Strengthening Primary Care Workforce Capacity in Dementia Diagnosis and Care: A Qualitative Study of Project Alzheimer's Disease-ECHO.

Primary care practitioners (PCPs) are the first point of contact for most patients with suspected dementia and have identified a need for more training and support around dementia diagnosis and care. This qualitative study examined the Alzheimer's Disease-Extension for Community Healthcare Outcomes (AD-ECHO) program. AD-ECHO was designed to strengthen PCP capacity in dementia through bimonthly virtual meetings with a team of dementia experts. We conducted 24 hr of direct observations at AD-ECHO sessions and interviewed 14 participants about their experiences participating. Using thematic analysis, we found that participants valued the supportive learning environment and resources; knowledge gained empowered them to take more action around dementia; they identified ways of disseminating knowledge gained into their practice settings, and many desired ongoing AD-ECHO engagement. However, most identified time as a barrier to participation. AD-ECHO has the potential to strengthen the primary care workforce's knowledge and confidence around dementia care.

Primary Care Pracitioner Perspectives on the Role of Primary Care in Dementia Diagnosis and Care.

Importance: Although the barriers to dementia care in primary care are well characterized, primary care practitioner (PCP) perspectives could be used to support the design of values-aligned dementia care pathways that strengthen the role of primary care. Objective: To describe PCP perspectives on their role in dementia diagnosis and care. Design, Setting, and Participation: In this qualitative study, interviews were conducted with 39 PCPs (medical doctors, nurse practitioners, and doctors of osteopathic medicine) in California between March 2020 and November 2022. Results were analyzed using thematic analysis. Main Outcomes and Measures: Overarching themes associated with PCP roles in dementia care. Results: Interviews were conducted with 39 PCPs (25 [64.1%] were female; 16 [41%] were Asian). The majority (36 PCPs [92.3%]) reported that more than half of their patients were insured via MediCal, the California Medicaid program serving low-income individuals. Six themes were identified that convey PCPs' perspectives on their role in dementia care. These themes focused on (1) their role as first point of contact and in the diagnostic workup; (2) the importance of long-term, trusting relationships with patients; (3) the value of understanding patients' life contexts; (4) their work to involve and educate families; (5) their activities around coordinating dementia care; and (6) how the care they want to provide may be limited by systems-level constraints. Conclusions and Relevance: In this qualitative study of PCP perspectives on their role in dementia care, there was alignment between PCP perspectives about the core values of primary care and their work diagnosing and providing care for people living with dementia. The study also identified a mismatch between these values and the health systems infrastructure for dementia care in their practice environment.

Factors Associated with Supportive Care Service Use Among California Alzheimer's Disease Patients and Their Caregivers.

BACKGROUND: Existing literature on factors associated with supportive care service (SCS) use is limited. A better understanding of these factors could help tailor SCS to the needs of frequent users, as well as facilitate targeted outreach to populations that underutilize available services. OBJECTIVE: To investigate the prevalence of SCS use and to identify factors associated with, and barriers to, service use. METHODS: California Alzheimer's Disease Center patients with AD (n = 220) participated in the study from 2006-2009. Patients and their caregivers completed assessments to determine SCS use. Cognitive, functional, and behavioral status of the patients were also assessed. A two-part hurdle analysis identified 1) factors associated with any service use and 2) service use frequency among users. RESULTS: Forty percent of participants reported using at least one SCS. Patients with more impaired cognition and activities of daily living and more of the following: total number of medications, comorbid medical conditions, and years of education were more likely to use any SCS (p < 0.05). Factors associated with more frequent SCS use included younger age, more years of education, older age of AD onset, female gender, and having a spouse or relative for a caregiver (p < 0.05). Caregivers frequently indicated insufficient time as a reason for not receiving enough services. CONCLUSION: Factors associated with any SCS use mostly differed from those associated with SCS frequency, suggesting different characteristics between those who initiate versus those who continue SCS use. Our findings highlight the importance of targeted education on services and identifying barriers to long-term SCS use.

Intelligent signal processing for detection system optimization.

A wavelet-neural network signal processing method has demonstrated approximately 10-fold improvement over traditional signal processing methods for the detection limit of various nitrogen and phosphorus compounds from the output of a thermionic detector attached to a gas chromatograph. A blind test was conducted to validate the lower detection limit. All 14 of the compound spikes were detected when above the estimated threshold, including all 3 within a factor of 2 above the threshold. In addition, two of six spikes were detected at levels of half the concentration of the nominal threshold. Another two of the six would have been detected correctly if we had allowed human intervention to examine the processed data. One apparent false positive in five nulls was traced to a solvent impurity, whose presence was subsequently identified by analyzing a solvent aliquot evaporated to 1% residual volume, while the other four nulls were properly classified. We view this signal processing method as broadly applicable in analytical chemistry, and we advocate that advanced signal processing methods should be applied as directly as possible to the raw detector output so that less discriminating preprocessing and postprocessing does not throw away valuable signal.

17q-linked frontotemporal dementia-amyotrophic lateral sclerosis without tau mutations with tau and alpha-synuclein inclusions.

BACKGROUND: Frontotemporal dementia (FTD) is a clinically heterogeneous condition that can be associated with clinical manifestations of an extrapyramidal disorder or motor neuron disease. A range of histologic patterns has been described in patients with FTD. The most common familial form of this condition is caused by mutations in the microtubule-associated protein tau gene (MAP tau) and is associated with neuronal or glial tau inclusions. OBJECTIVES: To determine the clinical, anatomic, and pathological features of San Francisco family A and to map the mutation responsible for disease in this family. DESIGN: A systematic clinical, neuropsychologic, neuroimaging, and chromosome segregation analysis of San Francisco family A was performed. A pathological and biochemical assessment of a family member was made. SETTING: Family study. PATIENTS: San Francisco family A, with FTD, variable extrapyramidal symptoms, and prominent motor neuron disease. Afflicted family members do not have a MAP tau coding or splice regulatory sequence mutation, and the MAP tau is genetically excluded. MAIN OUTCOME MEASURES: Comparison of clinical, neuropsychologic, neuroimaging, and linkage findings of San Francisco family A with other familial forms of FTD and amyotrophic lateral sclerosis (ALS). RESULTS: The most probable location for the mutation responsible for this condition is on chromosome arm 17q, distal to the MAP tau. All previously identified susceptibility loci for FTD and ALS are excluded. Autopsy findings from an afflicted family member show distinctive tau and alpha-synuclein inclusions. Another unique feature is that the insoluble tau protein consists predominantly of the 4R/0N isoform. CONCLUSION: The condition affecting members of San Francisco family A is clinically, pathologically, and genetically distinct from previous familial forms of FTD and ALS.

Transrectal catheter drainage of deep abdominal and pelvic abscesses using combined ultrasonography and fluoroscopy.

OBJECTIVE: To describe our experience with transrectal drainage of deep abdominal or pelvic abscesses guided by ultrasonography and fluoroscopy. DESIGN: Open study. SETTING: Teaching hospital, Sweden. SUBJECTS: Eight seriously ill patients with deep abdominal or pelvic abscesses. INTERVENTION: Ultrasonographic and fluoroscopic transrectal drainage. MAIN OUTCOME MEASURES: Clinical follow-up. RESULTS: Eight patients (2 septic, 2 with high fever, and 2 with moderate fever) were effectively and safely drained without general anaesthesia. Their condition improved considerably within hours after drainage. Three patients had recurrent abscesses as a result of the underlying disease. The drainage overcame the sepsis in two patients and allowed a later elective operation. CONCLUSIONS: Transrectal ultrasonographic and fluoroscopic drainage is an effective and safe method for treatment of deep abdominal or pelvic abscesses in seriously ill patients.

Power Doppler ultrasonography: alternative to computed tomography in abdominal trauma patients.

The aim of this study was to determine if power Doppler ultrasonography, contrast enhanced when necessary, can be used as an alternative to computed tomography in the diagnosis of trauma-related organ rupture or hematoma. Fifteen patients who had sustained abdominal trauma but who had normal results on B-mode scans were included in the study. Twenty organs (13 livers and 7 spleens) were examined with both contrast-enhanced computed tomography and power Doppler ultrasonography in a blinded fashion. Ultrasonographic contrast was used in five patients. Lack of contrast enhancement (computed tomography) or lack of color in power color Doppler ultrasonography in all or part of the organ was taken as a sign of rupture or hematoma. Five ruptures were detected with both modalities (two hepatic and three splenic). Thus, ultrasonography showed no false-positive or false-negative studies when compared to the computed tomographic results. No significant difference was found in the estimated size of the damaged area between the two types of investigation. The study indicates that power color Doppler ultrasonography may be considered an alternative when a computed tomographic scan of a trauma patient is impossible.

New sonographic imaging observations in focal pancreatitis.

The imaging findings that ultrasonographically differentiate focal acute pancreatitis (FAP) from a malignant lesion of the pancreas are described. Focal acute pancreatitis is ultrasonographically (US) characterized as a hypoechoic, homogeneous, localized, subsegmental, non-expansive and diffusely demarcated lesion located mostly in the head of the pancreas. It could not be visualized using CT. Endoscopic retrograde cholangiopancreatography (ERCP) performed in 13 of the 32 patients, showed chronic pancreatitis. Focal acute pancreatitis disappeared in 1-6 months at US follow-up. The clinical diagnoses were acute pancreatitis in 11 patients, chronic pancreatitis in 12 patients, biliary disease in 5 patients, hepatopathia in 1 patient while the diagnosis was unknown in 2 patients. No patient developed any pancreatic cancer during a median of 85 months of follow-up. In conclusion, the present data indicate that patients with FAP at US, without any focal lesion seen on either CT or ERCP, have a benign pancreatic lesion, which resolves in 1-6 months; thus, such patients probably do not need any further investigation or follow-up at all.

Colour Doppler imaging of shunts from the left portal branch in portal hypertension. Description of a typical pattern.

PURPOSE: To describe the typical colour Doppler appearance of a shunt through the parenchyma of the left lobe of the liver in portal hypertension. MATERIAL AND METHODS: Ultrasound images of 141 patients with biopsy-verified cirrhosis were reviewed. Special note was taken of the appearance of shunts from the left portal branch. RESULTS: In 28 patients, shunts from the left portal branch were detected ultrasonographically, 10 of which ran through the liver parenchyma on a course separated from the ligamentum teres. Seven of these 10 followed a tortuous course just below the surface of the liver creating a ball or corkscrew-like pattern. CONCLUSION: Shunts from the left portal branch are not uncommon and may represent the only ultrasonographically detectable pathology in these patients. Recognition of the typical pattern will facilitate their detection.

Color Doppler energy: detection of hypoperfused areas in renal transplants.

The aim of this study was to determine if an area of decreased color on color Doppler energy scans in a transplanted kidney could be related to significant pathologic conditions. Three hundred and ninety-eight scans in 150 patients were thus evaluated prospectively, and 12 such areas were found and correlated to B-mode, spectral, and color Doppler sonography as well as clinical and laboratory findings. A cause for the hypoperfused area was found in all cases; causes included two cases of focal infection, four arteriovenous fistulas, one kinking of an artery, and five perioperatively severed accessory arteries. We conclude that a color Doppler energy evaluation of perfusion differences can be used to detect pathologic lesions in a transplanted kidney.

Color Doppler energy: computer analysis for detection of volume flow variations.

The aims of this study were to (1) determine whether analysis of a color Doppler energy image can show small differences in volume flow and (2) determine the performance characteristics of color Doppler energy to aid future analyses. Flow through a silicone tube in a waterbath was insonated, and the images were analyzed by computer producing arbitrary values for the different flow volumes at different machine settings. A significant difference in the derived values was found at volume low changes of 10 ml/min. The differences are most pronounced when small amounts of color are shown in the vessel. This region of high sensitivity can be altered by changing the machine settings of filter, scale, or level. The angle of insonation must be taken into account. In conclusion, computer analysis of color Doppler energy can monitor changes in blood flow volume with a high sensitivity.

Color Doppler energy: computer analysis of color to assess angle dependency and detection of volume flow differences.

The aims of this study were to assess (1) any angle dependency of color Doppler energy and (2) if computer analysis of the color can distinguish variations in volume flow. Fluid flowing through a silicon tube in a waterbath was insonated and the color in the images analyzed by a computer. The color presentation on the screen decreases rapidly as the angle approaches 90 degrees. At angles that did not produce a saturation of the color in the tube, the computer analysis detected significant differences between different flow volumes. We have concluded that monitoring of volume flow changes by analysis of color Doppler energy is possible, but the angle of insonation must be taken into account.

Typical sonographic appearance of duodenal diverticulum.

During routine transabdominal ultrasonography of the hepatobiliary tract an occasional persistent bright linear or concave echo was detected that disrupted the normal images we routinely obtained of the pancreatic head. We began to suspect this echo to be the sonographic representation of a duodenal diverticulum. To confirm our suspicions we performed a prospective study. Over a 20 month period, 30 consecutive patients with a sonographically suspected duodenal diverticulum were followed up with either an upper gastrointestinal series, gastroscopy, or, depending on the patient's clinical symptoms, endoscopic retrograde cholangiopancreaticography. One patient was examined with simultaneous fluoroscopy and ultrasonography. The results of these examinations were then compared to the respective ultrasonograms by a qualified radiologist and sonographer. The suspected duodenal diverticulum, detected primarily with ultrasonography, was confirmed with follow-up examinations in all 30 patients. The persistent echo detected sonographically had the same anatomic position as the diverticulum seen during fluoroscopy. We concluded that duodenal diverticulum located near the pancreatic head has a rather typical sonographic appearance.

Bilateral isolated adrenal coccidioidomycosis.

A case of bilateral isolated adrenal coccidioidomycosis in a previously healthy and immunocompetent 43-year-old Caucasian male is presented. He had never travelled to a coccidioidomycosis endemic area. Subclinical adrenal dysfunction was found with elevated plasma ACTH and mineralocorticosteroid and androgen pathway abnormalities. The implement of the fungal infection on adrenal function, and the diagnosis and management of adrenal coccidioidomycosis are discussed.

Ultrasonography in gallstone ileus: a diagnostic challenge.

OBJECTIVE: To describe our experience with ultrasound diagnosis of gallstone ileus in six cases, and to assess the impact of our findings in the light of published reports. DESIGN: Open study. SETTING: Teaching hospital, Sweden. SUBJECTS: Six patients with gallstone ileus. INTERVENTION: Abdominal ultrasound examination. MAIN OUTCOME MEASURES--Correlation with plain abdominal films and with findings at laarotomy. RESULTS: In all six cases ultrasound gave a precise diagnosis of gallstone ileus, together with the exact location of the gallstone, whereas plain films usually indicated only intestinal obstruction of unknown cause. There was not mortality and only one postoperative complication, and all patients were alive and well at the time they were last seen. These results compare well with those of other reported series. CONCLUSION: The high morbidity and mortality of gallstone ileus may be reduced if ultrasonography is used in cases of undiagnosed abdominal pain, particularly in elderly patients with protracted symptoms.

Gallstone ileus demonstrated by CT.

OBJECTIVE: The appearance and evolution of gallstone ileus as seen by CT are reported. MATERIALS AND METHODS: CT examination was performed on three patients with unspecific abdominal pain. In one patient sequential investigations were performed over 7 months. RESULTS: In all cases the gallbladder was greatly distorted, contained air, and was in direct continuity with a thickened duodenal wall. The gallstone was detected in the small bowel in all cases. In one patient sequential CT examinations over several months demonstrated the evolution from uncomplicated gallstone disease to cholecystitis and finally to perforation of the gallstone into the duodenal bulb. CONCLUSION: Awareness of the CT findings in gallstone ileus may result in more rapid diagnosis and treatment, which may lead to a decrease in the rather high morbidity and mortality seen in this disease.

Acute puerperal breast abscesses: US-guided drainage.

Breast abscesses typically develop in lactating women. The recommended treatment is surgical incision and drainage with the patient under general anesthesia. Ultrasonically guided percutaneous drainage with local anesthesia was performed in 19 consecutive patients referred for treatment because of clinical signs of acute puerperal breast abscess. Eighteen of the 19 patients (95%) were successfully treated. Long-term follow-up (median, 12 months) did not show any recurrences, and the cosmetic results were excellent. Eight of the 19 patients (42%) continued nursing during and after treatment. Ten of the 19 (53%) were treated on an outpatient basis. On the basis of these results, the authors recommend ultrasonically guided percutaneous treatment for use in patients with acute puerperal breast abscesses.

Prevalence of abdominal aortic aneurysm in the offspring of patients dying from aneurysm rupture.

The prevalence of abdominal aortic aneurysm (AAA) is high in the brothers of patients with aneurysm. A genetic component in the development of AAA has, therefore, been postulated. In this study the offspring of patients who had died from AAA rupture were invited to undergo ultrasonography of the abdominal aorta. The attendance rate was 69 per cent. Thirty-nine sons of median age 60 (range 45-75) years and 23 daughters of median age 62 (range 42-80) years were examined. Abdominal aortic dilatation was found in eight men and one woman. The presence of aortic dilatation in these nine cases was not related to age, hypertension, smoking or symptoms of occlusive arterial disease. It is concluded that the sons of those who have died from ruptured AAA constitute a high-risk group for the development of this condition and should be considered for further screening.