Memory for the News: Does Event Transience Matter?

BACKGROUND: Health providers frequently probe patients' recall of current and/or remote news events to determine the extent of memory loss. Impaired memory for transient events (ie, in the news for a circumscribed time) may provide information regarding the onset of cognitive impairment. OBJECTIVE: To use the Transient News Events Test (TNET) to explore how memory changes over time in both older adults with cognitive impairment (CI) and noncognitively impaired (NCI) older adults. We also investigated the role of episodic and semantic memory on TNET performance. METHOD: Sixty-seven older adults completed the TNET as part of a comprehensive neuropsychological assessment. Analyses included t tests to evaluate group differences for TNET score and correlations between TNET and neuropsychological measures, including episodic and semantic memory tests. RESULTS: NCI adults demonstrated better memory for TNET items than adults with CI. The NCI and CI groups did not differ regarding memory for remote events; however, the CI group exhibited worse memory for recent events. There was a significant association between TNET score and the capacity for episodic and semantic memory in the CI group. In the NCI group, TNET score was significantly associated with episodic memory. CONCLUSION: Findings support the use of transient news events to assess remote memories in older adults. Novel remote memory measures broaden the scope of memory assessment far beyond what is feasible with traditional neuropsychological assessment and may provide insight into the onset of memory changes.

Comorbidity in severe asthma requiring systemic corticosteroid therapy: cross-sectional data from the Optimum Patient Care Research Database and the British Thoracic Difficult Asthma Registry.

OBJECTIVE: To determine the prevalence of systemic corticosteroid-induced morbidity in severe asthma. DESIGN: Cross-sectional observational study. SETTING: The primary care Optimum Patient Care Research Database and the British Thoracic Society Difficult Asthma Registry. PARTICIPANTS: Optimum Patient Care Research Database (7195 subjects in three age- and gender-matched groups)-severe asthma (Global Initiative for Asthma (GINA) treatment step 5 with four or more prescriptions/year of oral corticosteroids, n=808), mild/moderate asthma (GINA treatment step 2/3, n=3975) and non-asthma controls (n=2412). 770 subjects with severe asthma from the British Thoracic Society Difficult Asthma Registry (442 receiving daily oral corticosteroids to maintain disease control). MAIN OUTCOME MEASURES: Prevalence rates of morbidities associated with systemic steroid exposure were evaluated and reported separately for each group. RESULTS: 748/808 (93%) subjects with severe asthma had one or more condition linked to systemic corticosteroid exposure (mild/moderate asthma 3109/3975 (78%), non-asthma controls 1548/2412 (64%); p<0.001 for severe asthma versus non-asthma controls). Compared with mild/moderate asthma, morbidity rates for severe asthma were significantly higher for conditions associated with systemic steroid exposure (type II diabetes 10% vs 7%, OR=1.46 (95% CI 1.11 to 1.91), p<0.01; osteoporosis 16% vs 4%, OR=5.23, (95% CI 3.97 to 6.89), p<0.001; dyspeptic disorders (including gastric/duodenal ulceration) 65% vs 34%, OR=3.99, (95% CI 3.37 to 4.72), p<0.001; cataracts 9% vs 5%, OR=1.89, (95% CI 1.39 to 2.56), p<0.001). In the British Thoracic Society Difficult Asthma Registry similar prevalence rates were found, although, additionally, high rates of osteopenia (35%) and obstructive sleep apnoea (11%) were identified. CONCLUSIONS: Oral corticosteroid-related adverse events are common in severe asthma. New treatments which reduce exposure to oral corticosteroids may reduce the prevalence of these conditions and this should be considered in cost-effectiveness analyses of these new treatments.

The cost of treating severe refractory asthma in the UK: an economic analysis from the British Thoracic Society Difficult Asthma Registry.

Severe refractory asthma poses a substantial burden in terms of healthcare costs but relatively little is known about the factors which drive these costs. This study uses data from the British Thoracic Society Difficult Asthma Registry (n=596) to estimate direct healthcare treatment costs from an National Health Service perspective and examines factors that explain variations in costs. Annual mean treatment costs among severe refractory asthma patients were £2912 (SD £2212) to £4217 (SD £2449). Significant predictors of costs were FEV1% predicted, location of care, maintenance oral corticosteroid treatment and body mass index. Treating individuals with severe refractory asthma presents a substantial cost to the health service.

Inappropriate prescribing of combination inhalers in Northern Ireland: retrospective cross-sectional cohort study of prescribing practice in primary care.

BACKGROUND: Asthma management guidelines advocate a stepwise approach to asthma therapy, including the addition of a long-acting bronchodilator to inhaled steroid therapy at step 3. This is almost exclusively prescribed as inhaled combination therapy. AIMS: To examine whether asthma prescribing practice for inhaled combination therapy (inhaled corticosteroid/long-acting ß2-agonist (ICS/LABA)) in primary care in Northern Ireland is in line with national asthma management guidelines. METHODS: Using data from the Northern Ireland Enhanced Prescribing Database, we examined initiation of ICS/LABA in subjects aged 5-35 years in 2010. RESULTS: A total of 2,640 subjects (67%) had no inhaled corticosteroid monotherapy (ICS) in the study year or six months of the preceding year (lead-in period) and, extending this to a 12-month lead-in period, 52% had no prior ICS. 41% of first prescriptions for ICS/LABA were dispensed in January to March. Prior to ICS/LABA prescription, in the previous six months only 17% had a short-acting ß2-agonist (SABA) dispensed, 5% received oral steroids, and 17% received an antibiotic. CONCLUSIONS: ICS/LABA therapy was initiated in the majority of young subjects with asthma without prior inhaled steroid therapy. Most prescriptions were initiated in the January to March period. However, the prescribing of ICS/LABA did not appear to be driven by asthma symptoms (17% received SABA in the previous 6 months) or severe asthma exacerbation (only 5% received oral steroids). Significant reductions in ICS/LABA, with associated cost savings, would occur if the asthma prescribing guidelines were followed in primary care.

Clinical management and outcome of refractory asthma in the UK from the British Thoracic Society Difficult Asthma Registry.

Refractory asthma represents a significant unmet clinical need. Data from a national online registry audited clinical outcome in 349 adults with refractory asthma from four UK specialist centres in the British Thoracic Society Difficult Asthma Network. At follow-up, lung function improved, with a reduction in important healthcare outcomes, specifically hospital admission, unscheduled healthcare visits and rescue courses of oral steroids. The most frequent therapeutic intervention was maintenance oral corticosteroids and most steroid sparing agents (apart from omalizumab) demonstrated minimal steroid sparing benefit. A significant unmet clinical need remains in this group, specifically a requirement for therapies which reduce systemic steroid exposure.

Education Research: NeuroBytes: A New Rapid, High-Yield e-Learning Platform for Continuing Professional Development in Neurology.

OBJECTIVE: To determine whether NeuroBytes is a helpful e-Learning tool in neurology through usage, viewer type, estimated time and cost of development, and postcourse survey responses. BACKGROUND: A sustainable Continuing Professional Development (CPD) system is vital in neurology due to the field's expanding therapeutic options and vulnerable patient populations. In an effort to offer concise, evidence-based updates to a wide range of neurology professionals, the American Academy of Neurology (AAN) launched NeuroBytes in 2018. NeuroBytes are brief (<5 minutes) videos that provide high-yield updates to AAN members. METHODS: NeuroBytes was beta tested from August 2018 to December 2018 and launched for pilot circulation from January 2019 to April 2019. Usage was assessed by quantifying course enrollment and completion rates; feasibility by cost and time required to design and release a module; appeal by user satisfaction; and effect by self-reported change in practice. RESULTS: A total of 5,130 NeuroBytes enrollments (1,026 ± 551/mo) occurred from January 11, 2019, to May 28, 2019, with a median of 588 enrollments per module (interquartile range, 194-922) and 37% course completion. The majority of viewers were neurologists (54%), neurologists in training (26%), and students (8%). NeuroBytes took 59 hours to develop at an estimated $77.94/h. Of the 1,895 users who completed the survey, 82% were "extremely" or "very likely" to recommend NeuroBytes to a colleague and 60% agreed that the depth of educational content was "just right." CONCLUSIONS: NeuroBytes is a user-friendly, easily accessible CPD product that delivers concise updates to a broad range of neurology practitioners and trainees. Future efforts will explore models where NeuroBytes combines with other CPD programs to affect quality of training and clinical practice.

Age and Sex Associations with Systemic Corticosteroid-Induced Morbidity in Asthma.

BACKGROUND: Treatment of severe asthma may include high-dose systemic corticosteroid therapy, which is associated with substantial comorbidity. There is evidence to suggest that this burden is not evenly distributed across age, sex, and corticosteroid exposure levels. OBJECTIVE: To examine the associations between age, sex, comorbidity, and patterns of health care cost across groups differentiated by corticosteroid exposure. METHODS: Patients with severe asthma (n = 808) were matched by age and sex with patients with mild/moderate asthma (n = 3975) and nonasthma control subjects (n = 2412) from the Optimum Patient Care Research Database. Regression analysis was used to investigate the odds of a number of corticosteroid-induced comorbidities as it varied by cohort, age group, and sex. Prescribed drugs and publicly funded health care activity were monetized and annual costs per patient estimated. RESULTS: Patients aged 60 years or younger with high oral corticosteroid (OCS) exposure had greater odds of osteopenia, osteoporosis, glaucoma, dyspeptic disorders, chronic kidney disease, cardiovascular disease, cataracts, hypertension, and obesity (P < .01) relative to those with mild/moderate asthma (low OCS exposure) as well as to those with no asthma. This difference in odds was much less evident in older patients. Sex-related differences for the odds of most comorbidities related to high-dose OCS were also observed. This differential pattern of comorbidity prevalence was reflected in mean health care costs per patient per year. CONCLUSIONS: Results demonstrate important differential prevalence of corticosteroid-induced morbidity by age and sex, which is paralleled by differences in health care costs. This is important for clinicians in better understanding the risks of placing different age groups or sexes on systemic corticosteroids.

Prognostication of traumatic brain injury outcomes in older trauma patients: A novel risk assessment tool based on initial cranial CT findings.

INTRODUCTION: Advanced age has been traditionally associated with worse traumatic brain injury (TBI) outcomes. Although prompt neurosurgical intervention (NSI, craniotomy or craniectomy) may be life-saving in the older trauma patient, it does not guarantee survival and/or return to preinjury functional status. The aim of this study was to determine whether a simple score, based entirely on the initial cranial computed tomography (CCT) is predictive of the need for NSI and key outcome measures (e.g., morbidity and mortality) in the older (age 45+ years) TBI patient subset. We hypothesized that increasing number of categorical CCT findings is independently associated with NSI, morbidity, and mortality in older patients with severe TBI. METHODS: After IRB approval, a retrospective study of patients 45 years and older was performed using our Regional Level 1 Trauma Center registry data between June 2003 and December 2013. Collected variables included patient demographics, Injury Severity Score (ISS), Abbreviated Injury Scale Head (AISh), brain injury characteristics on CCT, Glasgow Coma Scale (GCS), Intensive Care Unit (ICU) and hospital length of stay (LOS), all-cause morbidity and mortality, functional independence scores, as well as discharge disposition. A novel CCT scoring tool (CCTST, scored from 1 to 8+) was devised, with one point given for each of the following findings: subdural hematoma, epidural hematoma, subarachnoid blood, intraventricular blood, cerebral contusion/intraparenchymal blood, skull fracture, pneumocephalus, brain edema/herniation, midline shift, and external (skin/face) trauma. Descriptive statistics and univariate analyses were conducted with 30-day mortality, in-hospital morbidity, and need for NSI as primary end-points. Secondary end-points included the length of stay in the ICU (ICULOS), step-down unit (SDLOS), and the hospital (HLOS) as well as patient functional outcomes, and postdischarge destination. Factors associated with the need for NSI were determined using matched NSI (n = 310) and non-NSI (n = 310) groups. All other analyses examined the combined patient sample (n = 620). Variables achieving a significance level of P < 0.20 were included in the logistic regression. Receiver operating characteristic curves, with corresponding area under the curve (AUC) determinations, were also analyzed. Statistical significance was set at α = 0.05. Data are presented as percentages, mean ± standard deviation, or adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs). RESULTS: A total of 620 patients were analyzed, including 310 patients who underwent NSI and 310 age- and ISS-matched non-NSI controls. Average patient age was 72.8 ± 13.4 years (64.1% male, 99% blunt trauma, mean ISS 25.1 ± 8.68, and mean AISh/GCS of 4.63/10.9). CCTST was the only variable independently associated with NSI (AOR 1.23, 95% CI 1.06-1.42) and was inversely proportional to initial GCS and functional outcome scores on discharge. Increasing CCTST was associated with greater mortality, morbidity, HLOS, SDLOS, ICULOS, and ventilator days. On multivariate analysis, factors independently associated with mortality included AISh (AOR 2.70, 95% CI 1.21-6.00), initial GCS (AOR 1.14, 1.07-1.22), and CCTST (AOR 1.31, 1.09-1.58). Variables independently associated with in-hospital morbidity included CCTST (AOR 1.16, 1.02-1.34), GCS (AOR 1.05, 1.01-1.09), and NSI (AOR 2.62, 1.69-4.06). Multivariate models incorporating factors independently associated with each respective outcome displayed good overall predictive characteristics for mortality (AUC 0.787) and in-hospital morbidity (AUC 0.651). Finally, modified CCTST demonstrated good overall predictive ability for NSI (AUC 0.755). CONCLUSION: This study found that the number of discrete findings on CCT is independently associated with major TBI outcome measures, including 30-day mortality, in-hospital morbidity, and NSI. Of note, multivariate models with best predictive characteristics incorporate both CCTST and GCS. CCTST is easy to calculate, and this preliminary investigation of its predictive utility in older patients with TBI warrants further validation, focusing on exploring prognostic synergies between CCTST, GCS, and AISh. If independently confirmed to be predictive of clinical outcomes and the need for NSI, the approach described herein could lead to a shift in both operative and nonoperative management of patients with TBI.