Prognostic implications of diagnosing frailty and sarcopenia in vascular surgery practice.

OBJECTIVE: Frailty and sarcopenia are related but independent conditions commonly diagnosed in older patients that can be used to assess their ability to tolerate the stress of major vascular surgery. For surgical decision-making, however, it is important to know the prognostic implications associated with each of these conditions. The study was designed to assess the association of frailty and sarcopenia phenotypes with long-term survival of patients undergoing surgical and nonsurgical management of vascular disease. METHODS: We retrospectively reviewed all patients presenting to the vascular surgery clinic at an academic hospital between December 2015 and August 2017 who underwent prospective frailty assessment with the Clinical Frailty Scale and who had abdominal computed tomography (CT) scans performed within the preceding 12 months. A single axial CT image at the caudal end of the third lumbar vertebra was assessed to measure cross-sectional areas of skeletal muscle. Sarcopenia was defined by established criteria specific for male and female patients. After patients were stratified by frailty and sarcopenia diagnoses along with comorbidities, the association with all-cause mortality was analyzed by Kaplan-Meier curves and Cox regression models. RESULTS: A total of 415 patients underwent both frailty and sarcopenia assessment, of whom 112 (27%) met sarcopenia criteria alone, 48 (12%) met only frailty criteria, and 56 (13%) met criteria for both phenotypes. There were 199 (48%) controls who met neither criterion. Vascular operations were performed in 167 (40%) patients after frailty and sarcopenia assessment, whereas 248 (60%) patients were managed nonoperatively with median (interquartile range) follow-up after CT imaging of 1.5 (1.1-2.2) years. Patients diagnosed with either phenotype were older (mean, 65 years vs 59 years; P < .001) and more likely to be male (69% vs 54%; P < .001) compared with patients without sarcopenia or frailty. Long-term survival was significantly decreased for patients diagnosed with either frailty alone or frailty and sarcopenia who underwent surgical or nonsurgical management (log-rank, P < .001 for both comparisons). In multivariate regression models, however, frailty was the only independent variable (hazard ratio, 7.7; 95% confidence interval, 3.2-18.7; P < .001) that predicted mortality. CONCLUSIONS: Frailty and sarcopenia overlap to varying degrees in patients presenting to vascular surgery clinics and can be used alone or in combination to predict long-term survival of older patients. However, our data indicate that it was only the diagnosis of frailty that was an independent predictor of mortality and had the strongest prognostic significance in patients undergoing both surgical and nonoperative management.

Transforming mental well-being for people with diabetes: research recommendations from Diabetes UK's 2019 Diabetes and Mental Well-Being Workshop.

AIMS: To identify key gaps in the research evidence base that could help to improve the mental well-being of people with diabetes, and to provide recommendations to researchers and research funders on how best to address them. METHODS: A 2-day international research workshop was conducted, bringing together research experts in diabetes and in mental health, people living with diabetes and healthcare professionals. RESULTS: The following key areas needing increased financial investment in research were identified: understanding the mechanisms underlying depression; understanding the multifactorial impact of social stigma; improving the language used by healthcare professionals; supporting people who find it difficult to engage with their diabetes; supporting significant others; supporting people with diabetes and eating disorders; improving models of care by learning from best practice; the potential benefits of screening and managing diabetes distress in routine diabetes care pathways; primary prevention of mental health issues at the time of diagnosis of diabetes; establishing the effectiveness of diabetes therapies on mood and other mental health issues; and understanding the impact of current diabetes technologies on mental health. Research recommendations as to how to address each of these priority areas were also developed. CONCLUSIONS: This inaugural position statement outlines recommendations to address the urgent unmet need related to the mental well-being of people living with diabetes, and calls on the research community and funders to develop research programmes and strategies to reduce this need.

High-throughput sequencing of cerebrospinal fluid for diagnosis of chronic Propionibacterium acnes meningitis in an allogeneic stem cell transplant recipient.

BACKGROUND: A 40-year-old man with chronic myelogenous leukemia presented multiple times over a period of 3 years with episodes of confusion, wide-based gait and falls because of recurrent hydrocephalus despite repeated therapeutic lumbar punctures. These problems occurred in the context of persistent cerebrospinal fluid (CSF) pleocytosis and leptomeningeal enhancement. Extensive diagnostic workups and therapeutic trials had failed to identify a clinically plausible cause or produce any significant improvement in the CSF and neuroimaging abnormalities. METHODS: We used high-throughput metagenomic shotgun sequencing to identify microbes in 2 CSF samples collected from the patient during his illness. These results were compared to sequence data from 1 CSF sample collected during treatment and 5 control CSF samples from other patients. RESULTS: We found sequences representing 53% and 67% of the Propionibacterium acnes genome in 2 CSF samples collected from the patient during his illness. Directed antimicrobial therapy was administered for 6 weeks with resolution of CSF and neuroimaging abnormalities. Sequencing of a sample obtained during treatment demonstrated that the P. acnes levels were decreased to background levels. After insertion of a ventriculo-peritoneal shunt, the patient returned to baseline status. CONCLUSIONS: High-throughput metagenomic shotgun sequencing revealed P. acnes as the cause of chronic meningitis that had eluded conventional attempts at diagnosis. Treatment directed at this organism resulted in cure of the infection and clinical improvement.

An encyclopedia of mouse genes.

The laboratory mouse is the premier model system for studies of mammalian development due to the powerful classical genetic analysis possible (see also the Jackson Laboratory web site, http://www.jax.org/) and the ever-expanding collection of molecular tools. To enhance the utility of the mouse system, we initiated a program to generate a large database of expressed sequence tags (ESTs) that can provide rapid access to genes. Of particular significance was the possibility that cDNA libraries could be prepared from very early stages of development, a situation unrealized in human EST projects. We report here the development of a comprehensive database of ESTs for the mouse. The project, initiated in March 1996, has focused on 5' end sequences from directionally cloned, oligo-dT primed cDNA libraries. As of 23 October 1998, 352,040 sequences had been generated, annotated and deposited in dbEST, where they comprised 93% of the total ESTs available for mouse. EST data are versatile and have been applied to gene identification, comparative sequence analysis, comparative gene mapping and candidate disease gene identification, genome sequence annotation, microarray development and the development of gene-based map resources.

Figural fluency: differential impairment in patients with left versus right frontal lobe lesions.

Based on an experimental study, Jones-Gotman and Milner demonstrated that patients with right frontal lobe lesions were impaired on design fluency. We sought a clinical adaptation and developed a psychometrically sound technique for design fluency. The present study explores the validity of the Ruff Figural Fluency Test (RFFT) in discriminating patients with either right frontal or nonright frontal lobe lesions. In the first of two studies, six subjects with circumscribed focal lesions were given the RFFT and the Jones-Gotman and Milner figural fluency task. In the second study, we identified a larger sample of 30 patients with focal lesions in the right frontal, left frontal, right posterior, or left posterior cortex. The results from both studies support the validity of the RFFT as a measure which is sensitive to right anterior dysfunction.

The Ruff 2 and 7 Selective Attention Test: a neuropsychological application.

The neuropsychological application of the Ruff 2 and 7 Selective Attention Test as a measure of visual selective attention was investigated. The instrument was constructed as a paper-and-pencil approach to evaluate sustained attention utilizing different distractor conditions in the study of voluntary or intentional aspects of attention. Four patient groups with cerebral lesions confined to either the right or left anterior or left or right posterior region (ns = 8, 8, 8, 6) were studied. Patients with right-hemispheric lesions showed a greater over-all reduction in processing speed independent of the serial or parallel processing mode in comparison to individuals with left-sided lesions. Furthermore, as predicted, the two groups with anterior brain damage showed a larger discrepancy between serial and parallel processing modes than patients with posterior lesions. Specifically, the right frontal cases showed the greatest differential of accuracy on the serial and parallel tasks.

Emergency response team: Hurricane Georges in Key West.

Hurricane Georges (category 2) struck Key West, Florida, on September 25, 1998. Lower Florida Keys Hospital, which serves Key West and the Lower Keys, had previously been evacuated of inpatients and staff. An emergency response team composed of three emergency medicine (EM) physicians and four EM nurses was sent at the request of the state to maintain emergency department (ED) operations at the hospital. Eighty-six patients presented to the ED during the 72-hour period. Medical problems accounted for the majority of visits (52.3%), with minor trauma next (41.9%). Initially, patients requiring hospitalization were evacuated, but as the storm neared, this was stopped. Six patients required hospitalization at Lower Florida Keys Hospital during the period that evacuations were unavailable. Four deaths occurred during the 24-hour period. Complicating factors included environmental conditions, limited laboratory and radiologic studies, limited medication stocks, and closure of local pharmacies before and after the hurricane. More than 300 nursing home patients were housed at the nearby jail shelter. Knowledge of such high-risk groups that remain in the vicinity is crucial to planning a response plan.