Psychiatric Symptoms in Patients With Dementia: Do Caregivers and Doctors See the Same Thing?

PURPOSE: Neuropsychiatric symptoms (NPS) are common in Alzheimer Disease (AD). Treatment could be optimized by supplementing the clinician's impression of a patient with information from the caregiver. Yet the agreement between caregivers and physicians on the presence of NPS in patients with AD is understudied. METHODS: Data were obtained from a 2-staged survey in neurology outpatient offices. At stage 1, patients (n=403) were documented by their physicians, including an assessment on the presence of NPS. At stage 2, patients' CGs (n=171) were asked about the presence of NPS in the patients, based on questions from the Neuropsychiatric Inventory. Caregivers were screened for depression with the Depression Screening Questionnaire. PATIENTS: The study sample comprised patients with mild or moderate AD. RESULTS: NPS frequency varied between 52.6% [95% confidence interval (CI), 44.9%-60.3%] and 67.2% (95% CI, 59.7%-74.2%, reported by CGs) and 34.2% (95% CI, 26.8%-42.1%) and 50.9% (95% CI, 42.9%-58.9%, reported by physicians). Apathy, depression, aggression, and irritability occurred most frequently according to both sources. κ values were lowest for euphoria (κ=0.03; 95% CI, -0.08 to 0.25), and highest for depression (κ=0.26; 95% CI, 0.11-0.43). CG depression was associated with an increased probability (odds ratio=2.9; 95% CI, 1.2-6.7) of disagreement between caregivers and physicians on the patient's mental status. CONCLUSION: NPS, though very prevalent in dementia patients, are perceived differently by caregivers and physicians. This divergence increases depending on the psychological health of caregivers.

Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications.

OBJECTIVES: To evaluate changes in the use of antipsychotics and medications with anticholinergic activity (MACs) during hospitalization in older adults with dementia and factors associated with antipsychotic prescriptions and increased anticholinergic burden (ACB). METHODS AND DESIGN: This retrospective cohort study included all patients aged 65 years or older with a discharge diagnosis of dementia hospitalized at the university hospital of Udine, Italy, from 2012 to 2014. Medications dispensed within 3 months before and after hospitalization were identified in community-pharmacy dispensations while those prescribed at discharge were collected from Hospital Electronic Medical Records (EMR). ACB was assessed using the Anticholinergic Cognitive Burden score. RESULTS: Among 1908 patients included, at discharge, 37.0% used one or more antipsychotic (9.4% before and 12.6% after hospitalization), 68.6% used one or more MAC (49.1% and 45.7%, respectively), and ACB of 38.4% of patients increased at discharge mainly because of a higher use of antipsychotics with anticholinergic activity (33% at discharge vs 12% before hospitalization). Prescription of antipsychotics at discharge was associated with prior treatment with antipsychotics (adjusted odds ratio [aOR] 4.85; 95%CI, 3.37-6.97), psychiatric conditions, (4.39; 3.47-5.54) and discharge from surgical department (2.17; 1.32-3.55). An increased ACB was associated with psychiatric conditions (1.91; 1.52-2.39), discharge from surgical (1.75; 1.09-2.80) or medical department (1.50; 1.04-2.17), and with cardiac insufficiency (1.41; 1.00-1.99). CONCLUSIONS: ACB was higher at discharge, and antipsychotics were the main drivers of this increase. Clinicians treating older adults with dementia should be aware of the risks associated with antipsychotics and that some of these medications may increase the risk of anticholinergic effects.

Cancer incidence in a cohort of asbestos-exposed workers undergoing health surveillance.

OBJECTIVES: To compare a local cohort of 2488 men occupationally exposed to asbestos and enrolled in a public health surveillance program with the 1995-2009 cancer incidence of the general population of Friuli Venezia Giulia (FVG) region, Northeast Italy, we conducted a historical cohort study. METHODS: Standardized incidence ratios (SIRs), with 95% confidence interval (95% CI), for specific cancer sites were estimated in the cohort and in subgroups of workers employed in shipbuilding between 1974 and 1994. For internal comparisons, we calculated incidence rate ratios (IRRs) for all cancers, lung cancer and mesothelioma, by level of exposure to asbestos and sector of employment adjusted for smoking habits and age at start of follow-up. RESULTS: Among cohort members the SIR was 8.82 (95% CI 5.95-12.61) for mesothelioma and 1.61 (95% CI 1.26-2.04) for lung cancer. In subgroup analyses, the SIR for lung cancer in subjects hired in shipbuilding between 1974 and 1984 was 2.09 (95% CI 1.32-3.13). In the overall cohort, a borderline increased incidence was also found for stomach cancer (SIR = 1.53 95% CI 0.96-2.31). Internal comparisons within the cohort show that among men with high asbestos exposure level the relative risk was almost threefold for lung cancer (IRR = 2.94 95% CI 1.01-8.57). CONCLUSIONS: This cohort experienced an excess in the incidence of both mesothelioma and lung cancer, showing increasing incidence rates at higher level of asbestos exposure. For lung cancer, the relative incidence was highest among workers hired in shipbuilding between 1974 and 1984.

Comparison of the molecular profile of brain metastases from colorectal cancer and corresponding primary tumors.

AIM: Little is known about molecular biology of brain metastasis (BM) from colorectal cancer and its concordance with matched primary tumors. MATERIALS & METHODS: We identified 56 consecutive colorectal cancer patients who underwent neurosurgical resection of BM. Tumor samples were tested for KRAS, NRAS, BRAF and PIK3CA. The molecular profile of the brain lesion was compared with the corresponding primary tumor. RESULTS: The molecular profile concordance rate was 95.1%. Median survival after neurosurgery was 5.5 months (95% CI: 4.7-6.3); median overall survival was 24.0 months (95% CI: 15.6-32.4). CONCLUSION: In this cohort, we report a high frequency of KRAS mutations and a very high concordance rate between the molecular status of BM and that of matched primary tumors.

Measures of outcome in metastatic breast cancer: insights from a real-world scenario.

No gold standard treatment exists for metastatic breast cancer (MBC). Clinical decision making is based on knowledge of prognostic and predictive factors that are extrapolated from clinical trials and, sometimes, are not reliably transferable to a real-world scenario. Moreover, misalignment between endpoints used in drug development and measures of outcome in clinical practice has been noted. The roles of overall survival (OS) and progression-free survival (PFS) as primary endpoints in the context of clinical trials are the subjects of lively debate. Information about these parameters in routine clinical practice is potentially useful to design new studies and/or to interpret the results of clinical research. This study analyzed the impact of patient and tumor characteristics on the major measures of outcome across different lines of treatment in a cohort of 472 patients treated for MBC. OS, PFS, and postprogression survival (PPS) were analyzed. The study showed how biological and clinical characteristics may have different prognostic value across different lines of therapy for MBC. After first-line treatment, the median PPS of luminal A, luminal B, and human epidermal growth factor receptor 2 (HER2)-positive groups was longer than 12 months. The choice of OS as a primary endpoint for clinical trials could not be appropriate with these subtypes. In contrast, OS could be an appropriate endpoint when PPS is expected to be low (e.g., triple-negative subtype after the first line; other subtypes after the third line). The potential implications of these findings are clinical and methodological.

Impact of low-dose computed tomography screening on lung cancer mortality among asbestos-exposed workers.

Background: We previously showed that low-dose computed tomography (LDCT) screening in asbestos-exposed workers is effective in detecting lung cancer (LC) at an early stage. Here, we evaluate whether LDCT screening could reduce mortality from LC in such a high-risk population. Methods: Within a cohort of 2433 asbestos-exposed men enrolled in an Occupational Health surveillance programme, we compared mortality between the participants in the ATOM002 study (LDCT-P, N = 926) and contemporary non-participants (LDCT-NP, N = 1507). We estimated standardized mortality ratios for the LDCT-P and LDCT-NP populations using regional and national rates (SMR_FVG and SMR_ITA, respectively). We compared survival for all causes, all neoplasms, LC and malignant neoplasm of pleura (MNP) between LDCT-P and LDCT-NP using Cox proportional hazard models adjusted for age, smoking history, asbestos exposure level and comorbidities. Results: A reduction in mortality from LC was observed in the LDCT-P group compared with regional and national figures (SMR_FVG = 0.55, 95% confidence interval (CI) 0.24-1.09; SMR_ITA = 0.51, 95% CI 0.22-1.01); this was not the case for the LDCT-NP group (SMR_FVG = 2.07, 95% CI 1.53-2.73; SMR_ITA = 1.98, 95% CI 1.47-2.61). A strong reduction in LC mortality was observed for the LDCT-P compared with the LDCT-NP [hazard ratio (HR) = 0.41, 95% CI 0.17-0.96]. Mortality was also reduced for all causes (HR = 0.61, 95% CI 0.44-0.84), but not for all neoplasms (HR = 0.97, 95% CI 0.62-1.50) and MNP (HR = 0.86, 95% CI 0.31-2.41) within the LDCT-P population. Conclusions: In our cohort, participation in the LDCT screening study was associated with reduced mortality from LC. This finding supports the use of LDCT in surveillance programmes for asbestos-exposed workers.

Type 2 Diabetes, Antidiabetic Medications, and Colorectal Cancer Risk: Two Case-Control Studies from Italy and Spain.

BACKGROUND: Type 2 diabetes mellitus has been associated with an excess risk of colorectal cancer, although the time-risk relationship is unclear, and there is limited information on the role of antidiabetic medications. AIM: We examined the association between type 2 diabetes, antidiabetic medications, and the risk of colorectal cancer, considering also duration of exposures. METHODS: We analyzed data derived from two companion case-control studies conducted in Italy and Spain between 2007 and 2013 on 1,147 histologically confirmed colorectal cancer cases and 1,594 corresponding controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by unconditional multiple logistic regression models, adjusted for socioeconomic factors and major potential confounding factors. RESULTS: Overall, 14% of cases and 12% of controls reported a diagnosis of diabetes, corresponding to an OR of colorectal cancer of 1.21 (95% CI 0.95-1.55). The OR was 1.49 (95% CI 0.97-2.29) for a duration of diabetes of at least 15 years. The OR was 1.53 (95% CI 1.06-2.19) for proximal colon cancer, 0.94 (95% CI 0.66-1.36) for distal colon cancer, and 1.32 (95% CI 0.94-1.87) for rectal cancer. In comparison with no use, metformin use was associated with a decreased colorectal cancer risk (OR 0.47, 95% CI 0.24-0.92), while insulin use was associated with an increased risk (OR 2.20, 95% CI 1.12-4.33); these associations were stronger for longer use (OR 0.36 and 8.18 for ≥10 years of use of metformin and insulin, respectively). CONCLUSION: This study shows evidence of a positive association between diabetes and colorectal cancer, mainly proximal colon cancer. Moreover, it indicates a negative association between colorectal cancer and metformin use and a positive association for insulin use.

A case-control study of occupational exposures and systemic sclerosis.

OBJECTIVES: A case-control study was conducted in Verona, Italy, to assess the relationship between occupation, occupational exposures and systemic sclerosis (SSc). METHODS: Fifty-five cases (46 female and nine male) and 171 controls were recruited. Interviews provided work histories, including job titles, industry and likelihood of occupational exposure to silica, hand-arm vibration, organic solvents, and other chemicals. Odds ratios (ORs) and 95% confidence intervals (95% CI) were estimated. RESULTS: Female teachers (OR 3.4, 95% CI 1.2-10.1) and textile workers (OR 2.1, 95% CI 1.0-4.6) were at an increased risk of SSc. Compared with those never exposed, age-adjusted and gender-adjusted ORs were 2.3 (95% CI 1.0-5.4) among subjects exposed to organic solvents, 2.5 (95% CI 0.8-8.0) for exposure to selected chemicals, 1.7 (95% CI 0.4-7.6) for exposure to silica, and 1.5 (95% CI 0.5-4.8) for usage of vibrating tools. When data analysis was stratified according to gender, only men showed a significant increase in risk for exposure to solvents and selected chemicals. CONCLUSIONS: The findings of this study tend to support the role of organic solvents and certain chemicals in SSc causation. The association with teaching and working in the textile industry suggests that other exposures are involved in the aetiology of SSc among women. However, because of the small number of subjects, particularly in stratified analyses, chance cannot be ruled out as an explanation of some findings of this study.