Cognitive Improvement in Older Adults in the Year After Hip Fracture: Implications for Brain Resilience in Advanced Aging.

OBJECTIVE: We examined cognitive function in nondemented, nondelirious older adults 1 year post hip fracture. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: Three hundred eighty-six hip fracture patients aged 60 years and older with no history of cognitive impairment, such as clinical dementia or persistent delirium, recruited from eight area hospitals 2-3 days after hip surgery (week 0), and 101 older adults with no recent acute medical events for control comparison. METHODS: Cognitive function was examined with the Repeatable Battery for the Assessment of Neuropsychological Status and the Short Blessed Test (SBT) at weeks 0 (SBT only), 4, and 52 using a repeated measures mixed model analysis. Baseline predictor variables included demographics, personality, genetic factors, and depressive symptom level. RESULTS: Hip fracture participants had lower cognitive scores than healthy comparisons. Cognitive scores improved in the hip fracture group relative to healthy comparison participants from week 4-52. The only significant predictor of cognitive improvement after hip fracture was education: individuals with college education showed cognitive improvement by week 52, while those with high school or less did not. CONCLUSION: Nondemented, nondelirious older adults suffering hip fracture have poorer cognitive function immediately after the fracture but then exhibit cognitive improvement over the ensuing year, especially among those with high education. This demonstrates brain resilience in older adults even in the context of advanced age, medical illness, and frailty.

Estimating correlation between multivariate longitudinal data in the presence of heterogeneity.

BACKGROUND: Estimating correlation coefficients among outcomes is one of the most important analytical tasks in epidemiological and clinical research. Availability of multivariate longitudinal data presents a unique opportunity to assess joint evolution of outcomes over time. Bivariate linear mixed model (BLMM) provides a versatile tool with regard to assessing correlation. However, BLMMs often assume that all individuals are drawn from a single homogenous population where the individual trajectories are distributed smoothly around population average. METHODS: Using longitudinal mean deviation (MD) and visual acuity (VA) from the Ocular Hypertension Treatment Study (OHTS), we demonstrated strategies to better understand the correlation between multivariate longitudinal data in the presence of potential heterogeneity. Conditional correlation (i.e., marginal correlation given random effects) was calculated to describe how the association between longitudinal outcomes evolved over time within specific subpopulation. The impact of heterogeneity on correlation was also assessed by simulated data. RESULTS: There was a significant positive correlation in both random intercepts (ρ = 0.278, 95% CI: 0.121-0.420) and random slopes (ρ = 0.579, 95% CI: 0.349-0.810) between longitudinal MD and VA, and the strength of correlation constantly increased over time. However, conditional correlation and simulation studies revealed that the correlation was induced primarily by participants with rapid deteriorating MD who only accounted for a small fraction of total samples. CONCLUSION: Conditional correlation given random effects provides a robust estimate to describe the correlation between multivariate longitudinal data in the presence of unobserved heterogeneity (NCT00000125).

Ovarian cancer in the United States: contemporary patterns of care associated with improved survival.

BACKGROUND: Ovarian cancer (OC) requires complex multidisciplinary care with wide variations in outcome. We sought to determine the impact of institutional and process of care factors on overall survival (OS) and delivery of guideline care nationally. METHODS: This was a retrospective cohort study of primary OC diagnosed from 1998 to 2007 using the National Cancer Data Base (NCDB) capturing 80% of all U.S. cases. Patient- (demographics, comorbidities, stage/grade), process of care (adherence to guidelines) and institutional- (facility type, case volume) factors were evaluated. Primary outcomes were OS and delivery of guideline therapy. Multivariable logistic regression and Cox proportional hazards models were used for analysis. RESULTS: We analyzed 96,802 consecutive cases. Five-year OS was 84%, 66.3%, 32% and 15.7% for stages I, II, III and IV, respectively. The annual mean facility case volumes varied by cancer center type (range: 5.7 to 26.7), with 25% of cases spread over 65% of centers--all treating fewer than 8 cases. Overall, 56% of cases received non-guideline care. Low facility case volume and higher comorbidity index independently predicted non-guideline care; high volume centers were less likely to deliver non-guideline care (OR: 0.44, 95% CI: 0.41-0.47). Delivery of non-guideline care (OR: 1.4, 95% CI: 1.36-1.44), and higher facility case volume (OR: 0.91, 95% CI: 0.86-0.96) were both independent predictors of OS. CONCLUSIONS: Delivery of guideline care and facility case volume are important drivers of overall survival. Most cancer centers treat very few women with OC. National efforts should focus on improved access to centers with expertise in OC and ensuring delivery of guideline care.

Motor and cognitive assessment of infants and young boys with Duchenne Muscular Dystrophy: results from the Muscular Dystrophy Association DMD Clinical Research Network.

Therapeutic trials in Duchenne Muscular Dystrophy (DMD) exclude young boys because traditional outcome measures rely on cooperation. The Bayley III Scales of Infant and Toddler Development (Bayley III) have been validated in developing children and those with developmental disorders but have not been studied in DMD. Expanded Hammersmith Functional Motor Scale (HFMSE) and North Star Ambulatory Assessment (NSAA) may also be useful in this young DMD population. Clinical evaluators from the MDA-DMD Clinical Research Network were trained in these assessment tools. Infants and boys with DMD (n = 24; 1.9 ± 0.7 years) were assessed. The mean Bayley III motor composite score was low (82.8 ± 8; p ≤ .0001) (normal = 100 ± 15). Mean gross motor and fine motor function scaled scores were low (both p ≤ .0001). The mean cognitive comprehensive (p=.0002), receptive language (p ≤ .0001), and expressive language (p = .0001) were also low compared to normal children. Age was negatively associated with Bayley III gross motor (r = -0.44; p = .02) but not with fine motor, cognitive, or language scores. HFMSE (n=23) showed a mean score of 31 ± 13. NSAA (n = 18 boys; 2.2 ± 0.4 years) showed a mean score of 12 ± 5. Outcome assessments of young boys with DMD are feasible and in this multicenter study were best demonstrated using the Bayley III.