COMPUTED TOMOGRAPHY PERFUSION IN ACUTE STROKE ASSESSMENT.

BACKGROUND: Traditionally, non-contrast computed tomography (CT) alone was used in the initial assessment of acute ischaemic stroke patients mainly to exclude haemorrhage or alternative pathology. SUMMARY: Late-window (beyond 6 hours) and recent large-volume endovascular mechanical thrombectomy (MT) trials integrated CT Perfusion (CTP) imaging to guide MT and/or intravenous thrombolysis (IVT) decision-making in stroke patients. KEY MESSAGES: In current clinical practice, many patients are being excluded from reperfusion therapy due to a lack of data from urgent investigations to assess cerebral vasculature and perfusion. Here, we explore the potential benefits of CTP incorporated into the initial CT protocol assessment of stroke patients.

Networks for future healthcare.

The Getting It Right First Time (GIRFT) process is designed to improve the care of patients in the NHS in England through in-depth review of services, benchmarking and presenting a data-driven evidence base to support change. It started as a pilot project targeting unwarranted variation in elective orthopaedic surgery. It rapidly became apparent that the approach of clinically-led deep dives to review the activity in individual orthopaedic units was effective in improving standards of care but also resulted in substantial cost savings that could be reinvested in the clinical service. GIRFT has now expanded to encompass 40 clinical specialties and is funded by NHS England. We describe the ethos of networks and give examples of GIRFT specialty programmes that have made networks a key component of their recommendations.

Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke.

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient 'journey' or 'patient pathway,' supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: A: Appropriate Antithrombotic therapy.B: Better functional and psychological status.C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

Efficacy of Continuous Performance Testing in Adult ADHD in a Clinical Sample Using QbTest.

OBJECTIVE: Continuous performance tests are widely used to aid diagnostic decision making and measure symptom reduction in adult ADHD clinical populations. The diagnostic accuracy of the Quantified Behavior Test plus (QbTest+), developed to identify ADHD populations as an objective measure of ADHD symptoms, was explored. METHODS: The utility of the QbTest+ was investigated in a clinical cohort of 69 adult patients referred to a specialist ADHD clinic in the UK. RESULTS: Scores from the QbTest+ failed to differentiate between patients diagnosed with ADHD and those who did not receive a diagnosis after full clinical assessment. CONCLUSIONS: Based on our findings, we recommend clinicians are cautious when interpreting results of the QbTest+ in clinical populations. This study highlights the need for investigation into the lack of validation of commonly used objective measures in ADHD populations.

Item Response Theory Analysis of the Texas Functional Living Scale.

OBJECTIVE: The Texas Functional Living Scale (TFLS) is a performance-based measure of functional abilities assessing the domains of time, money and calculation, communication, and memory. It is likely that certain items are more sensitive at different levels of functional impairment, with some signaling milder degrees of functional difficulty. This study analyzed psychometric characteristics of individual TFLS items using item response theory (IRT) in an outpatient clinical sample. METHOD: In total, 270 adult outpatients completed the TFLS during clinical neuropsychological evaluation. IRT analysis using 2PL and graded response model was applied to the TFLS. RESULTS: Item parameters, item characteristic curves, and information curves were produced. Item difficulty (a) parameters ranged from 1.05 to 2.23, and item discrimination (b) parameters ranged from -4.11 to 0.51. CONCLUSIONS: TFLS items were differentially sensitive along the continuum of functional impairment. Items that were most sensitive to milder degrees of functional impairment involved clock drawing, microwave programming, financial calculation, and prospective memory. Other items that were optimally precise in more severe degrees of functional impairment involved interacting with a calendar and a relatively simple financial calculation task. These findings suggest that the ability to pass at least some of the items on the TFLS may not necessarily reflect fully intact functional abilities. Certain TFLS items may be able to detect the presence of subtle functional difficulties.

Psychological Effects of the COVID-19 Imposed Lockdown on Adults with Attention Deficit/Hyperactivity Disorder: Cross-Sectional Survey Study.

BACKGROUND: The psychological effects of the COVID-19 government-imposed lockdown have been studied in several populations. These effects however have not been studied in adult populations with attention deficit/hyperactivity disorder (ADHD). OBJECTIVE: We wanted to investigate the psychological effects of the COVID-19 imposed lockdown on an adult population with ADHD. METHODS: We conducted a cross-sectional survey by administering the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7, Brief Adjustment Scale-6, Perceived Stress Scale, and Multidimensional Scale of Perceived Social Support to a pragmatic sample of adults with ADHD. RESULTS: In total, 24 individuals (male: n=18, 75%; female: n=6, 25%; age: mean 21.75 years, SD 1.85 years) were included in this study. The adults with ADHD we surveyed had significant levels of emotional distress during the COVID-19 pandemic period. However, there was no evidence of significant deterioration to the mental health of our sample during the COVID-19 pandemic. CONCLUSIONS: When treatment for ADHD is maintained, the effects of the COVID-19 pandemic on the mental health of adults with ADHD are mild. Targeted psychological interventions may be useful in such circumstances.

Dual-Task Gait Assessment in a Clinical Sample: Implications for Improved Detection of Mild Cognitive Impairment.

OBJECTIVES: Research has longitudinally linked dual-task gait dysfunction to mild cognitive impairment (MCI) and dementia risk. Our group previously demonstrated that dual-task gait speed assessment distinguished between subjective cognitive complaints (SCC) and MCI in a memory clinic setting, and also found that differences in dual-task gait speed were largely attributable to executive attention processes. This study aimed to reproduce these findings in a larger diverse sample and to extend them by examining whether there were group differences in single- versus dual-task cognitive performance (number of letters correctly sequenced backward). METHOD: Two-hundred fifty-two patients (M age = 66.01 years, SD = 10.46; 119 MCI, 133 SCC) presenting with cognitive complaints in an academic medical setting underwent comprehensive neuropsychological and gait assessment (single- and dual-task conditions). RESULTS: Patients with MCI walked slower and showed greater decrement in cognitive performance than those with SCC during dual-task conditions. Neuropsychological measures of executive attention accounted for significant variance in dual-task gait performance across diagnostic groups beyond demographic and health risk factors. DISCUSSION: Reproduction of our results within a sample over four times the previous size provides support for the use of dual-task gait assessment as a marker of MCI risk in clinical settings.

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).

Hallucinations and Delusions Signal Alzheimer's Associated Cognitive Dysfunction More Strongly Compared to Other Neuropsychiatric Symptoms.

OBJECTIVES: Neuropsychiatric symptoms (NPS) are common among individuals with dementia of the Alzheimer's type (DAT). We sought to characterize which NPS more purely relate to cognitive dysfunction in DAT, relative to other NPS. METHOD: Demographic, neurocognitive, neuroimaging, and NPS data were mined from the Alzheimer's Disease Neuroimaging Initiative database (n = 906). Using factor analysis, we analyzed the degree to which individual NPS were associated with DAT-associated cognitive dysfunction. We also employed item response theory to graphically depict the ability of individual NPS to index DAT-associated cognitive dysfunction across a continuum ranging from cognitively normal to mild DAT. RESULTS: Psychotic symptoms (hallucinations and delusions) were more strongly related to the continuum of DAT-associated cognitive dysfunction than other NPS, with the strength of the relationship peaking at high levels of disease severity. Psychotic symptoms also negatively correlated with brain volume and did not relate to the presence of vision problems. Aberrant motor behavior and apathy had relatively smaller associations with DAT-associated cognitive dysfunction, while other NPS showed minimal associations. DISCUSSION: Psychotic symptoms most strongly indexed DAT-associated cognitive dysfunction, whereas other NPS, such as depression and anxiety, were not as precisely related to the DAT-associated cognitive dysfunction.

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.

Statistical Model of Dynamic Markers of the Alzheimer's Pathological Cascade.

Objectives: Alzheimer's disease (AD) is a progressive disease reflected in markers across assessment modalities, including neuroimaging, cognitive testing, and evaluation of adaptive function. Identifying a single continuum of decline across assessment modalities in a single sample is statistically challenging because of the multivariate nature of the data. To address this challenge, we implemented advanced statistical analyses designed specifically to model complex data across a single continuum. Method: We analyzed data from the Alzheimer's Disease Neuroimaging Initiative (ADNI; N = 1,056), focusing on indicators from the assessments of magnetic resonance imaging (MRI) volume, fluorodeoxyglucose positron emission tomography (FDG-PET) metabolic activity, cognitive performance, and adaptive function. Item response theory was used to identify the continuum of decline. Then, through a process of statistical scaling, indicators across all modalities were linked to that continuum and analyzed. Results: Findings revealed that measures of MRI volume, FDG-PET metabolic activity, and adaptive function added measurement precision beyond that provided by cognitive measures, particularly in the relatively mild range of disease severity. More specifically, MRI volume, and FDG-PET metabolic activity become compromised in the very mild range of severity, followed by cognitive performance and finally adaptive function. Conclusion: Our statistically derived models of the AD pathological cascade are consistent with existing theoretical models.

How Do Scores on the ADAS-Cog, MMSE, and CDR-SOB Correspond?

OBJECTIVE: Clinicians and researchers who measure cognitive dysfunction often use the Alzheimer's Disease Assessment Scale--Cognitive Subscale (ADAS-Cog), the Mini-Mental State Examination (MMSE), or the Clinical Dementia Rating scale (CDR-SOB). But, the use of different measures can make it difficult to compare data across patients or studies. What is needed is a simple chart that shows how scores on these three important measures correspond to each other. METHODS: Using data from 1709 participants from the Alzheimer's Disease Neuroimaging Initiative and item response theory-based statistics, we analyzed how scores on each measure, the ADAS-Cog, the MMSE, and the CDR-SOB, correspond. RESULTS: Results indicated multiple inflections in CDR-SOB and ADAS-Cog scores within a given MMSE score, suggesting that the CDR-SOB and ADAS-Cog are more precise in measuring the severity of cognitive dysfunction than the MMSE. CONCLUSIONS: This study shows how scores on these three popular measures of cognitive dysfunction correspond to each other, which is very useful information for both researchers and clinicians.

Adding delayed recall to the ADAS-cog improves measurement precision in mild Alzheimer's disease: Implications for predicting instrumental activities of daily living.

As research increasingly focuses on preclinical stages of Alzheimer's disease (AD), instruments must be retooled to identify early cognitive markers of AD. A supplemental delayed recall subtest for the Alzheimer's Disease Assessment Scale-cognitive (ADAS-cog; Mohs, Rosen, & Davis, 1983; Rosen, Mohs, & Davis, 1984) is commonly implemented, but it is not known precisely where along the spectrum of cognitive dysfunction this subtest yields incremental information beyond what is gained from the standard ADAS-cog, or whether it can improve prediction of functional outcomes. An item response theory approach can analyze this in a psychometrically rigorous way. Seven hundred eighty-eight patients with AD or amnestic complaints or impairment completed a battery including the ADAS-cog and 2 activities of daily living measures. The delayed recall subtest slightly improved the ADAS-cog's measurement precision in the mild range of cognitive dysfunction and increased prediction of instrumental activities of daily living for individuals with subjective memory impairment.

A fresh perspective revealed by powerful trends in Alzheimer's disease research.

The paper, "Ethnicity Moderates Dementia's Biomarkers", by Royall and Palmer in this issue of Journal of Alzheimer's Disease represents the cutting edge of Alzheimer's disease (AD) research. The authors capitalize on several powerful and emerging trends in AD research that will surely reap benefits for our discipline during the next decade: latent variable models, biomarkers, and ethnicity. In this study, the authors specifically find that self-reported ethnicity moderates the dementing process and hypothesize that this is more likely due to distinct biological mechanisms than environmental influences.

Using the Alzheimer's Association web site to improve knowledge of Alzheimer's disease in health care providers.

BACKGROUND: The purpose of the current study was to investigate whether an informative Web site is effective at producing higher scores for an individual's knowledge of Alzheimer's disease (AD) relative to those who do not visit a Web site. METHODS: A total of 552 participants completed the study on Amazon's Mechanical Turk; half were randomly assigned to visit alz.org, while a control group did not. Both groups were given the AD Knowledge Scale (ADKS) to assess their knowledge of AD. RESULTS: Participants who visited alz.org scored significantly higher on the ADKS than those in the control group. Participants who were health care workers demonstrated higher scores than others in the experimental condition. Findings indicate that the Alzheimer's Association Web site is effective at producing higher scores for AD knowledge relative to no Web site at all and that it is especially helpful for health care workers compared to those who are not health care workers.

Implementation of a multicomponent intervention to optimise patient safety through improved oxygen prescription in a rural hospital.

OBJECTIVE: To rationalise oxygen procedures in adult medical and surgical inpatients with a view to improving patient safety. DESIGN: Prospective pre- and post-intervention audit. SETTING: Manning Hospital, a rural referral hospital in Taree NSW. PARTICIPANTS: Pre-intervention: 82 patients aged 72.7 ± 14.7 years. Post-intervention: 77 patients aged 73.6 ± 12.4 years. INTERVENTION: A multicomponent intervention composed of implementation of a local hospital oxygen policy, introduction of a specific oxygen prescription chart and targeted staff education. MAIN OUTCOME MEASURES: Satisfactory oxygen prescription, monitoring and titration. RESULTS: Only 2/82 (2.4%) patients had satisfactory oxygen prescription specifying target saturation, device and initial flow rate before the intervention compared with 26/77 (34%) patients post-intervention (χ(2) = 56.88, df = 5, P < 0.0001). Percentage of patients with conditions predisposing to hypercapnic respiratory failure who were overtreated with oxygen dropped from 9/19 (47%) to 4/22 (18%) following the study intervention (χ(2) = 4.011, df = 1, P = 0.04). Oxygen therapy monitoring was satisfactory during the audit period, but oxygen titration was unsatisfactory and did not significantly improve following the intervention. CONCLUSIONS: A multicomponent intervention can achieve a significantly increased rate of satisfactory oxygen prescriptions specifying target saturation, including in those who are at risk of hypercapnic respiratory failure.

Analysis of empathy in Doctor of Physical Therapy students: a multi-site study.

BACKGROUND: Empathy is a human emotion that is important in the effective provision of health care and amenable to change through explicit and implicit experiences in an individual's life. This study measured levels of empathy in students pursuing doctoral degrees in physical therapy and compared the influence of professional education at different institutions on these levels. METHODS: Our cross-sectional, two-cohort, multisite study used a modified version of the Jefferson Scale of Physician Empathy, Student Version, to investigate empathy levels at enrollment, mid-curriculum, and end-of-curriculum. Statistical tests of differences were performed between institutions, within institutions for each cohort across the three time points, and within institutions between cohorts. Data were analyzed using descriptive statistics, ANOVA, and the least squared difference test. Alpha was set at 0.05 for main test of difference and 0.04 for all post-hoc tests. RESULTS: For both cohorts, empathy levels differed significantly between institutions at program entry (Cohort 1, p=0.0150; Cohort 2, p=0.0273); within institutions the two cohorts were similar at the beginning of the first semester. In Cohort 1, no significant changes occurred within any institution; students at the two institutions with higher entering scores maintained their higher scores at the end of the last didactic semester. Students in Cohort 2 showed significant differences in empathy levels at the end of the last didactic semester within and between institutions (p=0.0251; p<0.0001). CONCLUSIONS: Empathy levels may differ at enrollment for PT students at different institutions even with similar recruitment approaches and no significant differences in student demographics between institutions. Despite uniform accreditation requirements for curriculum content, significant differences between institutions did exist in the last didactic semester in Cohort 2 but not Cohort 1. The direction and magnitude of such changes were not explained by institutional characteristics. This study challenges assumptions that measurements of empathy in students at one institution can be generalized to students at other institutions and that one cohort in the same institution can predict another cohort.

Greater precision when measuring dementia severity: establishing item parameters for the Clinical Dementia Rating Scale.

BACKGROUND/AIMS: An item response theory (IRT)-based scoring approach to the Clinical Dementia Rating Scale (CDR) can account for the pattern of scores across the CDR items (domains) and their differential abilities to indicate dementia severity. In doing so, an IRT-based approach can provide greater precision than other CDR scoring algorithms. However, neither a good set of item parameters nor an easily digestible set of instructions needed to implement this approach is readily available. METHODS: Participants were 1,326 patients at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Clinic. RESULTS: The item parameters necessary for an IRT-based scoring approach were identified (a parameters ranged from 3.01 to 6.22; b parameters ranged from -2.46 to 2.07). CONCLUSION: This study provides, and demonstrates how to easily apply, IRT-based item parameters for the CDR

Current and future instructional methods and influencing factors in anatomy instruction in physical therapy and medical schools in the U.S.

UNLABELLED: The purpose of this descriptive study was to investigate current and future instructional practices and the most important factors influencing those practices in anatomy laboratories within medical schools and physical therapy schools. METHODS: A survey instrument was developed using the Delphi method in 2008. In addition to refining the survey instrument, the participants in the Delphi study also provided their expert testimony on current and future teaching methods as well as influencing factors. The survey was then administered in 2009 to a random sampling of anatomy instructors in physical therapy (n = 60) and medical schools (n = 15). RESULTS: Cadaver dissection is currently the most common instructional technique, but its use is predicted by our experts and our general survey respondents to decline by 2020 in both medical and physical therapy schools. In the future, more instructional time will be devoted to imaging, computerized teaching aids, living/surface anatomy instruction, and prosections. The most important factors influencing anatomy education for all groups were budget, instructional time, and the availability of qualified anatomy instructors. Factors predicted to have little influence on anatomy instruction include student learning styles and ethical considerations. Contrary to current concerns expressed by some, health and safety concerns were also judged to have little influence on anatomy instruction. CONCLUSION: Evidence supports a trend of decreasing time on cadaver dissection and increasing time on technology-based instructional methods.

Estimating Premorbid Intelligence among Older Adults: The Utility of the AMNART.

This study examines the utility of the American version of the National Adult Reading Test (AMNART) as a measure of premorbid intelligence for older adults. In a sample of 130 older adults, aged 56 to 104, the AMNART was compared to other tests of premorbid intelligence. The results revealed that AMNART-estimated IQ was significantly higher than other premorbid estimates. Across specific educational groups (i.e., 0-12, 13-16, and 17 or more years of education), AMNART-estimated IQ was inflated relative to all other premorbid estimates. The AMNART also declined as cognitive impairment increased, and there was a significant interaction between aging-related diagnostic group and premorbid estimate. The AMNART may therefore overestimate premorbid ability relative to other premorbid measures, particularly among those with greater cognitive impairment and lower levels of education. These results suggest that the AMNART should be used cautiously among older adults and in conjunction with other estimates of premorbid ability.