Self-administered gerocognitive examination (SAGE) aids early detection of cognitive impairment at primary care provider visits.

Introduction: Current estimates indicate that up to 50-75% of dementia cases are undiagnosed at an early stage when treatments are most effective. Conducting robust accurate cognitive assessments can be time-consuming for providers and difficult to incorporate into a time-limited Primary Care Provider (PCP) visit. We wanted to compare PCP visits with and without using the self-administered SAGE to determine differences in identification rates of new cognitive disorders. Methods: Three hundred patients aged 65-89 without diagnosed cognitive disorders completing a non-acute office visit were enrolled (ClinicalTrials.gov identifier: NCT04063371). Two PCP offices conducted routine visits for 100 consecutive eligible patients each. One office used the SAGE in an additional 100 subjects and asked available informants about cognitive changes over the previous year. Chart reviews were conducted 60 days later. One-way analysis of variance and Fisher exact tests were used to compare the groups and outcomes. Results: When SAGE was utilized, the PCP documented the detection of new cognitive conditions/concerns six times (9% versus 1.5%) as often (p = 0.003). The detection rate was nearly 4-fold for those with cognitively impaired SAGE scores (p = 0.034). Patients having impaired SAGE score and informant concerns were 15-fold as likely to have new cognitive conditions/concerns documented (p = 0.0007). Among providers using SAGE, 86% would recommend SAGE to colleagues. Discussion: SAGE was easily incorporated into PCP visits and significantly increased identification of new cognitive conditions/concerns leading to new diagnoses, treatment, or management changes. The detection rate increased 15-fold for those with impaired SAGE scores combined with informant reports.

Self-reporting of psychoneurophysical (PNP) symptoms in adults with four chronic diseases: a protocol for a scoping review.

BACKGROUND: Patient self-reporting of health-specific information, including symptoms, allows healthcare providers to provide more timely, personalized, and patient-centered care to meet their needs. It is critical to acknowledge that symptom reporting draws from the individual's unique sociocultural background influencing how one perceives health and illness. This scoping review will explore whether racial groups with 4 chronic diseases (cardiovascular diseases, respiratory diseases, cancers, and diabetes) differ in self-reporting of psychoneurophysical (PNP) symptoms. The PNP symptoms of interest include depressive symptoms, fatigue, anxiety, pain, cognitive impairment, sleep impairment, mood impairment, irritability, and shortness of breath. METHODS: Four databases will be searched by a biomedical librarian: CINAHL Plus (EBSCOhost), Embase (Elsevier), PubMed (NLM), Web of Science: Core Collection (Clarivate Analytics), and limited to publications written in the English language. Two independent reviewers will screen the records' title, abstract, and then full text and extract the data from included articles using Covidence. A third reviewer will be used for resolving disagreements. Included articles must comprise adult patients with at least one of the specified chronic diseases who self-report at least one of the specified PNP symptoms. Studies that used clinician-administered questionnaires or obtained symptom responses from primary caregiver or patient designee will be excluded. Articles on patient-reported functionality or perceived quality of life will also be excluded from the review. Two reviewers will independently extract data (e.g., demographics, study design, racial group, chronic disease, measure/scale used for self-report) from each included article using Covidence and Microsoft Excel for data cleaning and analyses. DISCUSSION: This scoping review may potentially identify the relevant and practical implications related to clinical decision-making and health outcomes for patients experiencing the psychoneurophysical symptoms included in this study. The authors will present how the results can be utilized in clinical practice, health policy, and research planning. SYSTEMATIC REVIEW REGISTRATION: The protocol was registered on Open Science Framework (OSF) at: https://osf.io/ps7aw.

The Montreal Cognitive Assessment: Norms and Reliable Change Indices for Standard and MoCA-22 Administrations.

OBJECTIVE: The Montreal Cognitive Assessment (MoCA) is among the most frequently administered cognitive screening tests, yet demographically diverse normative data are needed for repeated administrations. METHOD: Data were obtained from 18,410 participants using the National Alzheimer's Coordinating Center Uniform Data Set. We developed regression-based norms using Tobit regression to account for ceiling effects, explored test-retest reliability of total scores and by domain stratified by age and diagnosis with Cronbach's alpha, and reported the cumulative change frequencies for individuals with serial MoCA administrations to gage expected change. RESULTS: Strong ceiling effects and negative skew were observed at the total score, domain, and item levels for the cognitively normal group, and performances became more normally distributed as the degree of cognitive impairment increased. In regression models, years of education was associated with higher MoCA scores, whereas older age, male sex, Black and American Indian or Alaska Native race, and Hispanic ethnicity were associated with lower predicted scores. Temporal stability was adequate and good at the total score level for the cognitively normal and cognitive disorders groups, respectively, but fell short of reliability standards at the domain level. CONCLUSIONS: MoCA total scores are adequately reproducible among those with cognitive diagnoses, but domain scores are unstable. Robust regression-based norms should be used to adjust for demographic performance differences, and the limited reliability, along with the ceiling effects and negative skew, should be considered when interpreting MoCA scores.

Improving Pharmacist-Led Pediatric Patient Education on Oral Chemotherapy at Home.

Oral chemotherapy (OC) has been increasingly used in pediatric patients diagnosed with cancer, which is primarily managed in the outpatient setting. Different from adults, pediatric patients face unique challenges in administering these hazardous medications at home. Because of the complexity of pediatric pharmaceutical care and the hazardous nature of chemotherapy agents, comprehensive patient education is imperative to mitigate the potential safety risks associated with OC administration at home. Pharmacists play a vital role in patient education and medication consultations. However, the lack of practice guidelines and limited resources supporting OC counseling are noted. Additional barriers include insufficient knowledge and training on OC, which can be improved by continuing education. In a regional children's hospital, a comprehensive OC education checklist was developed for pediatric patients and their caregivers to standardize consultations led by pharmacists. An infographic OC handout was also formulated to improve patient knowledge and awareness. Moreover, innovative approaches such as using telepharmacy, smartphone applications, and artificial intelligence have been increasingly integrated into patient care, which can help optimize OC consultations for children and adolescents. Further studies are warranted to enhance oral chemotherapy education specifically tailored for pediatric patients in outpatient settings.

Structure-guided Mutagenesis Reveals the Catalytic Residue that Controls the Regiospecificity of C6-Indole Prenyltransferases.

Indole is a significant structural moiety and functionalization of the C-H bond in indole-containing molecules expands their chemical space, and modifies their properties and/or activities. Indole prenyltransferases (IPTs) catalyze the direct regiospecific installation of prenyl, C5 carbon units, on indole-derived compounds. IPTs have shown relaxed substrate flexibility enabling them to be used as tools for indole functionalization. However, the mechanism by which certain IPTs target a specific carbon position is not fully understood. Herein, we use structure-guided site-directed mutagenesis, in vitro enzymatic reactions, kinetics and structural-elucidation of analogs to verify the key catalytic residues that control the regiospecificity of all characterized regiospecific C6 IPTs. Our results also demonstrate that substitution of PriB_His312 to Tyr leads to the synthesis of analogs prenylated at different positions than C6. This work contributes to understanding of how certain IPTs can access a challenging position in indole-derived compounds.

Cross-cultural considerations for teleneuropsychology with Asian patients.

OBJECTIVE: Recent teleneuropsychology (TeleNP) models provide some degree of guidance in the application of telecommunication technologies toward the practice of neuropsychology. However, there remains a paucity of peer-reviewed data on TeleNP practices with culturally diverse patients, including Asian patients. This manuscript describes the challenges related to TeleNP practices with Asian patients and offers practical recommendations to complement existing TeleNP guidelines. METHOD: Based on extant literature on multicultural applications of neuropsychology, weprovide recommendations for TeleNP services with Asian patients that pertain to specific components of a TeleNP evaluation, such as a) pre-evaluation preparation, b) determining the appropriateness of the referral, c) determining language proficiency, d) working with interpreters, e) informed consent and confidentiality issues, f) conducting a culturally sensitive clinical interview, g) behavioral observations and communication, h) test selection, and i) interpreting data and writing reports. CONCLUSIONS: Our recommendations for TeleNP services with Asian patients highlight the need for flexibility to accommodate cultural differences and commitment to the complex nature of working with patients requiring interpretation services, while also recognizing the importance of preserving the validity of neuropsychological methods. Moving forward, it is imperative that the field of neuropsychology increases the training and accessibility of neuropsychologists who are knowledgeable in providing TeleNP services to Asian patients, and promotes research on the validation of TeleNP for Asian and other ethnic minority groups.

Hair Cortisol Concentration, Perceived Stress, Mental Well-Being, and Cardiovascular Health in African American Older Adults: A Pilot Study.

(1) Background: African Americans experience high rates of psychological stress and hypertension, which increases their risk of cardiovascular disease with age. Easy-to-collect psychological and biological stress data are valuable to investigations of this association. Hair cortisol concentration (HCC), as a proxy biomarker of chronic stress exposure, provides such advantages in contrast to collection of multiple daily samples of saliva. Objective: To examine the relationships among HCC, perceived stress, mental well-being, and cardiovascular health (systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP)). (2) Methods: Cross-sectional secondary data (N = 25) were used from a mind-body intervention study in hypertensive African Americans ages 65 and older. Data included HCC, a four-item perceived stress scale, SF-36 mental components summary, and SBP/DBP. SBP + 2 (DBP)/3 was used to calculate MAP. (3) Results: The relationship between mental well-being and perceived stress (r = -0.497, p ≤ 0.01) and mental well-being and DBP (r = -0.458, p = 0.02) were significant. HCC change was not significant. In a regression model, every unit increase in well-being predicted a 0.42 decrease in DBP (ß = -0.42, 95% CI (-0.69-0.15)) and a 1.10 unit decrease in MAP (ß = -1.10, 95% CI (-1.99-0.20)). (4) Conclusions: This study contributes to the knowledge of physiologic data regarding the relationship between MAP and well-being. Findings from this study may aid in the development of interventions that address mental well-being and cardiovascular health in African American older adults with hypertension.

Small duct primary sclerosing cholangitis: A discrete variant or a bridge to large duct disease, a practical review.

The natural history, associations with inflammatory bowel disease (IBD), and long-term outcomes of large duct primary sclerosing cholangitis (ldPSC) have been well documented. Small duct primary sclerosing cholangitis (sdPSC) is a much less common and relatively more benign variant. The natural history of sdPSC has been difficult to characterize given the limited number of studies in the literature especially with regards to the subset of patients who progress to large duct involvement. It has been unclear whether sdPSC represented a subset of ldPSC, an earlier staging of ldPSC, or a completely separate and distinct entity of its own. Strong associations between sdPSC and IBD have been established with suspicion that concurrent sdPSC-IBD may be a key prognostic factor in determining which patients are at risk of progression to ldPSC. Little is known regarding the discrete circumstances that predisposes some patients with sdPSC to progress to ldPSC. It has been suspected that progression to large biliary duct involvement subjects this subset of patients to potentially developing life-threatening complications. Here the authors conducted a thorough review of the published sdPSC literature using Pubmed searches and cross-referencing to compile all accessible studies regarding cohorts of sdPSC patients in order better characterize the subset of sdPSC patients who progress to ldPSC and the associated outcomes.

Co-created health education intervention among older African American women living with hypertension.

INTRODUCTION: African Americans over the age of 60 years face disproportionate risk of developing hypertension, which can be mitigated with lifestyle changes. This study examines the acceptability and cost of a patient-centered, co-created health education intervention with older African Americans living with hypertension. METHODS: Twenty women participated in this study that included four weekly, two-hour group sessions centered on hypertension knowledge and calibration of home blood pressure monitors, stress and interpersonal relationship management, sleep and pain management, and healthy eating. The study took place in the Midwest United States. RESULTS: Descriptive statistics were used to analyze acceptability data that included attendance and a brief investigator-generated questionnaire. Twenty women were enrolled. Sixteen participants attended all four sessions, all reported they intended to continue using the intervention and felt it fit within their culture, routine, and self-care practices. The estimated cost of conducting the intervention was $227.00 (U.S. dollars) per participant. CONCLUSIONS: The co-created health education intervention was acceptable. Given the dire need for cost-effective interventions to improve the adoption of health promoting self-care management behavior, to reduce the prevalence of hypertension in African Americans, the results of this study have implications for future research and practice.

A Curious Case of Rectal Ejaculation.

Rectal-prostate fistulas are uncommon anatomical connections between the prostatic urethra and rectum that are typically iatrogenic but can also result from other underlying pathology. Here, we present a unique case of a rectal-prostate fistula causing the rectal passage of sperm. A 33-year-old male with a history of illicit drug use presented with five days of testicular pain and a substantial amount of sperm passage from his rectum with ejaculation for the past two years. Computed tomography and voiding cystourethrogram (VCUG) of the pelvis revealed evidence of a rectal-prostate fistula. He was treated with piperacillin-tazobactam, and a surgical fistula repair was performed. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior with documentation suggesting a traumatic Foley catheter placement and strong suspicion for premature balloon dilation in the prostatic urethra. Repeat VCUG revealed resolution of the fistula with mildly reduced antegrade ejaculatory volume. Cases secondary to Foley catheter placement have not been previously reported in the literature. Even though urethral catheters have been shown to be effective tools in healthcare, it is crucial for clinicians to recognize the numerous potential complications that oftentimes become an afterthought to many providers. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.

Mechanism of Gold-Silver Alloy Nanoparticle Formation by Laser Coreduction of Gold and Silver Ions in Solution.

Photochemical reduction of aqueous Ag+ and [AuCl4]- into alloy Au-Ag nanoparticles (Au-Ag NPs) with intense laser pulses is a green synthesis approach that requires no toxic chemical reducing agents or stabilizers; however size control without capping agents still remains a challenge. Hydrated electrons produced in the laser plasma can reduce both [AuCl4]- and Ag+ to form NPs, but hydroxyl radicals (OH·) in the plasma inhibit Ag NP formation by promoting the back-oxidation of Ag0 into Ag+. In this work, femtosecond laser reduction is used to synthesize Au-Ag NPs with controlled compositions by adding the OH· scavenger isopropyl alcohol (IPA) to precursor solutions containing KAuCl4 and AgClO4. With sufficient IPA concentration, varying the precursor ratio enabled control over the Au-Ag NP composition and produced alloy NPs with average sizes less than 10 nm and homogeneous molar compositions of Au and Ag. By investigating the kinetics of Ag+ and [AuCl4]- coreduction, we find that the reduction of [AuCl4]- into Au-Ag NPs occurs before most of the Ag+ is incorporated, giving us insight into the mechanism of Au-Ag NP formation.

A Comprehensive Approach to Assessment of Testamentary Capacity.

The growing aging population raises important implications for legal and clinical systems, including testamentary capacity (TC) assessment. Yet, there are limited comprehensive and standardized assessment measures for TC readily available for clinical use. A review of current assessment methods and standardized approaches for TC assessment is provided. Although several guidelines regarding TC assessment have been proposed in prior literature, existing standardized approaches do not appear to meet full criteria for TC. A comprehensive approach to assessment of testamentary capacity is proposed.

Mindfulness in Motion and Dietary Approaches to Stop Hypertension (DASH) in Hypertensive African Americans.

OBJECTIVES: Hypertension increases the risk of developing Alzheimer's disease or related dementias. This pilot study's purpose was to examine the feasibility and acceptability of a novel intervention, Mindfulness in Motion (MIM) and Dietary Approaches to Stop Hypertension DASH (MIM DASH), to improve diet, mindfulness, stress, and systolic blood pressure (BP) in older African Americans with mild cognitive impairment (MCI) and hypertension. DESIGN: Cluster randomized controlled trial. SETTING: Intergenerational community center in a large metropolitan area. PARTICIPANTS: African Americans with MCI and hypertension. Participants were divided into six groups randomized 1:1:1 to the MIM DASH group, attention only (non-hypertensive education) group, or true control group. The MIM DASH and attention only interventions were delivered in 8-weekly 2 hour group sessions. MIM included mindful movements from chair/standing, breathing exercises, and guided meditation. The DASH component used a critical thinking approach of problem solving, goal setting, reflection, and self-efficacy. The true control group received a DASH pamphlet at the end. MEASUREMENTS: Feasibility was tracked through enrollment and attendance records; acceptability was assessed through interviews. Blood pressure was measured using the Omron HEM-907XL Monitor. Dietary intake was measured by DASH-Q. Mindfulness was measured by the Cognitive and Affective Mindfulness Scale. Stress was measured by the Perceived Stress Scale. MCI was determined using the Self-Administered Gerocognitive Examination. Data were collected at baseline and 3-months. RESULTS: Median session attendance was six for the MIM DASH group and six for the attention only group. There were no changes in diet, mindfulness, or stress. There was a clinically significant reduction in systolic BP in the MIM DASH group (-7.2 mmHg) relative to the attention only group (-.7), and no change between the MIM DASH and true control groups. CONCLUSION: Results indicate that the MIM DASH intervention was feasible and culturally acceptable in African Americans with hypertension and MCI.

Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery: The Neurobics Randomized Clinical Trial.

Importance: Postoperative delirium in older adults is a common and costly complication after surgery. Cognitive reserve affects the risk of postoperative delirium, and thus preoperative augmentation of reserve as a preventive technique is of vital interest. Objective: To determine whether cognitive prehabilitation reduces the incidence of postoperative delirium among older adults. Design, Setting, and Participants: This was a prospective, single-blinded randomized clinical trial conducted from March 2015 to August 2019 at the Ohio State University Wexner Medical Center in Columbus. Patients 60 years and older undergoing major, noncardiac, nonneurological surgery under general anesthesia, with an expected hospital stay of at least 72 hours, were eligible for trial inclusion. Patients were excluded for preoperative cognitive dysfunction and active depression. Interventions: Participation in electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions. Main Outcomes and Measures: The primary outcome was incidence of delirium between postoperative day 0 to day 7 or discharge, as measured by a brief Confusion Assessment Method, Memorial Delirium Assessment Scale, or a structured medical record review. Secondary outcomes compared delirium characteristics between patients in the intervention and control groups. Results: Of the 699 patients approached for trial participation, 322 completed consent and 268 were randomized. Subsequently, 17 patients were excluded, leaving 251 patients in the primary outcome analysis. A total of 125 patients in the intervention group and 126 control patients were included in the final analysis (median [interquartile range] age, 67 [63-71] years; 163 women [64.9%]). Ninety-seven percent of the patients in the intervention group completed some brain exercise (median, 4.6 [interquartile range, 1.31-7.4] hours). The delirium rate among control participants was 23.0% (29 of 126). With intention-to-treat analysis, the delirium rate in the intervention group was 14.4% (18 of 125; P = .08). Post hoc analysis removed 4 patients who did not attempt any cognitive exercise from the intervention group, yielding a delirium rate of 13.2% (16 of 121; P = .04). Secondary analyses among patients with delirium showed no differences in postoperative delirium onset day or duration or total delirium-positive days across study groups. Conclusions and Relevance: The intervention lowered delirium risk in patients who were at least minimally compliant. The ideal activities, timing, and effective dosage for cognitive exercise-based interventions to decrease postoperative delirium risk and burden need further study. Trial Registration: ClinicalTrials.gov Identifier: NCT02230605.

Life-Threatening Intraventricular Rupture of Brain Abscess in a Patient With Undiagnosed Hereditary Hemorrhagic Telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic condition associated with mucocutaneous and visceral arteriovenous malformations (AVMs), including pulmonary AVMs, which predispose patients to systemic paradoxical emboli that can lead to brain abscesses. Intraventricular rupture of brain abscess (IVROBA) is a feared complication with a high mortality rate. Here, we present a case with brain abscesses complicated by IVROBA and ventriculitis as the initial presentation of HHT in an undiagnosed patient. We also discuss the diagnostic and therapeutic approach that resulted in this patient's clinical improvement.

Contribution of executive functioning to instrumental activities of daily living in older adults.

The Texas Functional Living Scale (TFLS) is a performance-based measure of instrumental activities of daily living (IADLs). Executive dysfunction has been linked to impairment on other IADL measures but has not been thoroughly investigated with the TFLS. This study examined the contribution of executive functioning to IADLs on the TFLS among 228 older adults (M age =76.0 +/- 6.5 years; 59% females) who completed the TFLS as part of comprehensive assessment at an outpatient neuropsychology clinic. Executive functioning measures included the Trail Making Test (TMT) Part B, the Controlled Oral Word Association Test, and the Wechsler Abbreviated Scale of Intelligence-II (WASI-II) Matrix Reasoning and Similarities subtests. Results from a hierarchical regression model revealed that only TMT Part B (ß = -.23, p = .023) and WASI-II Similarities (ß = .32, p = .002) scores significantly predicted TFLS Total scores after controlling for the contributions of demographics (i.e., age, education, and gender), and intellectual functioning and capabilities in other neurocognitive domains (i.e., WASI-II Vocabulary and Block Design subtests, TMT Part A, and Repeatable Battery for the Assessment of Neuropsychological Status Coding subtest, and the Immediate Memory, Delayed Memory, and Visuospatial/Construction Indices).

Factor Analysis of the Texas Functional Living Scale in an Outpatient Clinical Sample.

OBJECTIVE: Prior factor analysis of the Texas Functional Living Scale (TFLS), a performance-based measure of functional abilities, in a military veteran sample supported four factors discrepant from the published subscales. This study analyzed TFLS factor structure in a non-veteran clinical sample. METHOD: Two hundred seventy adult outpatients completed the TFLS during neuropsychological evaluation. Principal axis factor analysis with oblique promax rotation was conducted with age and education effects partialed out. RESULTS: Parallel analysis indicated five factors for extraction that accounted for a combined 48% of the variance. The first factor independently explained 26% of the total variance. Inspection of factor loadings suggested the following factor interpretations: complex calculations/time, complex visual search, praxis, memory, and basic calculations/math concepts. Five items did not significantly load onto any of the factors. CONCLUSIONS: Current results did not entirely correspond to the published subscales or prior results in a veteran sample. Further clarification of the TFLS factor structure is warranted.

Vascularized Pedicled Proximal Phalanx Flap for Spare Part for Reconstruction of Metacarpal Avulsion Injury.

Traumatic injuries to the hand with significant loss of bone or soft tissue can be quite difficult to reconstruct and often require an innovative and flexible surgical plan for reconstruction. We present a case of a young manual laborer with a significant crush avulsion injury involving his third and fourth metacarpals. We were able to preserve his fourth metacarpophalangeal joint by utilizing a pedicled vascularized proximal phalanx flap from the nonsalvageable third digit to reconstruct and provide osseous stability to the fourth metacarpal. The patient had excellent functional and aesthetic outcomes with full return to work at his farm by less than 12 months postoperatively.

The Use of Problem-Solving Therapy for Primary Care to Enhance Complex Decision-Making in Healthy Community-Dwelling Older Adults.

Some older adults who are cognitively healthy have been found to make poor decisions. The vulnerability of such older adults has been postulated to be the result of disproportionate aging of the frontal lobes that contributes to a decline in executive functioning abilities among some older adults. The purpose of this study was to investigate whether decision-making performance in older adults can be enhanced by a psychoeducational intervention. Twenty cognitively and emotionally intact persons aged 65 years and older were recruited and randomized into two conditions: psychoeducational condition [Problem-Solving Therapy for Primary Care (PST-PC)] and no-treatment Control group. Participants in the psychoeducational condition each received four 45-min sessions of PST-PC across a 2-week period. The Iowa Gambling Task (IGT) was administered as the outcome measure to the treatment group, while participants in the Control group completed the IGT without intervention. A significant interaction effect was observed between group status and the trajectory of score differences across trials on the IGT. Particularly, as the task progressed to the last 20% of trials, participants in the PST-PC group significantly outperformed participants in the Control group in terms of making more advantageous decisions. These findings demonstrated that a four-session problem-solving therapy can reinforce aspects of executive functioning (that may have declined as a part of healthy aging), thereby enhancing complex decision-making in healthy older adults.