Underestimation of Cognitive Impairment in Older Inpatients by the Abbreviated Mental Test Score versus the Montreal Cognitive Assessment: Cross-Sectional Observational Study.

BACKGROUND/AIMS: Cognitive impairment is prevalent in older inpatients but may be unrecognized. Screening to identify cognitive deficits is therefore important to optimize care. The 10-point Abbreviated Mental Test Score (AMTS) is widely used in acute hospital settings but its reliability for mild versus more severe cognitive impairment is unknown. We therefore studied the AMTS versus the 30-point Montreal Cognitive Assessment (MoCA) in older (≥75 years) inpatients. METHODS: The AMTS and MoCA were administered to consecutive hospitalized patients at ≥72 h after admission in a prospective observational study. MoCA testing time was recorded. Reliability of the AMTS for the reference standard defined as mild (MoCA <26) or moderate/severe (MoCA <18) cognitive impairment was assessed using the area under the receiver-operating curve (AUC). Sensitivity, specificity, positive and negative predictive values of low AMTS (<8) for cognitive impairment were determined. RESULTS: Among 205 patients (mean/SD age = 84.9/6.3 years, 96 (46.8%) male, 74 (36.1%) dementia/delirium), mean/SD AMTS was 7.2/2.3, and mean/SD MoCA was 16.1/6.2 with mean/SD testing time = 17.9/7.2 min. 96/205 (46.8%) had low AMTS whereas 174/185 (94%) had low MoCA: 74/185 (40.0%) had mild and 100 (54.0%) had moderate/severe impairment. Moderate/severe cognitive impairment was more prevalent in the low versus the normal AMTS group: 74/83 (90%) versus 25/102 (25%, p < 0.0001). AUC of the AMTS for mild and moderate/severe impairment were 0.86 (95% CI = 0.80-0.93) and 0.88 (0.82-0.93), respectively. Specificity of AMTS <8 for both mild and moderate/severe cognitive impairment was high (100%, 71.5-100, and 92.7%, 84.8-97.3) but sensitivity was lower (44.8%, 37.0-52.8, and 72.8%, 62.6-81.6, respectively). The negative predictive value of AMTS <8 was therefore low for mild impairment (10.9%, 5.6-18.7) but much higher for moderate/severe impairment (75.2%, 65.7-83.3). All MoCA subtests discriminated between low and normal AMTS groups (all p < 0.0001, except p = 0.002 for repetition) but deficits in delayed recall, verbal fluency and visuo-executive function were prevalent even in the normal AMTS group. CONCLUSION: The AMTS is highly specific but relatively insensitive for cognitive impairment: a quarter of those with normal AMTS had moderate/severe impairment on the MoCA with widespread deficits. The AMTS cannot therefore be used as a "rule-out" test, and more detailed cognitive assessment will be required in selected patients.

Clinical specialty training in UK undergraduate medical schools: a retrospective observational study.

OBJECTIVES: To determine if increased exposure to clinical specialties at medical school is associated with increased interest in pursuing that specialty as a career after foundation training. DESIGN: A retrospective observational study. SETTING: 31 UK medical schools were asked how much time students spend in each of the clinical specialties. We excluded two schools that were solely Graduate Entry, and two schools were excluded for insufficient information. MAIN OUTCOME MEASURES: Time spent on clinical placement from UK undergraduate medical schools, and the training destinations of graduates from each school. A general linear model was used to analyse the relationship between the number of weeks spent in a specialty at medical school and the percentage of graduates from that medical school entering each of the Core Training (CT1)/Specialty Training (ST1) specialties directly after Foundation Year 2 (FY2). RESULTS: Students spend a median of 85 weeks in clinical training. This includes a median of 28 weeks on medical firms, 15 weeks in surgical firms, and 8 weeks in general practice (GP). In general, the number of training posts available in a specialty was proportionate to the number of weeks spent in medical school, with some notable exceptions including GP. Importantly, we found that the number of weeks spent in a specialty at medical school did not predict the percentage of graduates of that school training in that specialty at CT1/ST1 level (ß coefficient=0.061, p=0.228). CONCLUSIONS: This study found that there was no correlation between the percentage of FY2 doctors appointed directly to a CT1/ST1 specialty and the length of time that they would have spent in those specialties at medical school. This suggests that curriculum adjustments focusing solely on length of time spent in a specialty in medical school would be unlikely to solve recruitment gaps in individual specialties.

How variable are the volumetric measurements from gated perfusion SPECT when a one-day stress-rest protocol is used?

BACKGROUND: Using myocardial perfusion scintigraphy (MPS), an increase in left ventricular (LV) volumes or a decrease in ejection fraction (EF) from rest to stress may be clinically important. The variation in these measures between the low-dose stress acquisition and high-dose rest acquisition in a one-day stress-rest protocol has not been established. We assessed the reproducibility of gated volumetric indices between stress and rest and the normal variation in ungated TID ratio for a one-day stress-rest 99mTc-tetrofosmin protocol. METHODS: Two thousand and one hundred and fifty eight (2158) 99mTc-tetrofosmin MPS patient studies were analyzed retrospectively. Studies were excluded for incomplete data, significant technical difficulties, or (for gated analysis but not for analysis of TID ratio) if the LV EF was > 75%. An analysis of gated data was undertaken to establish the reproducibility of ventricular volumes and EF between stress and rest scans. Ungated volume data were analyzed to determine the confidence limits of TID ratio according to ventricular volume. RESULTS: Gated data were analyzed for 621 patients without inducible hypoperfusion. Mean EF at rest was slightly higher than after stress (62.4% ± 10.3% vs 61.2% ± 10.4%, P < 0.001), and the standard deviation of the difference was 5.2% (95% CI 4.9% to 5.5%). Ungated volumes were available for 992 non-ischaemic patients. The upper 95% CI for TID ratio was 1.23. This increased from 1.20 to 1.37 between the highest and lowest deciles of rest ungated volume. CONCLUSION: Using a one-day stress-rest 99mTc-tetrofosmin protocol, a fall in LV EF between rest and stress of > 11.6% or a TID ratio of > 1.23 is likely to be clinically reliable. The upper limit of normal for TID ratio needs to be increased for patients with small LV chamber volumes.