62 research outputs found
Impact of an acute surgical unit in appendicectomy outcomes: A systematic review and meta-analysis
No full textClinical judgement by primary care physicians for the diagnosis of all‐cause dementia or cognitive impairment in symptomatic people
No full textBackgroundIn primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests.ObjectivesTo determine the diagnostic accuracy of GPs’ clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies.Search methodsWe searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021.Selection criteriaWe selected cross‐sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis.Data collection and analysisTwo review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS‐2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta‐analysis using the bivariate method.Main resultsWe identified 18,202 potentially relevant articles, of which 12,427 remained after de‐duplication. We assessed 57 full‐text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta‐analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS‐2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS‐2 domains.Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta‐analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61).For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40).It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD‐10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test.Authors' conclusionsClinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some ‐ such as some people with depression ‐ may suffer delayed intervention for an alternative treatable pathology.</p
Clinical history for diagnosis of dementia in men:Caerphilly Prospective Study
No full textBACKGROUND: Diagnosis of dementia often requires specialist referral and detailed, time-consuming assessments.AIM: To investigate the utility of simple clinical items that non-specialist clinicians could use, in addition to routine practice, to diagnose all-cause dementia syndrome.DESIGN AND SETTING: Cross-sectional diagnostic test accuracy study. Participants were identified from the electoral roll and general practice lists in Caerphilly and adjoining villages in South Wales, UK.METHOD: Participants (1225 men aged 45-59 years) were screened for cognitive impairment using the Cambridge Cognitive Examination, CAMCOG, at phase 5 of the Caerphilly Prospective Study (CaPS). Index tests were a standardised clinical evaluation, neurological examination, and individual items on the Informant Questionnaire for Cognitive Disorders in the Elderly (IQCODE).RESULTS: Two-hundred and five men who screened positive (68%) and 45 (4.8%) who screened negative were seen, with 59 diagnosed with dementia. The model comprising problems with personal finance and planning had an area under the curve (AUC) of 0.92 (95% confidence interval [CI] = 0.86 to 0.97), positive likelihood ratio (LR+) of 23.7 (95% CI = 5.88 to 95.6), negative likelihood ratio (LR-) of 0.41 (95% CI = 0.27 to 0.62). The best single item for ruling out was no problems learning to use new gadgets (LR- of 0.22, 95% CI = 0.11 to 0.43).CONCLUSION: This study found that three simple questions have high utility for diagnosing dementia in men who are cognitively screened. If confirmed, this could lead to less burdensome assessment where clinical assessment suggests possible dementia.</p
Decline in cognition from mid-life improves specificity of mini-mental state examination: diagnostic test accuracy in Caerphilly Prospective Study (CaPS)
No full textBackground: The merit of using baseline cognitive assessments in mid-life to help interpret cross-sectional cognitive tests scores in later life is uncertain.
Objective: Evaluate how accuracy for diagnosing dementia is enhanced by comparing cross-sectional results to a midlife measure.
Method: Cohort study of 2,512 men with repeated measures of Mini Mental State Examination (MMSE) over approximately 10 years. Index test MMSE at threshold of 24 indicating normal, as a cross-sectional measure and in combination with decline in MMSE score from mid-life. Reference standard consensus clinical diagnosis of dementia by two clinicians according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
Results: 1,150 men participated at phase 4 of whom 75 had dementia. A cross-sectional MMSE alone produced a sensitivity of 60% (50% to 70%) and specificity 95% (94% to 97%) with a threshold of ≥ 24 points indicating normal. For lower-scoring men in late life, with cross sectional scores of <22, combining cross-sectional AND a three-point or more decline over time had a sensitivity of 52% (39% to 64%) and specificity 99% (99% to 100%). For higher-scoring men in later life, with cross sectional scores <26 combining cross-sectional OR decline of at least three points had a sensitivity of 98% (92% to 100%) and specificity 38% (32% to 44%).
Conclusion: It may be helpful in practice to formally evaluate cognition in mid-life as a baseline to compare with if problems develop in future, as this may enhance diagnostic accuracy and classification of people in later life
Informant accuracy of IQCODE, AD8 and GPCOGi for diagnosis of dementia: does your friend know best?
No full textIncreasing numbers of people require evaluation for possible dementia. However, research on the accuracy of informant questionnaires in primary care remains limited. This study assessed the diagnostic accuracy of IQCODE, AD8, and GPCOGi based on the informant's relationship to the patient. We recruited 240 participants from 21 general practices in South West England. The reference standard for a diagnosis of dementia was made by a specialist clinician using ICD-10 criteria. A threshold of greater than 3.3 on IQCODE, greater or equal to 2 on AD8 and less than 5 on the informant component of GPCOG was used to indicate an abnormal test. Of 238 participants with informant data, 131 had dementia, 60 had CIND, and 47 had normal cognition. Median informant age was 70 years (IQR 60 years to 78 years). 71% of informants were female and 56% were spouses. On all three questionnaires, compared to spouses, adult descendants tended to score participants more cognitively impaired, whereas friends scored participants less cognitively impaired. However, there was little evidence of difference by informant type once fully adjusted. Sensitivity by informant type ranged from 91 to 100% for IQCODE, 94-100% for AD8 and 99% to100% for GPCOGi. There was no significant difference in sensitivity by informant type. Specificity by informant type ranged from 25 to 79% for IQCODE, 13-75% for AD8 and 17-38% for GPCOGi. Adult descendants tended to have the lowest specificity at 25% (95% CI 10-47%) for IQCODE, 13% (95% CI 3-32%) for AD8 and 17% (95% CI 5-37%) for GPCOGi. Friends tended to have the highest specificity at 79% (95% CI 49-95%) for IQCODE, 75% (95% CI 48-93%) for AD8 and 38% (95% CI 15-64%) for GPCOGi. An informant of any relationship type, using IQCODE, AD8 or GPCOGi may be useful for ruling out dementia but not for ruling it in. We found no evidence of difference between spouse or adult descendants but friends performed significantly better overall on IQCODE and AD8. [Abstract copyright: © 2025. The Author(s).
Towards improving diagnosis of memory loss in general practice:TIMeLi diagnostic test accuracy study protocol
No full textBackground People with cognitive problems, and their families, report distress and uncertainty whilst undergoing evaluation for dementia and perceive that traditional diagnostic evaluation in secondary care is insufficiently patient centred. The James Lind Alliance has prioritised research to investigate the role of primary care in supporting a more effective diagnostic pathway, and the topic is also of interest to health commissioners. However, there are very few studies that investigate the accuracy of diagnostic tests for dementia in primary care. Methods We will conduct a prospective diagnostic test accuracy study to evaluate the accuracy of a range of simple tests for diagnosing all-cause-dementia in symptomatic people aged over 70 years who have consulted with their general practitioner (GP). We will invite eligible people to attend a research clinic where they will undergo a range of index tests that a GP could perform in the surgery and also be assessed by a specialist in memory disorders at the same appointment. Participating GPs will request neuroimaging and blood tests and otherwise manage patients in line with their usual clinical practice. The reference standard will be the consensus judgement of three experts (neurologist, psychiatrist and geriatrician) based on information from the specialist assessment, GP records and investigations, but not including items in the index test battery. The target condition will be all-cause dementia but we will also investigate diagnostic accuracy for sub-types where possible. We will use qualitative interviews with patients and focus groups with clinicians to help us understand the acceptability and feasibility of diagnosing dementia in primary care using the tests that we are investigating. Discussion Our results will help clinicians decide on which tests to perform in someone where there is concern about possible dementia and inform commissioning of diagnostic pathways.</p
Laparoscopic rectal dissection preserves erectile function after ileal pouch–anal anastomosis: a two‐centre study
No full textMetabolic Syndrome, Diabetes, Poor Cognition, and Dementia in the Caerphilly Prospective Study.
No full text: We have examined whether metabolic syndrome is associated with intermediate risk of impaired cognition between people with and without diabetes. Men aged 45 to 59 years were identified from Caerphilly in South Wales, United Kingdom. Participation rate was 89% (41% of the original cohort) and 2,512 men were examined in phase one from July 1979 until September 1983. Follow-up examinations occurred at four intervals until 2004 when 1,225 men participated. Participants were categorized on the basis of their exposure to metabolic syndrome not diabetes (MSND) and diabetes (with or without metabolic syndrome) at each of the first three phases. Neuropsychological outcomes and clinical diagnosis of cognitive impairment not dementia (CIND) and dementia were assessed at phase five. The prevalence of MSND increased from 1% to 5% and for diabetes from 3% to 9% between phase one and phase three. 15% of participants had CIND and 8% dementia. People with diabetes, but not those with MSND, at phases one, two, or three had poorer cognition at phase five (adjusted ? coefficient AH4 -4.3 95% CI -7.9, -0.7; phase two: -2.5 95% CI -4.7, -0.3; phase three: -2.3 95% CI -4.2, -0.5). The adjusted odds ratio (phase one) for diabetes and CIND was 4.0 (95% CI 1.4, 11.5) and dementia 0.61 (95% CI 0.07, 5.37). After adjustment, higher systolic blood pressure was the only component of the metabolic syndrome associated with worse cognitive outcomes. Diabetes in mid-life, but not MSND, is associated with impaired cognition and increased odds of CIND in later life
Postoperative outcomes after laparoscopic or open gastrectomy. A national cohort study of 10,343 patients
No full textInternational audienceBackgroundLaparoscopy for gastric cancer has not been as popular compared with other digestive surgeries, with conflicting reports on outcomes. The aim of this study focuses on the surgical techniques comparing open and laparoscopy by assessing the morbi-mortality and long-term complications after gastrectomy.MethodsA retrospective study (2013–2018) was performed on a prospective national cohort (PMSI). All patients undergoing resection for gastric cancer with a partial gastrectomy (PG) or total gastrectomy (TG) were included. Overall morbidity at 90 post-operative days and long-term results were the main outcomes. The groups (open and laparoscopy) were compared using a propensity score and volume activity matching after stratification on resection type (TG or PG).ResultsA total of 10,343 patients were included. The overall 90-day mortality and morbidity were 7% and 45%, with reintervention required in 9.1%. High centre volume was associated with improved outcomes. There was no difference in population characteristics between groups after matching. An overall benefit for a laparoscopic approach after PG was found for morbidity (Open = 39.4% vs. Laparoscopy = 32.6%, p = 0.01), length of stay (Open = 14[10–21] vs. Laparoscopy = 11[8–17] days, p<0.0001). For TG, increased reintervention rate (Open = 10.8% vs. Laparoscopy = 14.5%, p = 0.04) and increased oesophageal stricture rate (HR = 2.54[1.67–3.85], p<0.001) were encountered after a laparoscopic approach. No benefit on mortality was found for laparoscopic approach in both type of resections after adjusted analysis.ConclusionsLaparoscopy is feasible for PG with a substantial benefit on morbidity and length of stay, however, laparoscopic TG should be performed with caution, with of higher rates of reintervention and oesophageal stricture
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