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BACKGROUND AND PURPOSE: The Total Calcification Score (TCS) is a visual rating scale to measure Primary Familial Brain Calcification (PFBC) related calcification severity on Computed Tomography (CT). We investigated the inter-and intrarater agreement of a modified TCS. MATERIALS AND METHODS: Patients aged ≥18 years with PFBC or Fahr's syndrome who visited the outpatient clinic of a Dutch academic hospital were included. The TCS was modified, for example by adding hippocampal calcification, and ranged from 0 to 95 points. Fifteen raters evaluated all CTs, of whom three evaluated the CTs twice. Their Entrustable Professional Activity (EPA) level ranged from II (medical student) to V (neuroradiologist). Agreement was assessed using the intraclass correlation coefficient (ICC) for the total score. Kendall's W and weighted Cohen's Kappa were used to determine the inter- and intrarater agreement for individual locations, respectively. RESULTS: Forty patients were included (mean age 60 years, 53% female). The median modified TCS was 34 (range 4-76). For all EPA levels, the interrater agreement of the modified TCS was excellent (ICC=0.97 (95% CI 0.95-0.98)). Kendall's W's were good to excellent for commonly affected locations, but poor to moderate for less commonly affected locations for raters with lower levels of expertise. The intrarater agreement of the modified TCS was excellent. Kappa's of most locations were substantial to almost perfect. CONCLUSIONS: The modified TCS can be used with excellent reproducibility of the overall amount of brain calcifications and with limited training, although for some individual calcification locations more expertise is needed. ABBREVIATIONS: CI, Confidence Interval; CT, Computed Tomography; EPA, Entrustable Professional Activity; IBGC, Idiopathic Basal Ganglia Calcification; ICC, Intraclass Correlation Coefficient; IQR, Interquartile Range; PFBC, Primary Familial Brain Calcification; SD, Standard Deviation, TCS, Total Calcification Score; UMCU, University Medical Center Utrecht.

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PURPOSE: Hypothermia is a serious condition in older adults. Knowledge of a priori chances of underlying diseases may affect initial management, hence prognosis. This systematic review provided an overview of existing literature on the incidences of underlying causes of hypothermia in older patients at the emergency department. METHODS: MEDLINE, The Cochrane Library, and Embase were searched up to February 1st, 2022. Inclusion criteria were age ≥ 65 years, emergency department setting, and body temperature < 36.0 degrees Celsius. Exclusion criteria were iatrogenic hypothermia, no underlying cause reported, and patient selection based on specific diseases. Title/abstract and full-text were screened and quality was assessed using the Joanna Briggs Institute Critical Appraisal Tool. Data were presented using descriptive statistics and narrative analyses. RESULTS: Forty-one reports were included, including 6 cohort studies and 35 case reports. The 6 studies involved 2173 hypothermic patients, whose age varied from a mean of 67 to a median of 79 years and temperature from a median of 30.8 to a mean of 33.7 degrees Celsius. One study reported about primary hypothermia (incidence of 44%). Acute medical illness was often reported as underlying cause of secondary hypothermia (49-51%). Reported incidences of infection and sepsis ranged from 10 to 32%, of trauma up to 14%, and of alcohol intoxication from 5 to 26%. CONCLUSION: Limited studies have been published regarding this topic, and the overall quality of the evidence was graded as low. Causes that should not be missed include acute medical illness, trauma, alcohol intoxication, primary hypothermia, thyroid failure, and drug-induced hypothermia.

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Hypothermia in older patients is a serious symptom, with high morbidity and mortality, and often an atypical presentation of an underlying problem. The most common causes are an infection and exposure to extreme cold ('accidental hypothermia'), but there are other, less common causes. These two cases show hypothermia as one of the symptoms in atypical presentations of underlying conditions. It is important to run diagnostics for infectious diseases and other underlying causes, and start antibiotics promptly. If there is no response to antibiotics and diagnostics do not reveal evidence of an infection, clinicians need to consider other causes of hypothermia.

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OBJECTIVE: To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. DESIGN: Cluster randomised controlled trial. SETTING: 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. PARTICIPANTS: 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). INTERVENTION: Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing. MAIN OUTCOME MEASURE: Primary outcome was first drug related hospital admission within 12 months. RESULTS: 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). CONCLUSIONS: Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02986425.

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