Publications by authors named "Adrian Wong"

230 Publications

Criteria, Processes and Determination of Competence in Basic Critical Care Echocardiography Training - a Delphi Process Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative.

Chest 2021 Sep 8. Epub 2021 Sep 8.

Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia.

With the paucity of high-quality studies on longitudinal basic critical care echocardiography (BCCE) training, expert-opinion guidelines have guided BCCE training. However, existing guidelines lack precise detail due to methodological flaws during guideline-development. To formulate methodologically robust guidelines on BCCE training using evidence and expert opinion, detailing specific criteria for every step, we conducted a modified Delphi process using the principles of the validated AGREE-II tool. Based on systematic reviews, the following domains were chosen - components of a longitudinal BCCE curriculum; pass-grade criteria for image-acquisition and image-interpretation; formative/summative assessment and final competence processes. Between April 2020 and May 2021, 21 BCCE experts participated in four rounds. Rounds 1 and 2 used five web-based questionnaires, including branching-logic software for directed questions to individual panelists. In round 3 (videoconference), the panel finalized the recommendations by vote. During the journal peer-review process, Round 4 was conducted as web-based questionnaires. After each round, the agreement threshold for each item was determined >80% for item-inclusion and <30% for item-exclusion. After rounds 1 and 2, agreement was reached on 62/114 item. To the 49 unresolved items, 12 additional items were added in round 3, with 56 reaching agreement and five items remaining unresolved. There was agreement that longitudinal BCCE training must include introductory training, mentored formative training, summative assessment for competence and final cognitive assessment. Items requiring multiple rounds included 2D views, Doppler, cardiac output, M-mode measurement, minimum scan numbers, pass-grade criteria. Regarding objective criteria for image-acquisition and image-interpretation quality, the panel agreed on maintaining the same criteria for formative and summative assessment, to categorize BCCE findings as major versus minor and a standardized approach to errors, criteria for readiness for summative assessment and supervisory options. In conclusion, this expert consensus statement presents comprehensive evidence-based recommendations on longitudinal BCCE training. However, they require prospective validation.
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http://dx.doi.org/10.1016/j.chest.2021.08.077DOI Listing
September 2021

Perioperative management considerations in patients taking prescribed psychoactive medications (including those for depression and Parkinson's disease).

Curr Opin Anaesthesiol 2021 Oct;34(5):582-589

Consultant Critical Care and Anaesthesia, King's College Hospital, London, UK.

Purpose Of Review: Given the number of drugs available in the anaesthetist's armamentarium, drug interactions need to be managed. This is particularly true of psychoactive medications which primarily act on the central nervous system, targeting neurotransmitter pathways often affected by anaesthetic agents. This review gives an overview of the potential interactions of commonly used psychoactive medications with anaesthetic agents and hence their perioperative considerations. As anaesthetists will already be very familiar with the benzodiazepines, they will not be discussed here. Electroconvulsive therapy will also not be discussed.

Recent Findings: A wide range of psychoactive medications can interact with drugs commonly used in perioperative care including anaesthetic agents. There is limited clinical research into their effects and hence these interactions are based on known pharmacological actions.

Summary: A cautious, pragmatic approach is recommended when managing patients on psychoactive medications requiring anaesthesia as part of their medical care.
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http://dx.doi.org/10.1097/ACO.0000000000001041DOI Listing
October 2021

The use of social media and online communications in times of pandemic COVID-19.

J Intensive Care Soc 2021 Aug 22;22(3):255-260. Epub 2020 Oct 22.

Department of Anaesthesia and Intensive Care, Mater Hospital, Belfast, Northern Ireland.

The use of social media as a tool for professional communication and education in healthcare has been increasing; pros and cons of such platforms were extensively debated in recent years with mixed results. During the COVID-19 pandemic, social media use has accelerated to the point of becoming a ubiquitous part of modern healthcare systems. As with any tool in healthcare, its risks and benefits need to be carefully considered. In this article, we review the use of social media in the current pandemic. Importantly, we will illustrate this using experiences from the perspective of large medical organisations and also identify the common pitfalls.
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http://dx.doi.org/10.1177/1751143720966280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373288PMC
August 2021

Machine-learning method for localization of cerebral white matter hyperintensities in healthy adults based on retinal images.

Brain Commun 2021 Jul 3;3(3):fcab124. Epub 2021 Jun 3.

Margaret KL Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia and Gerald Choa Neuroscience Centre, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China.

Retinal vessels are known to be associated with various cardiovascular and cerebrovascular disease outcomes. Recent research has shown significant correlations between retinal characteristics and the presence of cerebral small vessel disease as measured by white matter hyperintensities from cerebral magnetic resonance imaging. Early detection of age-related white matter changes using retinal images is potentially helpful for population screening and allow early behavioural and lifestyle intervention. This study investigates the ability of the machine-learning method for the localization of brain white matter hyperintensities. All subjects were age 65 or above without any history of stroke and dementia and recruited from local community centres and community networks. Subjects with known retinal disease or disease influencing vessel structure in colour retina images were excluded. All subjects received MRI on the brain, and age-related white matter changes grading was determined from MRI as the primary endpoint. The presence of age-related white matter changes on each of the six brain regions was also studied. Retinal images were captured using a fundus camera, and the analysis was done based on a machine-learning approach. A total of 240 subjects are included in the study. The analysis of various brain regions included the left and right sides of frontal lobes, parietal-occipital lobes and basal ganglia. Our results suggested that data from both eyes are essential for detecting age-related white matter changes in the brain regions, but the retinal parameters useful for estimation of the probability of age-related white matter changes in each of the brain regions may differ for different locations. Using a classification and regression tree approach, we also found that at least three significant heterogeneous subgroups of subjects were identified to be essential for the localization of age-related white matter changes. Namely those with age-related white matter changes in the right frontal lobe, those without age-related white matter changes in the right frontal lobe but with age-related white matter changes in the left parietal-occipital lobe, and the rest of the subjects. Outcomes such as risks of severe grading of age-related white matter changes and the proportion of hypertension were significantly related to these subgroups. Our study showed that automatic retinal image analysis is a convenient and non-invasive screening tool for detecting age-related white matter changes and cerebral small vessel disease with good overall performance. The localization analysis for various brain regions shows that the classification models on each of the six brain regions can be done, and it opens up potential future clinical application.
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http://dx.doi.org/10.1093/braincomms/fcab124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8249101PMC
July 2021

Reliability and validity of Six-Spot Step Test (SSST) in stroke survivors.

Eur J Phys Rehabil Med 2021 Jun 15. Epub 2021 Jun 15.

School of Nursing, The Hong Kong Polytechnic University, Hong Kong.

Background: The Six-Spot Step Test (SSST) was originally developed to assess walking ability while challenging balance during walking in patients with multiple sclerosis. It provides more comprehensive information on ambulatory abilities than several existing measures such as the Timed Up & Go test (TUG test), the Functional Gait Assessment, and the Dynamic Gait Index. To assess the advanced balance control ability of stroke survivors, we modified the SSST to serve this purpose.

Aim: The aim of this study was to expand the current understanding of the psychometric properties of the SSST using healthy older adults and stroke survivors.

Design: This study adopted an experimental design.

Setting: University-affiliated neurorehabilitation laboratory.

Population: A total of 50 study participants, including 25 chronic stroke survivors and 25 healthy older adults, were recruited from the community.

Methods: The SSST was administered to the stroke survivors twice (day 1 & 2) with a 1-week interval. The Fugl-Meyer assessment for the lower extremities (FMA-LE), the Berg Balance scale (BBS), the limit of stability (LOS) test, the Timed Up & Go test (TUG test), and the Chinese version of the Community Integration Measures (CIM-C) were assessed on day 1 by random order. The healthy control group was assessed with the Six-Spot Step Test only on day 1.

Results: The SSST showed excellent inter-rater, intra-rater, and test-retest reliability (intraclass correlation coefficient>0.95, p<0.001). Significant correlations were found between SSST performance and the FMA-LE results (r=0.517, p<0.05), BBS scores (q r =-0.531, p<0.05), and TUG test scores (r =0.828, p<0.001). The MDC in the mean SSST time for the affected leg and the unaffected leg in stroke survivors was 6.05s. The cutoff time was 10.11s (sensitivity, 80%; specificity, 92%) when kicking obstacles with the affected leg and 10.18s (sensitivity, 80%; specificity, 92%) when kicking obstacles with the unaffected leg.

Conclusions: The SSST was a reliable test and showed a significant correlation with FMA-LE scores, BBS scores, and TUG test times in stroke survivors.

Clinical Rehabilitation Impact: The SSST can be used to assess the advanced balance control of stroke survivors.
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http://dx.doi.org/10.23736/S1973-9087.21.06799-XDOI Listing
June 2021

Risk factors for delayed-onset dementia after stroke or transient ischemic attack-A five-year longitudinal cohort study.

Int J Stroke 2021 Jul 2:17474930211026519. Epub 2021 Jul 2.

Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.

Background: Stroke not only substantially increases the risk of incident dementia early after stroke but also the risk remains elevated years after.

Aim: We aimed to determine the risk factors of dementia onset more than three to six months after stroke or transient ischemic attack.

Methods: This is a single-center prospective cohort study. We recruited consecutive subjects with stroke/transient ischemic attack without early-onset dementia. We conducted an annual neuropsychological assessment for five years. We investigated the association between baseline demographic, clinical, genetic (APOEɛ4 allele), and radiological factors as well as incident recurrent stroke with delayed-onset dementia using Cox proportional hazards models.

Results: In total, 1007 patients were recruited, of which 88 with early-onset dementia and 162 who lost to follow-ups were excluded. Forty-nine (6.5%) out of 757 patients have incident delayed-onset dementia. The presence of ≥3 lacunes, history of ischemic heart disease, history of ischemic stroke, and a lower baseline Hong Kong version of the Montreal Cognitive Assessment (MoCA) score were significantly associated with delayed-onset dementia. APOEɛ4 allele, medial temporal lobe atrophy, and recurrent stroke were not predictive.

Conclusion: The presence of ≥3 lacunes, history of ischemic heart disease, history of ischemic stroke, and a lower baseline MoCA score are associated with delayed-onset dementia after stroke/transient ischemic attack.
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http://dx.doi.org/10.1177/17474930211026519DOI Listing
July 2021

MRI-based Alzheimer's disease-resemblance atrophy index in the detection of preclinical and prodromal Alzheimer's disease.

Aging (Albany NY) 2021 05 25;13(10):13496-13514. Epub 2021 May 25.

Division of Neurology, Department of Medicine and Therapeutics, Therese Pei Fong Chow Research Centre for Prevention of Dementia, The Chinese University of Hong Kong, Hong Kong SAR, China.

Alzheimer's Disease-resemblance atrophy index (AD-RAI) is an MRI-based machine learning derived biomarker that was developed to reflect the characteristic brain atrophy associated with AD. Recent study showed that AD-RAI (≥0.5) had the best performance in predicting conversion from mild cognitive impairment (MCI) to dementia and from cognitively unimpaired (CU) to MCI. We aimed to validate the performance of AD-RAI in detecting preclinical and prodromal AD. We recruited 128 subjects (MCI=50, CU=78) from two cohorts: CU-SEEDS and ADNI. Amyloid (A+) and tau (T+) status were confirmed by PET (C-PIB, F-T807) or CSF analysis. We investigated the performance of AD-RAI in detecting preclinical and prodromal AD (i.e. A+T+) among MCI and CU subjects and compared its performance with that of hippocampal measures. AD-RAI achieved the best metrics among all subjects (sensitivity 0.74, specificity 0.91, accuracy 85.94%) and among MCI subjects (sensitivity 0.92, specificity 0.81, accuracy 86.00%) in detecting A+T+ subjects over other measures. Among CU subjects, AD-RAI yielded the best specificity (0.95) and accuracy (85.90%) over other measures, while hippocampal volume achieved a higher sensitivity (0.73) than AD-RAI (0.47) in detecting preclinical AD. These results showed the potential of AD-RAI in the detection of early AD, in particular at the prodromal stage.
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http://dx.doi.org/10.18632/aging.203082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202853PMC
May 2021

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

Anaesthesiol Intensive Ther 2021 ;53(3):265-270

International Fluid Academy, Lovenjoel, Belgium.

The COVID-19 pandemic has tested the very elements of human factors and ergonomics (HFE) to their maximum. HFE is an established scientific discipline that studies the interrelationship between humans, equipment, and the work environment. HFE includes situation awareness, decision making, communication, team working, leadership, managing stress, and coping with fatigue, empathy, and resilience. The main objective of HF is to optimise the interaction of humans with their work environment and technical equipment in order to maximise patient safety and efficiency of care. This paper reviews the importance of HFE in helping intensivists and all the multidisciplinary ICU teams to deliver high-quality care to patients in crisis situations.
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http://dx.doi.org/10.5114/ait.2021.105760DOI Listing
September 2021

Aiming for zero fluid accumulation: First, do no harm.

Anaesthesiol Intensive Ther 2021 ;53(2):162-178

International Fluid Academy, Lovenjoel, Belgium.

Critically ill patients are often presumed to be in a state of "constant dehydration" or in need of fluid, thereby justifying a continuous infusion with some form of intravenous (IV) fluid, despite their clinical data suggesting otherwise. Overzealous fluid administration and subsequent fluid accumulation and overload are associated with poorer outcomes. Fluids are drugs, and their use should be tailored to meet the patient's individualized needs; fluids should never be given as routine maintenance unless indicated. Before prescribing any fluids, the physician should consider the patient's characteristics and the nature of the illness, and assess the risks and benefits of fluid therapy. Decisions regarding fluid therapy present a daily challenge in many hospital departments: emergency rooms, regular wards, operating rooms, and intensive care units. Traditional fluid prescription is full of paradigms and unnecessary routines as well as malpractice in the form of choosing the wrong solutions for maintenance or not meeting daily requirements. Prescribing maintenance fluids for patients on oral intake will lead to fluid creep and fluid overload. Fluid overload, defined as a 10% increase in cumulative fluid balance from baseline weight, is an independent predictor for morbidity and mortality, and thus hospital cost. In the last decade, increasing evidence has emerged supporting a restrictive fluid approach. In this manuscript, we aim to provide a pragmatic description of novel concepts related to the use of IV fluids in critically ill patients, with emphasis on the different indications and common clinical scenarios. We also discuss active deresuscitation, or the timely cessation of fluid administration, with the intention of achieving a zero cumulative fluid balance.
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http://dx.doi.org/10.5114/ait.2021.105252DOI Listing
January 2021

Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies.

Lancet Neurol 2021 04 17;20(4):294-303. Epub 2021 Mar 17.

Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Background: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk.

Methods: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602.

Findings: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models.

Interpretation: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted.

Funding: British Heart Foundation and Stroke Association.
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http://dx.doi.org/10.1016/S1474-4422(21)00024-7DOI Listing
April 2021

Evolving ischemic stroke subtypes in 15 years: A hospital-based observational study.

Int J Stroke 2021 Apr 7:17474930211005953. Epub 2021 Apr 7.

Division of Neurology, Department of Medicine and Therapeutics, 26451The Chinese University of Hong Kong, Hong Kong.

Background: Depicting the time trends of ischemic stroke subtypes may inform healthcare resource allocation on etiology-based stroke prevention and treatment.

Aim: To reveal the evolving ischemic stroke subtypes from 2004 to 2018.

Methods: We determined the stroke etiologies of consecutive first-ever transient ischemic attack or ischemic stroke patients admitted to a regional hospital in Hong Kong from 2004 to 2018. We analyzed the age-standardized incidences and the two-year recurrence rate of major ischemic stroke subtypes.

Results: Among 6940 patients admitted from 2004 to 2018, age-standardized incidence of ischemic stroke declined from 187.0 to 127.4 per 100,000 population (p < 0.001), driven by the decrease in large artery disease (43.0-9.67 per 100,000 population (p < 0.001)), and small vessel disease (71.9-45.7 per 100,000 population (p < 0.001)). Age-standardized incidence of cardioembolic stroke did not change significantly (p = 0.2). Proportion of cardioembolic stroke increased from 20.4% in 2004-2006 to 29.3% in 2016-2018 (p < 0.001). Two-year recurrence rate of intracranial atherothrombotic stroke reduced from 19.3% to 5.1% (p < 0.001) with increased prescriptions of statin (p < 0.001) and dual antiplatelet therapy (p < 0.001). In parallel with increased anticoagulation use across the study period (p < 0.001), the two-year recurrence of AF-related stroke reduced from 18.9% to 6% (p < 0.001).

Conclusion: Etiology-based risk factor control might have led to the diminishing stroke incidences related to atherosclerosis. To tackle the surge of AF-related strokes, arrhythmia screening, anticoagulation usage, and mechanical thrombectomy service should be reinforced. Comparable preventive strategies might alleviate the enormous stroke burden in mainland China.
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http://dx.doi.org/10.1177/17474930211005953DOI Listing
April 2021

Prognostic value of bioelectrical impedance analysis for assessment of fluid overload in ICU patients: a pilot study.

Anaesthesiol Intensive Ther 2021 ;53(1):10-17

Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium.

Introduction: The non-invasive analysis of body fluid composition with bio-electrical impedance analysis (BIA) provides additional information allowing for more persona-lised therapy to improve outcomes. The aim of this study is to assess the prognostic value of fluid overload (FO) in the first week of intensive care unit (ICU) stay.

Material And Methods: A retrospective, observational analysis of 101 ICU patients. Whole-body BIA measurements were performed, and FO was defined as a 5% increase in volume excess from baseline body weight.

Results: Baseline demographic data, including severity scores, were similar in both the fluid overload-positive (FO+, n = 49) patients and in patients without fluid overload (FO-, n = 52). Patients with FO+ had significantly higher cumulative fluid balance during their ICU stay compared to those without FO (8.8 ± 7.0 vs. 5.5 ± 5.4 litres; P = 0.009), VE (9.9 ± 6.5 vs. 1.5 ± 1.5 litres; P < 0.001), total body water (63.0 ± 9.5 vs. 52.8 ± 8.1%; P < 0.001), and extracellular water (27.0 ± 7.3 vs. 19.6 ± 3.7 litres; P < 0.001). The presence of 5%, 7.5%, and 10% fluid overload was directly associated with increased ICU mortality rates. The percentage fluid overload (P = 0.039) was an independent predictor for hospital mortality.

Conclusions: A higher mortality rate in ICU-patients with FO was observed. FO is an independent prognostic factor because neither APACHE-II, SOFA, nor SAPS-II significantly differed on admission between survivors and non-survivors. Further research is needed to confirm these data prospectively and to evaluate whether BIA-guided deresuscitation in the subacute phase will improve mortality rates.
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http://dx.doi.org/10.5114/ait.2021.103526DOI Listing
January 2021

Hospital Mortality and Resource Implications of Hospitalisation with COVID-19 in London, UK: A Prospective Cohort Study.

Crit Care Res Pract 2021 27;2021:8832660. Epub 2021 Jan 27.

Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, SE5 9RS, London, UK.

Background: Coronavirus disease 2019 (COVID-19) had a significant impact on the National Health Service in the United Kingdom (UK), with over 35 000 cases reported in London by July 30, 2020. Detailed hospital-level information on patient characteristics, outcomes, and capacity strain is currently scarce but would guide clinical decision-making and inform prioritisation and planning.

Methods: We aimed to determine factors associated with hospital mortality and describe hospital and ICU strain by conducting a prospective cohort study at a tertiary academic centre in London, UK. We included adult patients admitted to the hospital with laboratory-confirmed COVID-19 and followed them up until hospital discharge or 30 days. Baseline factors that are associated with hospital mortality were identified via semiparametric and parametric survival analyses.

Results: Our study included 429 patients: 18% of them were admitted to the ICU, 52% met criteria for ICU outreach team activation, and 61% had treatment limitations placed during their admission. Hospital mortality was 26% and ICU mortality was 34%. Hospital mortality was independently associated with increasing age, male sex, history of chronic kidney disease, increasing baseline C-reactive protein level, and dyspnoea at presentation. COVID-19 resulted in substantial ICU and hospital strain, with up to 9 daily ICU admissions and 41 daily hospital admissions, to a peak census of 80 infected patients admitted in the ICU and 250 in the hospital. Management of such a surge required extensive reorganisation of critical care services with expansion of ICU capacity from 69 to 129 beds, redeployment of staff from other hospital areas, and coordinated hospital-level effort.

Conclusions: COVID-19 is associated with a high burden of mortality for patients treated on the ward and the ICU and required substantial reconfiguration of critical care services. This has significant implications for planning and resource utilisation.
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http://dx.doi.org/10.1155/2021/8832660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864763PMC
January 2021

Future developments in the imaging of the gastrointestinal tract: the role of ultrasound.

Curr Opin Crit Care 2021 04;27(2):147-156

Faculty of Engineering, Department of Electronics and Informatics, VUB, Brussels, Belgium.

Purpose Of Review: The purpose of this review is to summarize the utilization and most recent developments with regard to the use of ultrasound when imaging the abdomen and gastrointestinal tract.

Recent Findings: Although the use of ultrasound to assess the anatomy of the various abdominal organs is well established within radiology and critical care, its use as part of functional and physiological assessment is still evolving. Recent developments have extended the use of ultrasound beyond standard B-mode/2D imaging techniques to incorporate more functional and haemodynamic assessment. These include the use of contrast-enhanced ultrasound (CEUS), elastography, and colour Doppler techniques.

Summary: Whilst Doppler techniques are reasonably well established within critical care ultrasound (CCUS), especially in echocardiography, CEUS and elastography are less well known. CEUS utilizes a purely intravascular contrast agent whilst elastography measures the degree of deformation or stiffness in various organs. Whilst their use individually may be limited; they may play a role in a multiparametric assessment. Mirroring the overall trends in critical care ultrasound development, abdominal ultrasound assessment is best integrated in a holistic approach and adapted to the individual patient.
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http://dx.doi.org/10.1097/MCC.0000000000000815DOI Listing
April 2021

Correction: Electronic Cognitive Screen Technology for Screening Older Adults With Dementia and Mild Cognitive Impairment in a Community Setting: Development and Validation Study.

J Med Internet Res 2021 01 19;23(1):e26724. Epub 2021 Jan 19.

Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong).

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http://dx.doi.org/10.2196/26724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854035PMC
January 2021

A Retrospective Comparison of the Effectiveness and Safety of Intravenous Olanzapine Versus Intravenous Haloperidol for Agitation in Adult Intensive Care Unit Patients.

J Intensive Care Med 2021 Jan 11:885066620984450. Epub 2021 Jan 11.

Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Objective: Intravenous (IV) olanzapine could be an alternative to first-generation antipsychotics for the management of agitation in intensive care unit (ICU) patients. We compared the effectiveness and safety of IV olanzapine to IV haloperidol for agitation management in adult patients in the ICU at a tertiary academic medical center.

Methods: A retrospective cohort study was conducted. The primary outcome was the proportion of patients who achieved a Richmond Agitation Sedation Scale (RASS) score of < +1 within 4 hours of IV olanzapine or IV haloperidol administration. Secondary outcomes included the proportion of patients who required rescue medications for agitation within 4 hours of initial IV olanzapine or IV haloperidol administration, incidence of adverse events and ICU length of stay.

Results: In the 192 patient analytic cohort, there was no difference in the proportion of patients who achieved a RASS score of < +1 within 4 hours of receiving IV olanzapine or IV haloperidol (49% vs. 42%, p = 0.31). Patients in the IV haloperidol group were more likely to receive rescue medications (28% vs 55%, p < 0.01). There was no difference in the incidence of respiratory events or hypotension between IV olanzapine and IV haloperidol. Patients in the IV olanzapine group experienced more bradycardia (11% vs. 3%, p = 0.04) and somnolence (9% vs. 1%, p = 0.02) compared to the IV haloperidol group. Patients in the IV olanzapine group had a longer median ICU length of stay (7.5 days vs. 5 days, p = 0.04).

Conclusion: In this retrospective cohort study, there was no difference in the effectiveness of IV olanzapine compared to IV haloperidol for the management of agitation. IV olanzapine was associated with an increased incidence of bradycardia and somnolence.
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http://dx.doi.org/10.1177/0885066620984450DOI Listing
January 2021

Pandemic of the aging society - sporadic cerebral small vessel disease.

Chin Med J (Engl) 2021 01 5;134(2):143-150. Epub 2021 Jan 5.

Division of Neurology, Department of Medicine and Therapeutics, The Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.

Abstract: Age-related sporadic cerebral small vessel disease (CSVD) has gained increasing attention over the past decades because of its increasing prevalence associated with an aging population. The widespread application of and advances in brain magnetic resonance imaging in recent decades have significantly increased researchers' understanding in the in vivo evolution of CSVD, its impact upon the brain, its risk factors, and the mechanisms that explain the various clinical manifestation associated with sporadic CSVD. In this review, we aimed to provide an update on the pathophysiology, risk factors, biomarkers, and the determinants and spectrum of the clinical manifestation of sporadic CSVD.
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http://dx.doi.org/10.1097/CM9.0000000000001320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817343PMC
January 2021

Characterization of the adiponectin promoter + Cre recombinase insertion in the Tg(Adipoq-cre)1Evdr mouse by targeted locus amplification and droplet digital PCR.

Adipocyte 2021 12;10(1):21-27

Section on Growth and Obesity and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health , Bethesda, MD, USA.

The Tg(Adipoq-cre)1Evdr mouse has become an important tool in adipose tissue biology. However, the exact genomic transgene integration site has not been established. Using Targeted Locus Amplification (TLA) we found the transgene had integrated on mouse chromosome 9 between exons 6 and 7 of . We detected transgene-transgene fusion; therefore, we used droplet digital polymerase chain reaction to identify copy number. In two separate experiments, we digested with BAMHI and with HindIII to separate potentially conjoined sequences. We found one copy of intact present in each experiment, indicating transgene-transgene fusion in other parts of the BAC that would not contribute to tissue-specific expression. copy number for Tg(Adipoq-cre)1Evdr mice can be potentially used to identify homozygous mice.
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http://dx.doi.org/10.1080/21623945.2020.1861728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781622PMC
December 2021

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus.

Crit Care 2020 12 24;24(1):702. Epub 2020 Dec 24.

Ospedale Niguarda C' Grande, Milan, Italy.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.
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http://dx.doi.org/10.1186/s13054-020-03369-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759024PMC
December 2020

Electronic Cognitive Screen Technology for Screening Older Adults With Dementia and Mild Cognitive Impairment in a Community Setting: Development and Validation Study.

J Med Internet Res 2020 12 18;22(12):e17332. Epub 2020 Dec 18.

Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.

Background: A digital cognitive test can be a useful and quick tool for the screening of cognitive impairment. Previous studies have shown that the diagnostic performance of digital cognitive tests is comparable with that of conventional paper-and-pencil tests. However, the use of commercially available digital cognitive tests is not common in Hong Kong, which may be due to the high cost of the tests and the language barrier. Thus, we developed a brief and user-friendly digital cognitive test called the Electronic Cognitive Screen (EC-Screen) for the detection of mild cognitive impairment (MCI) and dementia of older adults.

Objective: The aim of this study was to evaluate the performance of the EC-Screen for the detection of MCI and dementia in older adults.

Methods: The EC-Screen is a brief digital cognitive test that has been adapted from the Rapid Cognitive Screen test. The EC-Screen uses a cloud-based platform and runs on a tablet. Participants with MCI, dementia, and cognitively healthy controls were recruited from research clinics and the community. The outcomes were the performance of the EC-Screen in distinguishing participants with MCI and dementia from controls, and in distinguishing participants with dementia from those with MCI and controls. The cohort was randomly split into derivation and validation cohorts based on the participants' disease group. In the derivation cohort, the regression-derived score of the EC-Screen was calculated using binomial logistic regression. Two predictive models were produced. The first model was used to distinguish participants with MCI and dementia from controls, and the second model was used to distinguish participants with dementia from those with MCI and controls. Receiver operating characteristic curves were constructed and the areas under the curves (AUCs) were calculated. The performances of the two predictive models were tested using the validation cohorts. The relationship between the EC-Screen and paper-and-pencil Montreal Cognitive Assessment-Hong Kong version (HK-MoCA) was evaluated by the Pearson correlation coefficient.

Results: A total of 126 controls, 54 participants with MCI, and 63 participants with dementia were included in the study. In differentiating participants with MCI and dementia from controls, the AUC of the EC-Screen in the derivation and validation cohorts was 0.87 and 0.84, respectively. The optimal sensitivity and specificity in the derivation cohorts were 0.81 and 0.80, respectively. In differentiating participants with dementia from those with MCI and controls, the AUC of the derivation and validation cohorts was 0.90 and 0.88, respectively. The optimal sensitivity and specificity in the derivation cohort were 0.83 and 0.83, respectively. There was a significant correlation between the EC-Screen and HK-MoCA (r=-0.67, P<.001).

Conclusions: The EC-Screen is suggested to be a promising tool for the detection of MCI and dementia. This test can be self-administered or assisted by a nonprofessional staff or family member. Therefore, the EC-Screen can be a useful tool for case finding in primary health care and community settings.
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http://dx.doi.org/10.2196/17332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775823PMC
December 2020

High serum neurofilament levels among Chinese patients with aquaporin-4-IgG-seropositive neuromyelitis optica spectrum disorders.

J Clin Neurosci 2021 Jan 13;83:108-111. Epub 2020 Dec 13.

Lui Che Woo Institute of Innovative Medicine, Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region. Electronic address:

Background: Serum neurofilament light chain (sNfL) is a promising biomarker for neuromyelitis optica spectrum disorders (NMOSD) and multiple sclerosis (MS), but there is limited validation data in specific ethnic and disease groups.

Objective: To investigate the levels of sNfL in a cohort of Chinese patients with NMOSD and compare sNfL levels in patients with different disease courses and treatments.

Methods: We analysed sNfL levels in 153 Chinese patients with NMOSD (n = 51) and MS (n = 102) using single-molecule array (Simoa) technology. The sNfL levels were compared with those of 71 healthy controls from two centres in southern China. For each disease, we assessed correlations between sNfL and disease phases and treatments.

Results: Higher levels of sNfL were found in the patients with NMOSD [17.97 (10.55-27.94) pg/mL] and MS [15.83 (8.92-25.67) pg/mL] compared to healthy controls [10.09 (7.19-13.29) pg/mL, p < 0.001]. No significant differences were found between the AQP4-IgG-positive NMOSD group and OCB-positive MS group.

Conclusions: sNfL measured by Simoa technology is a potential candidate blood biomarker for the diagnosis and disease monitoring of NMOSD in Chinese patients, warranting further prospective and multicentre studies.
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http://dx.doi.org/10.1016/j.jocn.2020.11.016DOI Listing
January 2021

Transforming the Medication Regimen Review Process Using Telemedicine to Prevent Adverse Events.

J Am Geriatr Soc 2021 02 24;69(2):530-538. Epub 2020 Nov 24.

Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background/objectives: Federally-mandated consultant pharmacist-conducted retrospective medication regimen reviews (MRRs) are designed to improve medication safety in nursing homes (NH). However, MRRs are potentially ineffective. A new model of care that improves access to and efficiency of consultant pharmacists is needed. The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for NH residents using medication reconciliation and prospective MRR on admission plus ongoing clinical decision support alerts throughout the residents' stay.

Design: Quality improvement study using a stepped-wedge design comparing the novel service to usual care in a one-year evaluation from November 2016 to October 2017.

Setting: Four NHs (two urban, two suburban) in Southwestern Pennsylvania.

Participants: All residents in the four NHs were screened. There were 2,127 residents admitted having 652 alerts in the active period.

Intervention: Upon admission, pharmacists conducted medication reconciliation and prospective MRR for residents and also used telemedicine for communication with cognitively-intact residents. Post-admission, pharmacists received clinical decision support alerts to conduct targeted concurrent MRRs and telemedicine.

Measurement: Main outcome was incidence of high-risk medication, alert-specific ADEs. Secondary outcomes included all-cause hospitalization, 30-day readmission rates, and consultant pharmacists' recommendations.

Results: Consultant pharmacists provided 769 recommendations. The intervention group had a 92% lower incidence of alert-specific ADEs than usual care (9 vs 31; 0.14 vs 0.61/1,000-resident-days; adjusted incident rate ratio (AIRR) = 0.08 (95% confidence interval (CI) = 0.01-0.40]; P = .002). All-cause hospitalization was similar between groups (149 vs 138; 2.33 vs 2.70/1,000-resident-days; AIRR = 1.06 (95% CI = 0.72-1.58); P = .75), as were 30-day readmissions (110 vs 102; 1.72 vs 2.00/1,000-resident-days; AIRR = 1.21 (95% CI = 0.76-1.93); P = .42).

Conclusions: This is the first evaluation of the impact of pharmacist-led patient-centered telemedicine services to manage high-risk medications during transitional care and throughout the resident's NH stay, supporting a new model of patient care.
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http://dx.doi.org/10.1111/jgs.16946DOI Listing
February 2021

Weight-Based Dosing Versus a Fixed-Dose Regimen of 4-Factor Prothrombin Complex Concentrate in Obese Patients Requiring Vitamin K Antagonist Reversal.

Am J Cardiovasc Drugs 2021 May 5;21(3):355-361. Epub 2020 Nov 5.

Department of Pharmacy, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA.

Introduction: Despite an increase in the use of fixed-dose protocols of 4-factor prothrombin complex concentrate (4F-PCC) for the reversal of vitamin K antagonists (VKAs), there remains a paucity of data in obese patients. In this study, we aimed to compare the proportion of patients attaining international normalized ratio (INR) goals using a weight-based dosing strategy versus a fixed-dose regimen of 4F-PCC.

Methods: This was a retrospective study conducted in patients 18 years of age or older, weighing ≥ 100 kg, who received either a weight-based dose or fixed dose of 4F-PCC (2000 units) for the reversal of VKA, and had a documented baseline and post-treatment INR. The primary outcome was the proportion of patients achieving an INR of < 2 for all indications of warfarin reversal, except in patients with intracranial hemorrhage, where the goal was an INR of < 1.5.

Results: A total of 44 patients met the inclusion criteria; 25 patients in the weight-based dosing group and 19 patients in the fixed-dose group. The median baseline INR was similar in both groups (weight-based dosing group 3.2 [interquartile range {IQR} 2.8-3.7] vs fixed-dose group 3.0 [IQR 2.7-4.9], p = 1). The median post-treatment INR was significantly lower in the weight-based dosing group compared to the fixed-dose group (1.3 [IQR 1.2-1.5] vs 1.6 [IQR 1.5-1.9], p < 0.01). However, there was no significant difference in the primary outcome between both groups (weight-based dosing strategy 84% vs fixed dose strategy 90%, p = 0.68).

Conclusion: Our findings suggest that a fixed-dose regimen of 2000 units in obese patients weighing ≥ 100 kg is adequate to achieve these INR goals.
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http://dx.doi.org/10.1007/s40256-020-00442-wDOI Listing
May 2021

Prolonged visual fixation as a surrogate marker of cholinergic deficit in Parkinson's disease: A 2-year follow-up study.

Parkinsonism Relat Disord 2020 12 11;81:60-66. Epub 2020 Oct 11.

Department of Psychiatry, The Chinese University of Hong Kong, G/F, Multi-centre Building, 9 Chuen on Road, Tai Po Hospital, Tai Po, Hong Kong Special Administrative Region. Electronic address:

Introduction: The search for biomarkers of cognitive impairment in Parkinson's disease is driven by the potential clinical applications in disease prognostication. Various eye tracking studies on cognitive functions in Parkinson's disease suggest a promising role of eye movement parameters as a biomarker for cognitive decline but the clinical utility has not been validated in longitudinal studies. The present study aims to investigate the longitudinal progression of eye fixation duration in a visual search task and its correlation with domain-specific cognitive impairment.

Method: This is a 2-year follow-up study on a group of non-demented Parkinson's disease patients, with baseline eye movement metrics and multi-domain cognitive functions measured, to assess the association between domain-specific cognitive impairment and progression of visual fixation duration.

Results: A total of 49 from the original 62 non-demented Parkinson's disease patients were re-examined at a 2-year follow-up. 15 cases (31%) were classified as having mild cognitive impairment. Visual fixation duration was significantly prolonged after 2 years. Using repeated measures ANOVA, impairment in semantic verbal fluency, visual and verbal recognition memory and orienting function of attention had a significant effect on prolonging visual fixation over time.

Conclusion: Correlation between prolonged visual fixation and multiple domains of cognitive impairment related to cholinergic dysfunction in repeated measures over two years provides preliminary evidence for the eye tracking paradigm as a surrogate marker for cholinergic deficit in Parkinson's disease. The clinical utility in terms of disease prognostication is yet to be confirmed in prospective longitudinal studies with longer follow-up periods.
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http://dx.doi.org/10.1016/j.parkreldis.2020.10.019DOI Listing
December 2020

Pseudo B-line in pneumothorax: first look at the patient. Author's reply.

Intensive Care Med 2021 01 8;47(1):139-140. Epub 2020 Oct 8.

Department of Critical Care Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto, Toronto, Canada.

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http://dx.doi.org/10.1007/s00134-020-06246-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541351PMC
January 2021

Vancomycin Dosing Practices among Critical Care Pharmacists: A Survey of Society of Critical Care Medicine Pharmacists.

Infect Dis (Auckl) 2020 25;13:1178633720952078. Epub 2020 Sep 25.

St. Louis College of Pharmacy, St. Louis, MO, USA.

Introduction: Critically ill patients and their pharmacokinetics present complexities often not considered by consensus guidelines from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Prior surveys have suggested discordance between certain guideline recommendations and reported infectious disease pharmacist practice. Vancomycin dosing practices, including institutional considerations, have not previously been well described in the critically ill patient population.

Objectives: To evaluate critical care pharmacists' self-reported vancomycin practices in comparison to the 2009 guideline recommendations and other best practices identified by the study investigators.

Methods: An online survey developed by the Research and Scholarship Committee of the Clinical Pharmacy and Pharmacology (CPP) Section of the Society of Critical Care Medicine (SCCM) was sent to pharmacist members of the SCCM CPP Section practicing in adult intensive care units in the spring of 2017. This survey queried pharmacists' self-reported practices regarding vancomycin dosing and monitoring in critically ill adults.

Results: Three-hundred and sixty-four responses were received for an estimated response rate of 26%. Critical care pharmacists self-reported largely following the 2009 vancomycin dosing and monitoring guidelines. The largest deviations in guideline recommendation compliance involve consistent use of a loading dose, dosing weight in obese patients, and quality improvement efforts related to systematically monitoring vancomycin-associated nephrotoxicity. Variation exists regarding pharmacist protocols and other practices of vancomycin use in critically ill patients.

Conclusion: Among critical care pharmacists, reported vancomycin practices are largely consistent with the 2009 guideline recommendations. Variations in vancomycin dosing and monitoring protocols are identified, and rationale for guideline non-adherence with loading doses elucidated.
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http://dx.doi.org/10.1177/1178633720952078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522823PMC
September 2020

Psychometrics and diagnostic properties of the Montreal Cognitive Assessment 5-min protocol in screening for Mild Cognitive Impairment and dementia among older adults in Tanzania: A validation study.

Int J Older People Nurs 2021 Jan 13;16(1):e12348. Epub 2020 Sep 13.

School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong.

Background: The prevalence of dementia in Tanzania, as in other developing countries, is progressively increasing. Yet international screening instruments for mild cognitive impairment are lacking.

Objectives: The aim of this study was to determine the psychometrics and the diagnostic ability of the Montreal Cognitive Assessment 5 minutes protocol (MoCA-5-min) among older adults in the rural Tanzania.

Methods: The MoCA-5-min and the Identification and Intervention for Dementia in Elderly Africans (IDEA) cognitive screening were concurrently administered through face to face to 202 community-dwelling older adults in Chamwino district. Exploratory factor analysis (EFA) using principal component method and oblique rotation was performed to determine the underlying factor structure of the scale. The concurrent and construct as well as predictive validities of the MoCA-5-min were examined by comparing its score with IDEA cognitive screening and psychiatrist's diagnosis using DSM-V criteria, respectively.

Results: The EFA found that all the MoCA-5-min items highly loaded into one component, with factor loading ranging from 0.550 to 0.879. The intraclass correlation coefficient for 6 weeks test-retest reliability was 0.85. Its strong significant correlation with the IDEA screening (Pearson's r = 0.614, p < 0.001) demonstrated a good concurrent validity. Using the psychiatrist's rating as the gold standard, MoCA-5-min demonstrated the optimal cut-off score for MCI at 22, which yielded the sensitivity of 80% and specificity of 74%; and dementia at score of 16 giving a sensitivity of 90% and specificity of 80%. Upon stratifying the sample into different age groups, the optimal cut-off scores tended to decrease with the increase in age.

Conclusion: The MoCA-5-min is reliable and provides a valid and accurate measure of cognitive decline among older population in the rural settings of Tanzania. The use of varying cut-off scores across age groups may ensure more precise discriminatory power of the MoCA-5-min.

Implications For Practice: Availability of the MoCA-5-min in Tanzania will facilitate clinicians to timely detect dementia at both pre-clinical and clinical stages. Its availability will also encourage further research and international collaborations in dementia prevention programs.
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http://dx.doi.org/10.1111/opn.12348DOI Listing
January 2021

Tackling challenges in care of Alzheimer's disease and other dementias amid the COVID-19 pandemic, now and in the future.

Alzheimers Dement 2020 11 12;16(11):1571-1581. Epub 2020 Aug 12.

Department of Geriatric Medicine Peninsula Health, Peninsula Clinical School, Monash University, Clayton, Victoria, Australia.

We have provided an overview on the profound impact of COVID-19 upon older people with Alzheimer's disease and other dementias and the challenges encountered in our management of dementia in different health-care settings, including hospital, out-patient, care homes, and the community during the COVID-19 pandemic. We have also proposed a conceptual framework and practical suggestions for health-care providers in tackling these challenges, which can also apply to the care of older people in general, with or without other neurological diseases, such as stroke or parkinsonism. We believe this review will provide strategic directions and set standards for health-care leaders in dementia, including governmental bodies around the world in coordinating emergency response plans for protecting and caring for older people with dementia amid the COIVD-19 outbreak, which is likely to continue at varying severity in different regions around the world in the medium term.
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http://dx.doi.org/10.1002/alz.12143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436526PMC
November 2020

The use of contrast-enhanced ultrasound in COVID-19 lung imaging.

J Ultrasound 2020 Aug 4. Epub 2020 Aug 4.

Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.

Lung ultrasound has become an essential tool for rapid bedside assessment in critically unwell patients, proving helpful in assessment of COVID-19 due to logistics of cross-sectional imaging. Contrast enhanced ultrasound (CEUS) further characterizes sonographic features of COVID-19 as multiple areas of infarction, a finding not reproducible on other widely available imaging modalities. CEUS also has the benefit of being cheap, radiation-free, without risk of nephrotoxicity, and can be performed at the bedside. It is predicted that lung CEUS in COVID-19 may help guide prognosis and management. We describe three cases of CEUS in COVID-19.
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http://dx.doi.org/10.1007/s40477-020-00517-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401471PMC
August 2020
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