Visualisation of lenticulostriate arteries using contrast-enhanced time-of-flight magnetic resonance angiography at 7 Tesla.

7 Tesla-field-strength (7 T) Magnetic Resonance Imaging allows the small perforating arteries in the brain to be visualised, and this modality may allow visualisation of the arterial pathology in cerebral small vessel disease. Most studies have used standard Time-of-Flight (ToF) Magnetic Resonance Angiography (MRA). Whether the use of contrast enhancement improves perforating artery visualisation at 7 T remains unclear. In a prospective study, we compared standard ToF MRA with contrast-enhanced (CE) ToF MRA at 7 T for the visualisation of the lenticulostriate arteries (LSAs). Ten patients with symptomatic lacunar stroke were recruited (mean age, SD, 64 ± 9.9 years). Visualisation was assessed using a visual rating scale administered by two independent expert readers and length of the LSAs visible. Visualisation of the LSAs was improved with CE ToF MRA. The mean Visibility and Sharpness Score was higher for CE ToF MRA over standard ToF MRA (2.55 ± 0.64 vs. 1.75 ± 0.68; P = 0.0008). The mean length of LSA visualised was significantly longer with CE ToF MRA compared to standard ToF MRA (24.4 ± 4.5 vs. 21.9 ± 4.0 mm; P = 0.01). CE ToF MRA offers improved visualisation of the LSAs over standard ToF MRA. The addition of contrast may improve the ability to visualise cerebral small vessel disease arterial pathology.

The Prognostic and Discriminatory Utility of the Clinical Frailty Scale and Modified Frailty Index Compared to Age.

Background: There is no consensus on the optimal method for the assessment of frailty. We compared the prognostic utility of two approaches (modified Frailty Index [mFI], Clinical Frailty Scale [CFS]) in older adults (≥65 years) hospitalised with COVID-19 versus age. Methods: We used a test and validation cohort that enrolled participants hospitalised with COVID-19 between 27 February and 30 June 2020. Multivariable mixed-effects logistic modelling was undertaken, with 28-day mortality as the primary outcome. Nested models were compared between a base model, age and frailty assessments using likelihood ratio testing (LRT) and an area under the receiver operating curves (AUROC). Results: The primary cohort enrolled 998 participants from 13 centres. The median age was 80 (range:65−101), 453 (45%) were female, and 377 (37.8%) died within 28 days. The sample was replicated in a validation cohort of two additional centres (n = 672) with similar characteristics. In the primary cohort, both mFI and CFS were associated with mortality in the base models. There was improved precision when fitting CFS to the base model +mFI (LRT = 25.87, p < 0.001); however, there was no improvement when fitting mFI to the base model +CFS (LRT = 1.99, p = 0.16). AUROC suggested increased discrimination when fitting CFS compared to age (p = 0.02) and age +mFI (p = 0.03). In contrast, the mFI offered no improved discrimination in any comparison (p > 0.05). Similar findings were seen in the validation cohort. Conclusions: These observations suggest the CFS has superior prognostic value to mFI in predicting mortality following COVID-19. Our data do not support the use of the mFI as a tool to aid clinical decision-making and prognosis.

Clinical Features, Inpatient Trajectories and Frailty in Older Inpatients with COVID-19: A Retrospective Observational Study.

INTRODUCTION: We describe the clinical features and inpatient trajectories of older adults hospitalized with COVID-19 and explore relationships with frailty. METHODS: This retrospective observational study included older adults admitted as an emergency to a University Hospital who were diagnosed with COVID-19. Patient characteristics and hospital outcomes, primarily inpatient death or death within 14 days of discharge, were described for the whole cohort and by frailty status. Associations with mortality were further evaluated using Cox Proportional Hazards Regression (Hazard Ratio (HR), 95% Confidence Interval). RESULTS: 214 patients (94 women) were included of whom 142 (66.4%) were frail with a median Clinical Frailty Scale (CFS) score of 6. Frail compared to nonfrail patients were more likely to present with atypical symptoms including new or worsening confusion (45.1% vs. 20.8%, p < 0.001) and were more likely to die (66% vs. 16%, p = 0.001). Older age, being male, presenting with high illness acuity and high frailty were independent predictors of death and a dose-response association between frailty and mortality was observed (CFS 1-4: reference; CFS 5-6: HR 1.78, 95% CI 0.90, 3.53; CFS 7-8: HR 2.57, 95% CI 1.26, 5.24). CONCLUSIONS: Clinicians should have a low threshold for testing for COVID-19 in older and frail patients during periods of community viral transmission, and diagnosis should prompt early advanced care planning.

Frailty Assessment in Clinical Practice: Opportunity in the Midst of a Pandemic.

Emerging evidence from studies of older adults hospitalised with COVID-19 suggests that there is a high prevalence of frailty in this patient group. We reflect on the measurement of frailty in older patients hospitalized as an emergency and the translation of frailty from a research to a clinical concept. We consider whether, despite the contemporary challenges in the care of older adults as a result of COVID-19, there are opportunities for care quality improvement during a pandemic.

Incidence and outcome of interrupted geriatric rehabilitation requiring acute hospital transfer.

BACKGROUND AND AIMS: Elderly rehabilitation programs provide a period of rehabilitation to optimize a safe home discharge after acute hospitalization of older adults. Often, these patients may have their rehabilitation interrupted when they become unwell and subsequently require transfer back to an acute hospital setting. We will look at the incidence and outcome of this interruption. This paper aimed to determine the incidence of interrupted post-acute geriatric rehabilitation requiring acute hospital transfer and to analyze the outcome of the transfers. METHODS: An analysis of a retrospective cohort of elderly patients admitted into a 22-bed community-based geriatric rehabilitation unit over a 48-month period. RESULTS: Five hundred thirty-nine patients were admitted for rehabilitation. Fifty (9.3%) patients had their rehabilitation interrupted and were transferred to an acute hospital setting. Sixty-six percent were females; mean age 82.1 ± 8.7 years. Final diagnosis was acute severe infections (44%), traumatic fracture secondary to fall (10%), intraabdominal complications (10%), cardiac complications (8%), and acute neurological event (6%). Of these patients, 42% had a fatal outcome while 32% returned for rehabilitation. CONCLUSION: Interrupted geriatric rehabilitation requiring acute hospital transfer occurred in 9.3% of patients; acute severe infection was the most common cause. These transfers were associated with significant mortality. Rehabilitation programs should focus improvement efforts on identifying suitable patients for rehabilitation, optimizing care transitions, and minimizing rates of transfers.