defined when determining glycemic control targets. What this study adds:  Our study found that tight glycemic control was highly prevalent in frail and pre-frail older adults. Our findings highlight the importance of assessing for tight glycemic control based on frailty status and further work is needed to aid implementation of screening and intervention policies to avoid the attendant harms of tight glycemic control.

'Insight' in medical training: what, why, and how?

The term 'insight' is generically defined in English language as the ability to perceive deeper truths about people and situations. In clinical practice, patient insight is known to have important implications in treatment compliance and clinical outcomes, and can be assessed clinically by looking for the presence of illness awareness, correct attribution of symptoms to underlying condition, and acceptance of treatment. In this article, we suggest that cultivating insight is actually a highly important, yet often overlooked, component of medical training, which may explain why some consistently learn well, communicate effectively, and quickly attain clinical competency, while others struggle throughout their clinical training and may even be difficult to remediate. We herein define 'insight' in the context of medical training as having an astute perception of personal cognitive processes, motivations, emotions, and ability (strengths, weaknesses, and limitations) that should drive self-improvement and effective behavioural regulation. We then describe the utility of cultivating 'insight' in medical training through three lenses of (i) promoting self-regulated, lifelong clinical learning, (ii) improving clinical competencies and person-centred care, and (iii) enhancing physician mental health and well-being. In addition, we review educational pedagogies that are helpful to create a medical eco-system that promotes the cultivation of insight among its trainees and practitioners. Finally, we highlight several tell-tale signs of poor insight and discuss psychological and non-psychological interventions that may help those severely lacking in insight to become more amenable to change and remediation.

Clinical reasoning in real-world practice: a primer for medical trainees and practitioners.

Clinical reasoning is a crucial skill and defining characteristic of the medical profession, which relates to intricate cognitive and decision-making processes that are needed to solve real-world clinical problems. However, much of our current competency-based medical education systems have focused on imparting swathes of content knowledge and skills to our medical trainees, without an adequate emphasis on strengthening the cognitive schema and psychological processes that govern actual decision-making in clinical environments. Nonetheless, flawed clinical reasoning has serious repercussions on patient care, as it is associated with diagnostic errors, inappropriate investigations, and incongruent or suboptimal management plans that can result in significant morbidity and even mortality. In this article, we discuss the psychological constructs of clinical reasoning in the form of cognitive 'thought processing' models and real-world contextual or emotional influences on clinical decision-making. In addition, we propose practical strategies, including pedagogical development of a personal cognitive schema, mitigating strategies to combat cognitive bias and flawed reasoning, and emotional regulation and self-care techniques, which can be adopted in medical training to optimize physicians' clinical reasoning in real-world practice that effectively translates learnt knowledge and skill sets into good decisions and outcomes.

Providing family updates: a primer for the medical trainee.

Providing family updates is a common clinical task for medical trainees and practitioners working in hospital settings. Good clinical communication skills are essential in clinical care as it is associated with improved patient satisfaction, understanding of condition, treatment adherence, and better overall clinical outcomes. Moreover, poor communications are often the source of medical complaints. However, while patient-centred communication skills training has generally been incorporated into clinical education, there hitherto remains inadequate training on clinical communications with patients' families, which carry different nuances. In recent years, it is increasingly recognized that familial involvement in the care of hospitalized patients leads to better clinical and psychological outcomes. In fact, in Asian populations with more collectivistic cultures, families are generally highly involved in patient care and decision-making. Therefore, effective clinical communications and regular provision of family updates are essential to build therapeutic rapport, facilitate familial involvement in patient care, and also provide a more holistic understanding of the patient's background and psychosocial set-up. In this article, we herein describe a seven-step understand the clinical context, gather perspectives, deliver medical information, address questions, concerns and expectations, provide tentative plans, demonstrate empathy, postcommunication reflections model as a practical guide for medical trainees and practitioners in provision of structured and effective family updates in their clinical practice.

The Impact of Frailty, Falls and Cognition on Osteoporosis Management in the Oldest Old.

Data and clinical guidelines on the management of osteoporosis in nonagenarians are lacking. The aim of this study was to assess the characteristics of osteoporosis management and identify any gaps or trends in a cohort of nonagenarians who were newly diagnosed with osteoporosis during an inpatient admission. A retrospective analysis of nonagenarians admitted to the medicine department of a tertiary hospital who were newly diagnosed with osteoporosis based on extracted ICD-10 codes. Baseline demographics, frailty based on the clinical frailty scale, comorbidities, initiation, compliance and adverse effects on osteoporosis medication were analysed. Mean age of the study group was 93.0 ± 2.5 years. There was a high prevalence of frailty (71.7%), cognitive impairment (34.2%) and recurrent falls (30.0%). 82.5% were started on osteoporosis treatment with denosumab (43.4%) being the most prescribed, followed by alendronate (41.4%). Cognitive impairment and male gender were associated with less likelihood of being on osteoporosis treatment on multivariate analysis. Having a previous fracture was associated with a higher likelihood of being on osteoporosis treatment. There was a discontinuation rate of 49.5% with a mean time to discontinuation of 26.3 ± 22.9 months. There was a high rate of osteoporosis treatment in nonagenarians with osteoporosis. The presence of previous fractures was associated with initiation of osteoporosis medications, whereas frailty and falls had no impact on treatment decisions. Cognitive impairment and males were associated with a lower rate of initiation of osteoporosis medication.

Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients.

BACKGROUND: frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT). OBJECTIVE: we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years. METHODS: in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1-3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation. RESULTS: a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04-2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002). CONCLUSIONS: frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.

Association between dentition and frailty and cognitive function in community-dwelling older adults.

OBJECTIVES: To evaluate dentition status amongst community-dwelling older adults and its association with frailty and cognitive impairment. METHODOLOGY: One thousand forty-seven community-dwelling older adults aged ≥65 years were surveyed in an epidemiologic population-based cohort study in Singapore between April 2015 and August 2016. Data on demographics, dentition status, chronic diseases, activities and instrumental activities on daily-living, cognition (age- and education-specific MMSE cut-offs), frailty (FRAIL scale), perceived health and functional status were collected. Multiple logistic regression was performed to examine the association between dentition, frailty and cognition. RESULTS: Mean age of participants was 71.2 ± 5.5 years. The prevalence of denture use was 70.7% and edentulism 7.9%. Compared to edentulousness, having teeth was associated with lower odds of cognitive impairment and higher odds of being robust or pre-frail. Denture-wearers compared with edentulous persons were less likely to be male, had higher education level and more likely be robust or pre-frail. CONCLUSION AND IMPLICATIONS: There were significant associations between dentition status, frailty and cognition in our study where those with remining teeth and / or dentures had better overall outcomes. As oral health, frailty and cognitive impairments are all modifiable risk factors for healthy ageing, countries should consider population level screening for oral health, frailty and cognitive impairment.

GIST of the stomach masquerading as recurrent falls in an older adult: a case report and review.

BACKGROUND: Gastric tumors become increasingly prevalent with advanced age but can be challenging to diagnose in older adults who may present with non-specific symptoms. Here, we report a rare case of an occult gastric tumor associated with mesenteric panniculitis that presented with recurrent falls precipitated by vertigo. CASE PRESENTATION: We describe a diagnostically challenging case of cryptogenic gastric tumor associated with mesenteric panniculitis in a 74-year-old female who presented with abdominal bloating and recurrent falls precipitated by vertigo, dehydration, acute kidney injury and electrolyte deficiencies, but had no alarm symptoms. Her symptoms resolved after laparoscopic wedge resection of the gastric tumor. CONCLUSIONS: Our case highlights that while alarm symptoms such as dysphagia, weight loss, gastrointestinal bleeding and vomiting are considered indications for endoscopy, clinicians should also maintain a high index of suspicion for gastric tumors in older patients who may present with atypical symptoms.

Binding Differences of Two Homochiral [Ru(bpy)2dppz]2+ Complexes with poly(U)·poly(A)*poly(U) Triplex RNA.

The first investigation of chiral ruthenium(II) complexes Δ- and Λ-[Ru(bpy)2dppz]2+ and triplex RNA poly(U)·poly(A)*poly(U) was carried out, which showed that Δ enantiomer displayed significant ability in stabilizing model triplex RNA.