The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). The SCMR web site ( https://www.scmr.org ) hosts a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. In this publication, we provide a digital archive of the 2019 Case of the Week series as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.
Abstract Objectives Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into ‘no delirium’ or ‘control’ groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. Methods Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. Results These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. Conclusions The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
Importance There is a need for observational studies to supplement evidence from clinical trials, and the target trial emulation (TTE) framework can help avoid biases that can be introduced when treatments are compared crudely using observational data by applying design principles for randomized clinical trials. Adalimumab (ADA) and tofacitinib (TOF) were shown to be equivalent in patients with rheumatoid arthritis (RA) in a randomized clinical trial, but to our knowledge, these drugs have not been compared head-to-head using routinely collected clinical data and the TTE framework. Objective To emulate a randomized clinical trial comparing ADA vs TOF in patients with RA who were new users of a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD). Design, Setting, and Participants This comparative effectiveness study emulating a randomized clinical trial of ADA vs TOF included Australian adults aged 18 years or older with RA in the Optimising Patient Outcomes in Australian Rheumatology (OPAL) data set. Patients were included if they initiated ADA or TOF between October 1, 2015, and April 1, 2021; were new b/tsDMARD users; and had at least 1 component of the disease activity score in 28 joints using C-reactive protein (DAS28-CRP) recorded at baseline or during follow-up. Intervention Treatment with either ADA (40 mg every 14 days) or TOF (10 mg daily). Main Outcomes and Measures The main outcome was the estimated average treatment effect, defined as the difference in mean DAS28-CRP among patients receiving TOF compared with those receiving ADA at 3 and 9 months after initiating treatment. Missing DAS28-CRP data were multiply imputed. Stable balancing weights were used to account for nonrandomized treatment assignment. Results A total of 842 patients were identified, including 569 treated with ADA (387 [68.0%] female; median age, 56 years [IQR, 47-66 years]) and 273 treated with TOF (201 [73.6%] female; median age, 59 years [IQR, 51-68 years]). After applying stable balancing weights, mean DAS28-CRP in the ADA group was 5.3 (95% CI, 5.2-5.4) at baseline, 2.6 (95% CI, 2.5-2.7) at 3 months, and 2.3 (95% CI, 2.2-2.4) at 9 months; in the TOF group, it was 5.3 (95% CI, 5.2-5.4) at baseline, 2.4 (95% CI, 2.2-2.5) at 3 months, and 2.3 (95% CI, 2.1-2.4) at 9 months. The estimated average treatment effect was −0.2 (95% CI, −0.4 to −0.03; P = .02) at 3 months and −0.03 (95% CI, −0.2 to 0.1; P = .60) at 9 months. Conclusions and Relevance In this study, there was a modest but statistically significant reduction in DAS28-CRP at 3 months for patients receiving TOF compared with those receiving ADA and no difference between treatment groups at 9 months. Three months of treatment with either drug led to clinically relevant average reductions in mean DAS28-CRP, consistent with remission.
Abstract Background In 2012‐2014, an observational cohort study of postoperative delirium (POD) in an elective arthroplasty population recruited 315 individuals aged over 65 without a diagnosis of dementia. This follow‐up study aims to determine what effect POD has on cognitive function eight years later. Method Preoperatively, participants underwent cognitive assessments and sampling of blood and cerebrospinal fluid (CSF) which were analysed for amyloid‐beta (Aβ)40, Aβ42, glial fibrillary acidic protein (GFAP), neurofilament light (NFL) and interleukin (IL)‐6. In 2021, n = 172 of n = 264 surviving participants completed virtual cognitive assessments and agreed to have their medical records reviewed. For those who had died (n = 50), death certificates were obtained to determine if the participant died with a diagnosis of dementia. Univariate analyses and binary logistic regression were undertaken to investigate factors associated with mild cognitive impairment (MCI)/dementia in this cohort at eight years (Table 1). In cases when MCI or dementia was suspected, an expert consensus panel reviewed medical notes, cognitive test scores and informant reports to determine if a participant had MCI or dementia. Result Of the n = 222 participants, n = 30 had POD in 2012‐2014 and n = 22 had developed dementia or MCI. On univariate analyses, those who developed MCI/dementia at eight years were significantly older at the time of surgery (p = .02), had greater preoperative functional impairment (p = .02), and depression (p = .03) and performed worse on a number of cognitive tasks pre‐operatively (p<.05). Rates of POD were significantly greater in those who subsequently developed MCI/dementia (p = .03). In those who developed MCI/dementia, preoperative plasma and CSF measures of Aβ42 were significantly lower (p<.01), while CSF neurofilament light (NFL) and plasma IL‐6, GFAP and NFL were significantly higher (p<.05). On multivariate analyses, CSF Aβ42 (p = .02) and preoperative phonemic fluency (p = .01) remained significant predictors of MCI/dementia, while POD did not (Table 1). Conclusion This study did not find an independent association between delirium following elective arthroplasty and the development of MCI/dementia eight years later. The results of our study indicate preoperative CSF Aβ42 and cognitive function predict longer‐term outcomes and that the association between delirium and subsequent MCI and dementia is not independent of these factors.
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