The impact of race and other demographic factors on the false positive rates of five embedded Performance Validity Tests (PVTs) in a Veteran sample.

INTRODUCTION: It is common to use normative adjustments based on race to maintain accuracy when interpreting cognitive test results during neuropsychological assessment. However, embedded performance validity tests (PVTs) do not adjust for these racial differences and may result in elevated rates of false positives in African American/Black (AA) samples compared to European American/White (EA) samples. METHODS: Veterans without Major Neurocognitive Disorder completed an outpatient neuropsychological assessment and were deemed to be performing in a valid manner (e.g., passing both the Test of Memory Malingering Trial 1 (TOMM1) and the Medical Symptom Validity Test (MSVT), (n = 531, EA = 473, AA = 58). Five embedded PVTs were administered to all patients: WAIS-III/IV Processing Speed Index (PSI), Brief Visuospatial Memory Test-Revised: Discrimination Index (BVMT-R), TMT-A (secs), California Verbal Learning Test-II (CVLT-II) Forced Choice, and WAIS-III/IV Digit Span Scaled Score. Individual PVT false positive rates, as well as the rate of failing two or more embedded PVTs, were calculated. RESULTS: Failure rates of two embedded PVTs (PSI, TMT-A), and the total number of PVTs failed, were higher in the AA sample. The PSI and TMT-A remained significantly impacted by race after accounting for age, education, sex, and presence of Mild Neurocognitive Disorder. There were PVT failure rates greater than 10% (and considered false positives) in both groups (AA: PSI, TMT-A, and BVMT-R, 12-24%; EA: BVMT-R, 17%). Failing 2 or more PVTs (AA = 9%, EA = 4%) was impacted by education and Mild Neurocognitive Disorder but not by race. CONCLUSIONS: Individual (timed) PVTs showed higher false positive rates in the AA sample even after accounting for demographic factors and diagnosis of Mild Neurocognitive Disorder. Requiring failure on 2 or more embedded PVTs reduced false positive rates to acceptable levels across both groups (10% or less) and was not significantly influenced by race.

Demographic differences in performance validity test failure.

OBJECTIVE: The present study investigated demographic differences in performance validity test (PVT) failure in a Veteran sample. METHOD: Data were extracted from clinical neuropsychological evaluations. Only veterans who identified as men, as either European American/White (EA) or African American/Black (AA) were included (n = 1261). We investigated whether performance on two frequently used PVTs, the Test of Memory Malingering (TOMM), and the Medical Symptom Validity Test (MSVT), differed by age, education, and race using separate logistic regressions. RESULTS: Veterans with younger age, less education, and Veterans Affairs (VA) service-connected disability were significantly more likely to fail both PVTs. Race was not a significant predictor of MSVT failure, but AA patients were significantly more likely than EA patients to fail the TOMM. For all significant demographic predictors in the models, effects were small. In a subsample of patients who were given both PVTs (n = 461), the effects of race on performance remained. CONCLUSIONS: Performance on the TOMM and MSVT differed by age and level of education. Performance on the TOMM differed between EA and AA patients, whereas performance on the MSVT did not. These results suggest that demographic factors may play a small but measurable role in performance on specific PVTs.

Self-reported disability-seeking predicts PVT failure in veterans undergoing clinical neuropsychological evaluation.

Objective: This study examined disability-related factors as predictors of PVT performance in Veterans who underwent neuropsychological evaluation for clinical purposes, not for determination of disability benefits. Method: Participants were 1,438 Veterans who were seen for clinical evaluation in a VA Medical Center's Neuropsychology Clinic. All were administered the TOMM, MSVT, or both. Predictors of PVT performance included (1) whether Veterans were receiving VA disability benefits ("service connection") for psychiatric or neurological conditions at the time of evaluation, and (2) whether Veterans reported on clinical interview that they were in the process of applying for disability benefits. Data were analyzed using binary logistic regression, with PVT performance as the dependent variable in separate analyses for the TOMM and MSVT. Results: Veterans who were already receiving VA disability benefits for psychiatric or neurological conditions were significantly more likely to fail both the TOMM and the MSVT, compared to Veterans who were not receiving benefits for such conditions. Independently of receiving such benefits, Veterans who reported that they were applying for disability benefits were significantly more likely to fail the TOMM and MSVT than were Veterans who denied applying for benefits at the time of evaluation. Conclusions: These findings demonstrate that simply being in the process of applying for disability benefits increases the likelihood of noncredible performance. The presence of external incentives can predict the validity of neuropsychological performance even in clinical, non-forensic settings.

The minimal effect of depression on cognitive functioning when accounting for TOMM performance in a sample of U.S. veterans.

While many studies have demonstrated a relationship between depression and cognitive deficits, most have neglected to include measurements of performance validity. This study examined the relationship between depression and cognition after accounting for noncredible performance. Participants were veterans referred for outpatient clinical evaluation. The first set of regression analyses (N = 187) included age, sex, and education in Model 1, Beck Depression Inventory-2 (BDI-2) added in Model 2, and pass/failure of Test of Memory Malingering (TOMM) added in Model 3 as predictors of 12 neuropsychological test indices. The second set of analyses (N = 559) mirrored the first but with Major Depressive Disorder (MDD) diagnosis in Models 2 and 3. In the first analyses, after including TOMM in the model, only the relationship between BDI-2 and verbal fluency remained significant, but this did not survive a Bonferroni correction. In the second analyses, after including TOMM and Bonferroni correction, MDD diagnosis was a significant predictor only for CVLT-II Short Delay Free Recall. Therefore, the relationship between depression and cognition may not be driven by frank cognitive impairment, but rather by psychological mechanisms, which has implications for addressing depressed individuals' concerns about their cognitive functioning and suggest the value of providing psychoeducation and reassurance.

Comparison of conventional and actuarial neuropsychological criteria for mild cognitive impairment in a clinical setting.

INTRODUCTION: Evidence-based practice in neuropsychology involves the use of validated tests, cutoff scores, and interpretive algorithms to identify clinically significant cognitive deficits. Recently, actuarial neuropsychological criteria (ANP) for identifying mild cognitive impairment were developed, demonstrating improved criterion validity and temporal stability compared to conventional criteria (CNP). However, benefits of the ANP criteria have not been investigated in non-research, clinical settings with varied etiologies, severities, and comorbidities. This study compared the utility of CNP and ANP criteria using data from a memory disorders clinic. METHOD: Data from 500 non-demented older adults evaluated in a Veterans Affairs Medical Center memory disorders clinic were retrospectively analyzed. We applied CNP and ANP criteria to the Repeatable Battery for the Assessment of Neuropsychological Status, compared outcomes to consensus clinical diagnoses, and conducted cluster analyses of scores from each group. RESULTS: The majority (72%) of patients met both the CNP and ANP criteria and both approaches were susceptible to confounding factors such as invalid test data and mood disturbance. However, the CNP approach mislabeled impairment in more patients with non-cognitive disorders and intact cognition. Comparatively, the ANP approach misdiagnosed patients with depression at a third of the rate and those with no diagnosis at nearly half the rate of CNP. Cluster analyses revealed groups with: 1) minimal impairment, 2) amnestic impairment, and 3) multi-domain impairment. The ANP approach yielded subgroups with more distinct neuropsychological profiles. CONCLUSIONS: We replicated previous findings that the CNP approach is over-inclusive, particularly for those determined to have no cognitive disorder by a consensus team. The ANP approach yielded fewer false positives and better diagnostic specificity than the CNP. Despite clear benefits of the ANP vs. CNP, there was substantial overlap in their performance in this heterogeneous sample. These findings highlight the critical role of clinical interpretation when wielding these empirically-derived tools.

Rivastigmine Transdermal Patch Treatment for Moderate to Severe Cognitive Impairment in Veterans with Traumatic Brain Injury (RiVET Study): A Randomized Clinical Trial.

Cognitive impairment is common in veterans with histories of traumatic brain injury (TBI). Cholinergic deficits have been hypothesized as contributors to this impairment. We report the effects of cholinesterase inhibitor rivastigmine transdermal patch treatment in veterans with TBI and post-traumatic memory impairment. Our objective was to evaluate the efficacy and safety of a 9.5 mg/24 h (10 cm2) rivastigmine patch in veterans of military conflicts with persistent moderate to severe memory impairment at least 12 weeks after TBI. This randomized, outpatient, double-blind, placebo-controlled 12-week trial with an exploratory double-blind phase of an additional 14 weeks was conducted at 5 VA Medical Centers, among veterans with closed, non-penetrating TBI who met or exceeded modified American Congress of Rehabilitation Medicine criteria for mild TBI with verbal memory deficits, as assessed by the Hopkins Verbal Learning Test, Revised (HVLT-R). Patients were randomized 1:1 to rivastigmine or matching placebo patches after a 1-week single-blind, placebo run-in phase. At randomization, patients received 4.6 mg/24 h rivastigmine patches or matching placebo increased to a 9.5 mg/24 h patch after 4 weeks. The primary efficacy outcome measure was the proportion of participants who had at least a five-word improvement on the HVLT-R Total Recall Index (Trials 1-3). A total of 3671 participants were pre-screened, of whom 257 (7.0%) were screened; 96 (37%) randomized, and 94 included in study analyses. Responder rates were 40.8% (20 of 49) and 51.1% (23 of 45) in the rivastigmine and placebo groups, respectively (p = 0.41). A mixed-effect model including treatment, time, and treatment-by-time interaction indicated no significant difference in treatment effect over time between the groups (p = 0.24). Overall, there were no significant differences in changes for all secondary outcomes between the rivastigmine and placebo groups. The most commonly observed adverse events were application site reactions. This trial provides the largest sample to date of veterans with TBI and post-traumatic memory deficits enrolled in a pharmacological trial. Trial Registration: clinicaltrials.gov Identifier: NCT01670526.

The Drosophila E78 nuclear receptor regulates dietary triglyceride uptake and systemic lipid levels.

BACKGROUND: Lipid levels are maintained by balancing lipid uptake, synthesis, and mobilization. Although many studies have focused on the control of lipid synthesis and mobilization, less is known about the regulation of lipid digestion and uptake. RESULTS: Here we show that the Drosophila E78A nuclear receptor plays a central role in intestinal lipid homeostasis through regulation of the CG17192 digestive lipase. E78A mutant adults fail to maintain proper systemic lipid levels following eclosion, with this effect largely restricted to the intestine. Transcriptional profiling by RNA-seq revealed a candidate gene for mediating this effect, encoding the predicted adult intestinal lipase CG17192. Intestine-specific disruption of CG17192 results in reduced lipid levels similar to that seen in E78A mutants. In addition, dietary supplementation with free fatty acids, or intestine-specific expression of either E78A or CG17192, is sufficient to restore lipid levels in E78A mutant adults. CONCLUSION: These studies support the model that E78A is a central regulator of adult lipid homeostasis through its effects on CG17192 expression and lipid digestion. This work also provides new insights into the control of intestinal lipid uptake and demonstrate that nuclear receptors can play an important role in these pathways.

Drosophila estrogen-related receptor directs a transcriptional switch that supports adult glycolysis and lipogenesis.

Metabolism and development must be closely coupled to meet the changing physiological needs of each stage in the life cycle. The molecular mechanisms that link these pathways, however, remain poorly understood. Here we show that the Drosophila estrogen-related receptor (dERR) directs a transcriptional switch in mid-pupae that promotes glucose oxidation and lipogenesis in young adults. dERR mutant adults are viable but display reduced locomotor activity, susceptibility to starvation, elevated glucose, and an almost complete lack of stored triglycerides. Molecular profiling by RNA-seq, ChIP-seq, and metabolomics revealed that glycolytic and pentose phosphate pathway genes are induced by dERR, and their reduced expression in mutants is accompanied by elevated glycolytic intermediates, reduced TCA cycle intermediates, and reduced levels of long chain fatty acids. Unexpectedly, we found that the central pathways of energy metabolism, including glycolysis, the tricarboxylic acid cycle, and electron transport chain, are coordinately induced at the transcriptional level in mid-pupae and maintained into adulthood, and this response is partially dependent on dERR, leading to the metabolic defects observed in mutants. Our data support the model that dERR contributes to a transcriptional switch during pupal development that establishes the metabolic state of the adult fly.

Five-factor structure of the RBANS is supported in an Alzheimer's disease sample: Implications for validation of neuropsychological assessment instruments.

Development of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was theoretically driven, with the goal of providing an assessment of abilities across five cognitive domains. Since its development, numerous factor analytic studies have failed to provide empirical support for the proposed five-factor structure and, furthermore, have lacked consensus on the internal structure of this instrument. A key limitation of these prior studies is the use of normal or mixed clinical samples, a practice that can obscure distinctions that may be evident in specific homogeneous clinical samples. The current study examined the factor structure of the RBANS in a sample of 107 male Veterans diagnosed with probable Alzheimer's disease (AD). Confirmatory factor analysis of a model reflecting the five Index Scores (Immediate Memory, Visuospatial/Constructional, Language, Attention, and Delayed Memory) found that the proposed five-factor structure fit the data well. These findings suggest that the RBANS does measure five distinct constructs and use of Index Scores is appropriate. Furthermore, the current findings highlight the importance of testing construct validity of neuropsychological assessment instruments in specific homogeneous samples.

Electrodiagnostic consultations in Zambia: Referral characteristics and neuromuscular disorders.

INTRODUCTION: Research on neuromuscular disorders in sub-Saharan Africa is scarce. We aimed to delineate referral characteristics and the neuromuscular disorders observed among electrodiagnostic (EDX) consultations in a tertiary care setting in Zambia. METHODS: EDX records were reviewed for all specialist-performed studies after the establishment of the laboratory. The frequency of demographic, medical characteristics, and final EDX impressions are presented. RESULTS: Among 108 referrals, 52% were male, 84% were adults (mean age 44 years). Referrals were predominantly outpatients (85%) and sent by neurologists (68%). HIV infection was common (12%). Diabetes was rare (3%). Overall, 77% of studies were abnormal. Polyneuropathy was the most common abnormal EDX finding, followed by motor neuron disease. DISCUSSION: A diverse range of neuromuscular diseases was evaluated among EDX referrals in Zambia. Though labor and expertise intensive, access to EDX consultation can enhance clinical care and facilitate research and surveillance of neuromuscular disorders in the region.

The influence of traumatic brain injury on treatment outcomes of Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) in veterans.

BACKGROUND: The co-occurrence of posttraumatic stress disorder (PTSD), substance use disorders (SUD), and traumatic brain injury (TBI) in veterans of Operations Enduring/Iraqi Freedom and New Dawn has received much attention in the literature. Although hypotheses have been presented and disseminated that TBI history will negatively influence treatment response, little data exist to support these claims. The present study investigates the influence of TBI history on response to COPE (Concurrent Treatment of PTSD and SUD Using Prolonged Exposure), a 12-session, integrated psychotherapy designed to address co-occurring PTSD and SUD. METHOD: Participants were 51 veterans with current PTSD and SUD enrolled in a clinical trial examining COPE. Assessments of PTSD symptoms, substance use, and depression were collected at baseline and each treatment session. A TBI measure was used to dichotomize veterans into groups with and without a history of TBI (ns=30 and 21, respectively). RESULTS: Participants with and without TBI history demonstrated significant improvements in PTSD and depression symptoms during the course of treatment. However, participants with TBI history experienced less improvement relative to participants without TBI history. CONCLUSIONS: The present findings suggest that, although patients with a TBI history respond to treatment, their response to treatment was less so than that observed in patients without a TBI history. As such, identification, symptom monitoring, and treatment practices may require alteration and further special consideration in individuals with PTSD, SUD and TBI.

An Intervention to Decrease the Occurrence of Invalid Data on Neuropsychological Evaluation.

OBJECTIVE: This study tested whether patients who were given a handout based on deterrence theory, immediately prior to evaluation, would provide invalid data less frequently than patients who were simply given an informational handout. METHOD: All outpatients seen for clinical evaluation in a VA Neuropsychology Clinic were randomly given one of the two handouts immediately prior to evaluation. The "Intervention" handout emphasized the importance of trying one's hardest, explicitly listed consequences of valid and invalid responding and asked patients to sign and initial it. The "Control" handout provided general information about neuropsychological evaluation. Examiners were blinded to condition. Patients were excluded from analyses if they were diagnosed with major neurocognitive disorder or could not read the handout. Medical Symptom Validity Test (MSVT) was used to determine performance validity. RESULTS: Groups did not differ on age, education, or litigation status. For the entire sample (N = 251), there was no effect of handout on passing versus failing MSVT. However, among patients who were seeking disability benefits at the time of evaluation (n = 70), the Intervention handout was associated with lower frequency of failing MSVT than the Control handout. CONCLUSIONS: This brief, theory-based, cost-free intervention was associated with lower frequency of invalid data among patients seeking disability benefits at the time of clinical evaluation. We suggest methodological modifications that might produce a more potent intervention that could be effective with additional subsets of patients.

A comparison of four embedded validity indices for the RBANS in a memory disorders clinic.

This examination of four embedded validity indices for the Repeated Battery for the Assessment of Neuropsychological Status (RBANS) explores the potential utility of integrating cognitive and self-reported depressive measures. Examined indices include the proposed RBANS Performance Validity Index (RBANS PVI) and the Charleston Revised Index of Effort for the RBANS (CRIER). The CRIER represented the novel integration of cognitive test performance and depression self-report information. The sample included 234 patients without dementia who could be identified as having demonstrated either valid or invalid responding, based on standardized criteria. Sensitivity and specificity for invalid responding varied widely, with the CRIER emerging as the best all-around index (sensitivity = 0.84, specificity = 0.90, AUC = 0.94). Findings support the use of embedded response validity indices, and suggest that the integration of cognitive and self-report depression data may optimize detection of invalid responding among older Veterans.

Psychological characteristics of individuals who put forth inadequate cognitive effort in a secondary gain context.

The current study sought to characterize the psychological architecture of individuals who put forth inadequate effort. The Minnesota Multiphasic Personality Inventory, 2nd Edition-Restructured Form was used to identify dimensions of psychological functioning in a mixed outpatient sample of U.S. Veterans referred for neuropsychological evaluation as part of their clinical care. After accounting for external financial incentive and symptom overreporting, results showed that the inadequate effort group (n = 23, mean age = 42.48) scored higher than the adequate effort group (n = 29, mean age = 44.31) on neurologic complaints (NUC) and lower on behavioral/externalizing dysfunction (BXD), antisocial behaviors (RC4), and disconstraint (DISC-r). Lower scores on BXD, RC4, and DISC-r could indicate higher behavioral constraint-a psychological characteristic that has been linked to the pursuit of high-value future rewards. Alternatively, lower scores on these scales could have reflected a self-presentation strategy aimed at minimizing externalizing and RC4 in order to appear more psychological healthy. Implications of each of these interpretations are discussed.

[Formula: see text]inadequate effort on neuropsychological evaluation is associated with increased healthcare utilization.

Patients who exert inadequate effort on neuropsychological examination might not receive accurate diagnoses and recommendations, and might not cooperate fully with other aspects of healthcare. This study examined whether inadequate effort is associated with increased healthcare utilization. Of 355 patients seen for routine, clinical neuropsychological examination at a VA Medical Center, 283 (79.7%) showed adequate effort and 72 (20.3%) showed inadequate effort, as determined at time of evaluation using the Word Memory Test and/or Test of Memory Malingering. Utilization data included number of Emergency Department (ED) visits and inpatient hospitalizations in the year following evaluation. Patients who had shown inadequate effort on examination had more Emergency Department visits, more inpatient hospitalizations, and more days of inpatient hospitalization in the year after evaluation, compared to patients who had exerted adequate effort. This finding was not attributable to group differences in age or medical/psychiatric comorbidities. Thus, patients who exerted inadequate effort showed greater healthcare utilization in the year following evaluation. Such patients might use more resources since diagnostic evaluations are inconclusive. Inadequate effort on examination might also serve as a "marker" for more general failure to cooperate fully in one's healthcare, possibly resulting in greater utilization.

CE hospital service utilization is reduced following neuropsychological evaluation in a sample of U.S. veterans.

The aim of this study was to evaluate the objective value of neuropsychological evaluation (NPE) through reduction in Emergency Room (ER) visits and hospitalizations. Retrospective analysis examined trends in ER visits and hospitalizations in 440 U.S. veterans who completed NPE between the years of 2003 and 2010. Within-subjects comparisons showed significant decreases in incidence of hospitalization and length of hospitalization in the year after evaluation compared to the year prior. Mean number of hospitalizations declined from 0.31 (SD = 0.64) pre-NPE to 0.22 (SD = 0.59) post-NPE; there were a total of 41 fewer hospitalizations in the year following NPE. Mean length of hospitalization decreased from 1.9 days (SD = 5.6) pre-NPE to 1.06 days (SD = 3.9) post-NPE; there were a total of 368 fewer days of hospitalization post-NPE. This reduction was not attributable to age or time. Incidence of ER visits also decreased from pre-NPE (M = 0.74, SD = 1.3) to post-evaluation (M = 0.69, SD = 1.3), though this was not significant. These findings provide preliminary evidence of the clinical and potential economic value of neuropsychological services within a medical setting. Follow-up studies should examine individual and exam-specific factors that may contribute to reduced utilization.

Performance on Standard Indexes of Effort Among Patients with Dementia.

Assessment of response validity is an integral part of neuropsychological practice. Although many studies have demonstrated the efficacy of stand alone and embedded effort measures in a variety of medical and compensation-seeking contexts, much less is known about the robustness of these measures in elderly populations, particularly in patients with dementia. Although older adults may be viewed as less likely to intentionally feign symptoms for an external gain, there are a variety of other factors that could result in suboptimal effort, including fatigue, lack of interest or cooperation in the testing process, or failure to fully appreciate the implications of the assessment on treatment care and outcome. The current study examined the clinical utility of several stand alone and embedded effort measures including the Repeatable Battery for the Assessment of Neuropsychological Status Effort Index, Trail-Making Test Ratio, Rey 15-Item Test, and the Test of Memory Malingering in a sample of patients with dementia. Results found that the majority of effort indexes demonstrated unacceptably high false-positive error rates with specificity levels as high as 83%. These findings demonstrate the need for caution in interpreting effort measure performance in dementia samples due to the fact that despite their best effort, many patients with dementia fail effort measures and are at risk for being misclassified.

Attentional functioning in patients with posttraumatic stress disorder: a preliminary study.

OBJECTIVE: To compare patients with posttraumatic stress disorder (PTSD) to patients without psychiatric or cognitive disorders on neuropsychological measures of attention. METHODS: The sample included 19 patients with PTSD and 22 participants with no cognitive or psychiatric diagnosis. All had been referred for clinical neuropsychological evaluation at a VA Medical Center. None were diagnosed with dementia, delirium, or current substance dependence except nicotine or caffeine, and none had a history of stroke or of traumatic brain injury with loss of consciousness. Patients were excluded if they failed to exert adequate effort on testing. RESULTS: PTSD patients performed significantly more poorly than patients without psychiatric diagnoses on Digit Span. CONCLUSION: PTSD patients were impaired relative to participants without psychiatric diagnoses on a measure of focused attention. Several factors, including the small sample size, suggest that the results should be considered preliminary.

A pilot trial of neuropsychological evaluations conducted via telemedicine in the Veterans Health Administration.

INTRODUCTION: Many veterans live in rural areas distant from Veterans Affairs Medical Centers (VAMCs) and receive primary medical care from community-based outpatient clinics (CBOCs). These veterans often must travel great distances to the nearest VAMC for neuropsychological evaluations, resulting in poor access to care, travel reimbursement costs, fee-basis evaluations of uncontrolled quality, and driving safety concerns. Return trips for feedback compound complications. Accordingly, we initiated a pilot trial of neuropsychological evaluation and feedback via telemedicine (i.e., clinical videoconferencing). SUBJECTS AND METHODS: Participants were veterans referred for neuropsychological evaluation from a rural CBOC 115 miles from the regional VAMC. All veterans were given the choice to undergo evaluation at the CBOC via telemedicine or in-person at the VAMC. Telemedicine equipment allowed presentation of digitized material with simultaneous patient observation. Testing materials were organized in numbered folders and given to veterans by CBOC clerks immediately prior to evaluation. Clerks returned completed materials via facsimile. RESULTS: Fifteen veterans from the rural CBOC were seen for neuropsychological evaluation. Eight chose telemedicine evaluation. Groups based on evaluation modality appeared similar on demographics, referral basis, resulting neuropsychiatric diagnoses, and follow-through on recommendations. No significant technical or clinical difficulties were encountered, and veterans reported satisfaction with telemedicine. All veterans requested feedback via telemedicine. CONCLUSIONS: Neuropsychological evaluation via telemedicine is feasible and appears comparable to in-person evaluation. Experiences are encouraging and consistent with the broader literature on the acceptance of and satisfaction with clinical videoconferencing. Future studies will assess possible psychometric issues in clinical populations.

Losing sight under pressure.

A non-communicative patient with vascular dementia who was admitted to hospital with non-specific symptoms. Ophthalmic emergencies are rare, however they should be considered as part of a systemic work-up in unexplained non-specific presentations, particularly in patients who are not able to communicate as in the case we present here.