Cerebrospinal fluid opening pressure in clinical practice – a prospective study

Journal of Neurology - Measurement of CSF opening pressure (CSFOP) is valuable and much used in the investigation of several neurological conditions. However, there are different opinions regarding...     

Conscious Presence and Self Control as a measure of situational awareness in soldiers – A validation study

Background

The concept of `mindfulness´ was operationalized primarily for patients with chronic stressors, while it is rarely used in reference to soldiers. We intended to validate a modified instrument on the basis of the Freiburg Mindfulness Inventory (FMI) to measure soldiers’ situational awareness (“mindfulness”) in stressful situations/missions. The instrument we will explore in this paper is termed the Conscious Presence and Self Control (CPSC) scale.

Methods

The CPSC and further instruments, i.e., Perceived Stress Scale (PSS), stressful military experiences (PCL-M), life satisfaction (BMLSS), Positive Life Construction (ePLC), and self-perceived health affections (VAS), were administered to 281 German soldiers. The soldiers were mainly exposed to explosive ordnance, military police, medical service, and patients with posttraumatic stress disorders.

Results

The 10-item CPSC scale exhibited a one-factorial structure and showed a good internal consistence (Cronbach´s alpha = .86); there were neither ceiling nor bottom effects. The CPSC scores correlated moderately with Positive Life Construction and life satisfaction, and negatively with perceived stress and health affections. Regression analyses indicated that posttraumatic stress disorder symptoms (negative), and the development of effective strategies to deal with disturbing pictures and experiences (positive) were the best predictor of soldiers´ CPSC scores. Soldiers with health affections exhibiting impact upon their daily life had significantly lower CPSC scores than those without impairment (F=8.1; p < .0001).

Conclusions

As core conceptualizations of `mindfulness´ are not necessarily discussed in a military context, the FMI was adopted for military personnel populations, while its two factorial structure with the sub-constructs `acceptance´ and `presence´ was retained. The resulting 10-item CPSC scale had good internal consistence, sound associations with measures of health affections and life satisfaction, and thus can be used as a short and rapid measure in pre-post mission and interventional studies.     

DemTect®– effective to asses MCI and dementia – validation study of the Polish language version

Objectives: To validate DemTect®, a highly sensitive psychometric screening tool – designed to identify patients with mild cognitive impairment (MCI) and patients with dementia (AD).

Method: A prospective cohort/cross-sectional study was designed. The data were collected from a group of 224 subjects, including 85 patients with MCI, 109 with Alzheimer's disease (AD) and 30 healthy control (HC) subjects. All subjects underwent a detailed neuropsychological assessment including CT, the assessment of biological parameters and a psychometric examination using DemTect®, MMSE, TYM, CDT and FAS.

Results: Subjects ranged in age from 55 to 94 years, with a mean age of 71.42 ± 9.86 years. Classification rates of DemTect® were superior for both the MCI and AD groups compared with the MMSE, with high sensitivities of 90% (cut-off ≤15) and 96.8% (cut-off < 10), respectively. The DemTect® Polish language version proved to be independent of age and education level.

Conclusion: The Polish language version of the DemTect® scale is easy to administer. It may be seen as a superior cognitive screening tool in day-to-day practice as it achieves more accurate differentiation between HC/MCI/AD compared with MMSE.     

The SERVE-HF safety notice in clinical practice – experiences of a tertiary sleep center

BackgroundIn May 2015, the results of the SERVE-HF trial – addressing adaptive servoventilation (ASV) in chronic congestive heart failure (CHF) patients with central sleep apnea (CSA) – prompted a field safety notice. It was recommended to identify CHF patients treated with ASV and to advise the discontinuation of the treatment. We aimed to analyze the identification process and effect of ASV discontinuation on affected patients.Methods126 patients treated with ASV on May 13th, 2015 at our institution were retrospectively analyzed. Treatment decisions, effect of ASV discontinuation and clinical course were followed for a year. Patients on ASV with CHF were compared to those without CHF.ResultsThe risk criteria of the safety notice were fulfilled by 10.3% of patients (13/126). Additional echocardiographies were performed in 38%. ASV was discontinued in 93% of patients without adverse events (emergency hospitalization in n = 1). CSA reappeared immediately. Day- or nighttime symptoms were reported by 61%. Symptomatic patients were started on alternative treatments. CHF and non-CHF patients differed in cardiac function and type of SDB. CHF patients had shorter overall treatment duration. Compliance to ASV was similar in both groups with a median usage of 412 min (269; 495)/night in the CHF group and 414.5 min (347; 480) in the non-CHF group.ConclusionIdentification of patients “at risk” is feasible but outcome of discontinuation of ASV cannot be evaluated based on these data. ASV withdrawal in patients with stable chronic CHF and CSA leads to an immediate return of sleep disordered breathing. Symptomatic patients may ask for alternative treatment options.     

The Icelandic child mental health study. An epidemiological study of Icelandic children 2–18 years of age using the Child Behavior Checklist as a screening instrument

The purpose of this study was to test the applicability of a standardised procedure for assessing Icelandic children's behaviour/emotional problems and competencies, and to identify differences related to demographic variables. This study focuses upon the method of using the Child Behavior Checklist (CBCL) by Achenbach to estimate the reported prevalence by parents and adolescents of emotional and behaviour problems in children from 2–16 years of age and self-reported prevalence of adolescents from 11–18 years, selected at random from the general population, both in urban and rural areas. The information was obtained by mailing checklists with a letter to parents of children 2–10 years of age. The checklists for adolescents 11–18 years of age were distributed by teachers in school. Those adolescents who were not in school received the checklists by mail at their homes. The Child Behavior Checklists used for analyses were completed by 109 parents of 2–3 year old children; 943 parents of 4–16 year old children, and 545 non-referred adolescents from the general population. The rate of response was lowest for the youngest age group, 47%, but increased to 62% with increasing age of the child. The response rate among the adolescents answering the Youth Self Report was 64%. Comparisons with the Child Behavior Checklist from this study are presented with Dutch, American, French, Canadian, German and Chilean samples and show striking similarities in four of these countries on the behaviour/emotional problems reported.

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Zusammenfassung Der Zweck dieser Studie war es, die Anwendbarkeit eines standardisierten Instruments zur Erfassung von Verhaltensauffälligkeiten, emotionalen Problemen und Kompetenzen auf isländische Kinder zu testen und Unterschiede zu erfassen, die auf demographische Variablen zurückzuführen sind. Diese Studie konzentriert sich auf die Methode der Anwendung der CBCL von Achenbach bei Zufallsstichproben aus der Allgemeinbevölkerung sowohl städtischer als auch ländlicher Regionen, um die von Eltern und Jugendlichen berichteten Prävalenzraten emotionaler Probleme bzw. Verhaltensauffälligkeiten von Kindern im Alter von 2–16 Jahren und von selbst berichteten Prävalenzraten von Jugendlichen zwischen 11 und 18 Jahren einzuschätzen. Um die entsprechenden Informationen zu gewinnen, wurden die CBCL-Fragebögen zusammen mit einem Begleitbrief an Eltern von 2–10jährigen Kindern versandt. Die Fragebögen für die Jugendlichen zwischen 11 und 18 Jahren wurden von Lehrern in der Schule verteilt. Denjenigen Jugendlichen, die nicht in der Schule waren, wurden die Fragebögen per Post nach Hause gesandt. Die CBCL-Fragebögen, die zur Auswertung kamen, wurden von 109 Eltern von 2–3jährigen Kindern, von 943 Eltern von 4–16jährigen Kindern und von 545 nicht überwiesenen Jugendlichen aus der Allgemeinbevölkerung ausgefüllt. Die Rücklaufquote war am niedrigsten bei der jüngsten Altersgruppe (47%) und wuchs mit zunehmendem Alter des Kindes auf 62% an. Die Rücklaufquote unter den Jugendlichen, die den Youth Self Report ausgefüllt hatten, betrug 64%. Es werden Vergleiche zwischen den Ergebnissen dieser Studie mit Stichproben aus den Niederlanden, Amerika, Frankreich, Kanada, Deutschland und Chile angestellt, wobei sich auffallende Ähnlichkeiten in vier dieser Länder im Hinblick auf die berichteten Verhaltens- und emotionalen Probleme ergeben.

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Résumé Le but de cette étude est de tester l'applicabilité d'une procédure standardisée dont le but est, d'une part, d'évaluer les problèmes et capacités aussi bien émotionnels que comportementaux ainsi que, d'autre part, d'identifier les différences dûes aux variables démographiques. Cette étude se concentre sur la méthode d'utilisation de la liste de contrôle (Child Behavior Checklist) selon Aschenbach afin d'évaluer la prépondérance des problèmes émotionnels et comportementaux chez les enfants de 2 à 16 ans rapportés par les parents et adolescents, et celle rapportée par des adolescents de 11 à 18 ans eux-mêmes, sélectionnés de manière arbitraire dans l'ensemble de la population, aussi bien en milieu rural qu'urbain. Les informations ont été obtenues grâce à l'envoi de listes accompagnées d'une lettre à un certain nombre de parents d'enfants agès de 2 à 10 ans. Les listes concernant les adolescents agés de 11 à 18 ans furent distribuées dans les écoles par les enseignants. Les jeunes gens qui ne se trouvaient pas à l'école ont reçu la liste chez eux par courrier. Les listes de contrôle utilsées dans le cadre de l'analyse ont été complétées par 109 parents d'enfants agés de 2 à 3 ans, 943 parents d'enfants de 4 à 16 ans ainsi que 545 adolescents issus de l'ensemble de la population et à l'age resté indéterminé. Le taux de réponses s'est avéré plus faible pour le groupe d'age le plus bas, 47%, lequel cependant s'est accru à 62% avec l'age des enfants concernés. Le taux de réponse au rapport sur la jeunesse par elle-même (Youth Self Report) parmis les adolescents fût de 64%. Des comparaisons avec les listes de contrôle du comportement enfantin ont été rendues possible par l'existence de sondages hollandais, américains, français, canadiens, allemands et chiliens, lesquelles montrent des similitudes notables quant aux problèmes émotionnels et comportementaux dans quatre de ces pays.

     

Microembolic signals and clinical outcome in patients with acute stroke – a prospective study

The occurrence of microembolic signals (MES) in patients with transient ischemic attack (TIA) or stroke has already been described; the influence of the time interval between onset of symptoms and transcranial Doppler monitoring (TCD) on the MES rate or MES prevalence and the possible prognostic value of the early detected MES rate on the outcome of TIA or stroke symptoms in a 3 month interval are discussed. In a prospective study we evaluated 61 patients consecutively admitted to our stroke unit after their first ischemic neurological deficit involving the vascular territory of MCA and/or ACA. All of the patients underwent a 30-minute bilateral transcranial Doppler monitoring of their MCAs for the identification of MES. Monitoring was performed within 12.3 + -9.3 (average mean + -SD) hours of stroke onset for the first time, the second time 48 hours after first TCD monitoring. Prognosis for the recovery of neurological deficits was evaluated by using the Barthel index (BI) and Scandinavian Stroke Scale (SSS) at the time of admission of the patient to the stroke unit, and with Barthel indices after one month and after 3 months. As a result, 56% of all patients showed MES in at least one of the two registrations. MES were recorded not only on the symptomatic side. The MES prevalence between both TCD monitorings was significantly different (total MES prevalence: 1st TCD: 26 patients: 2nd TCD: 13 patients; p < 0.04; ipsilateral MES prevalence: 1st TCD: 19 patients; 2nd TCD: 9 patients; p < 0.01). The regression analysis showed a significant influence of the total MES rate on both neurological scores at admission (SSS: 0.03; Barthel index: 0.04), but not for the Barthel scores after one and three months. In conclusion, we found an influence of the time interval between onset of neurological symptoms of TIA or stroke on the MES rate and the prevalence of MES. The prevalence of MES or the MES rate, found after a short time interval to the onset of symptoms, did not have a prognostic value on the outcome of neurological deficits up to a three month follow-up.     

Psychometric Equivalence of a Paper-Based and Computerized (iPad) Version of the Memory Orientation Screening Test (MOST®)

The Memory Orientation Screening Test (MOST^®) is a 29-point scale for identifying and following mild and major neurocognitive disorders in older patients. Previous research demonstrated validity in separating patients with normal vs. impaired cognition and high correlations with tests of memory and attention. This study compares the original paper-based MOST^® with a computerized (iPad app) version, the MOST^®-96120, to determine the equivalence of formats. A total of 98 consecutive older patients were administered identical versions of the MOST and MOST-96120 in a random order, separated by 1 hour of interspersed testing, in a 3-hour neuropsychological evaluation. MOST and MOST-96120 scores were compared with each other, with global cognitive ratings, and with standardized tests of memory and attention. Both versions had equivalent means and standard deviations, very high inter-test correlation (r = .92, p < .001), and equal correlations with outcome measures. Both versions separated patients into normal vs. mild NCD vs. major NCD categories with equal accuracy. ANOVA showed no significant difference between versions or presentation order. Both versions correlated very highly with cognitive level and neuropsychological endpoints, confirming previous research. The MOST-96120 is a computerized neuropsychological assessment device that demonstrates equivalence with its paper-based original, allowing for confident reliance on the findings of previous research.     

Confusion assessment method in the diagnostics of delirium among aged hospital patients: Would it serve better in screening than as a diagnostic instrument?

BACKGROUND: The Confusion Assessment Method (CAM) is an easy, four-step algorithmic diagnostic test developed to detect delirium. OBJECTIVE: To determine how sensitive and specific the CAM is in diagnosing delirium when compared with fully operationalized criteria of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) editions III, III revised, and IV, and the International Classification of Diseases (ICD) 10th edition. METHODS: A cross-sectional study with blinded assessments was performed on consecutive elderly patients (>70 years) (n=81) in two acute geriatric hospitals in Helsinki, Finland. The sensitivity, specificity, likelihood ratios, and positive and negative predictive values of CAM were assessed with the DSM-III, DSM-III-R, DSM-IV, and ICD-10 criteria of delirium used as reference standards. RESULTS: Sensitivity rates of the CAM were proved to be only moderate (0.81-0.86) against all formal criteria of delirium. The specificity rates were lower (0.63-0.84), and far less than reported in previous studies using global assessment of the reference standard. Instead of the DSM-III-R, from which it is derived, the CAM seems more concordant with the DSM-IV criteria of delirium. The likelihood ratio for a positive CAM test was 5.06 and for a negative test 0.23, when compared with the DSM-IV. CONCLUSION: The CAM seems to be an acceptable screening instrument for delirium, but the diagnosis should be ensured according to the formal criteria of delirium, preferably by the DSM-IV.     

What explains variations in the clinical use of mild cognitive impairment (MCI) as a diagnostic category?

BACKGROUND: Mild cognitive impairment (MCI) is proposed to describe the transitional stage between normal cognitive aging and dementia. It has had significant impact in the field of dementia research, but it remains controversial whether or not it should be used as a diagnostic category in clinical practice. METHODS: Semi-structured interviews were carried out with international experts (N = 37) in the field of dementia research and practice. These interviews explored the advantages and difficulties of using MCI as a clinical diagnosis. RESULTS: There is wide variation in the clinical use of MCI. This variation depends on institutional factors and two types of cultural factors: (a) clinical culture, and (b) the "evidential culture" -- how research and guidelines figure in clinical practice. CONCLUSION: The study shows the importance of combining values-based practice with evidence-based practice in the early diagnosis of dementia.     

Is the Bahasa Malaysia version of the Montreal Cognitive Assessment (MoCA-BM) a better instrument than the Malay version of the Mini Mental State Examination (M-MMSE) in screening for mild cognitive impairment (MCI) in the elderly?

IntroductionMild Cognitive Impairment (MCI) is a known precursor to Alzheimer disease, yet there is a lack of validated screening instruments for its detection among the Malaysian elderly.ObjectiveTo compare the Bahasa Malaysia version of the Montreal Cognitive Assessment (MoCA-BM) with the Malay version of the Mini Mental State Examination (M-MMSE) in the detection of MCI among the Malaysian elderly.MethodologyThis is a cross-sectional study conducted at the primary care centre of Universiti Kebangsaan Malaysia, Kuala Lumpur from December 2011 to mid-January 2012. Subjects aged 60 and above were recruited using systematic sampling method. Cut-off scores of 22/23 for MoCA-BM and 25/26 for M-MMSE were adopted. Kappa value and Pearson’s correlation coefficient were used to ascertain the correlation between MOCA-BM and M-MMSE. Data were analysed using Mann–Whitney and Chi Square tests.ResultsThe mean age of the 180 subjects enrolled was 65.3 years (SD = 5.4). They had a median of 6 years (IqR 25–75 = 5–11) total formal education. The prevalence of MCI using MoCA-BM and M-MMSE was 55.6% and 32.8% respectively. The odds of developing MCI were 1.153 (95% CI = 1.055, 1.261; p < 0.05) for every 1 year increase in age, 0.813 (95% CI = 0.690, 0.959; p < 0.05) with every extra year of education. Increasing age and lower education level were significantly associated with MCI. The MoCA-BM showed good internal consistency with Cronbach’s alpha of 0.80. It had moderate correlation with M-MMSE (Pearson correlation coefficient = 0.770, p < 0.001) and moderate agreement for detecting MCI with Kappa values of 0.497 (p < 0.001).ConclusionThe prevalence of MCI was higher using MoCA-BM compared to M-MMSE. Both instruments showed moderate concordance for screening MCI with correlation of their scores.     

The German version of the revised Adolescent Sleep-Wake Scale (rASWS) – A validation study in pediatric pain patients and school children

ObjectiveSleep problems are common in children and adolescents with chronic pain. The revised Adolescent Sleep-Wake Scale (rASWS) is an internationally well-established instrument to assess sleep quality in adolescents. So far, no German version is available. The study aimed to provide a validated German version of the rASWS, specifically for use in children and adolescents with chronic pain.MethodsThe translated questionnaire was validated in a sample of N = 159 pediatric outpatients with chronic pain (8–17 years; 65.4% female), who presented to a specialized pediatric pain center. For cross-validation a community sample of N = 1348 school children was analyzed.ResultsConfirmatory factor analysis was conducted to examine the factor structure of the original 10-item 3-factor model in the sample of children and adolescents with chronic pain, which showed poor model fit. Model modifications were carried out by deleting 3 items with low factor loadings stepwise. The overall model fit of the final 3-factor model containing 7 items was excellent. Cronbach's α of the derived scales ranged from 0.74 to 0.86. Cross-validation in a community sample of school children confirmed the superiority of the 7-item model. The convergent validity of the measure was proved by moderate correlations between the rASWS and self-reported sleep problems. Associations with chronic pain characteristics were evident for pain-related disability.ConclusionsThe use of the 7-item version of the rASWS for German-speaking children and adolescents with and without chronic pain is recommended as a self-report measure of sleep quality.     

Impact of cerebro-spinal fluid biomarkers of Alzheimer’s disease in clinical practice: a multicentric study

CSF biomarkers of Alzheimer’s disease are well validated in clinical research; however, their pragmatic utility in daily practice is still unappreciated. These biomarkers are used in routine practice according to Health Authority Recommendations. In 604 consecutive patients explored for cognitive disorders, questionnaires were prospectively proposed and filled. Before and after CSF biomarker results, clinicians provided a diagnosis and an estimate of their diagnostic confidence. Analysis has compared the frequency of diagnosis before and after CSF biomarker results using the net reclassification improvement (NRI) method. We have evaluated external validity comparing with data of French Bank National of AD (BNA). A total of 561 patients [Alzheimer’s disease (AD), n = 253; non-AD, n = 308] were included (mean age, 68.6 years; women, 52 %). Clinically suspected diagnosis and CSF results were concordant in 65.2 % of cases. When clinical hypothesis and biological results were discordant, a reclassification occurred in favour of CSF biomarkers results in 76.9 %. The NRI was 39.5 %. In addition, the results show a statistically significant improvement in clinician confidence for their diagnosis. In comparison with BNA data, patients were younger and more frequently diagnosed with AD. Clinicians tend to heavily rely on the CSF AD biomarkers results and are more confident in their diagnoses using CSF AD biomarkers. Thus, these biomarkers appear as a key tool in clinical practice.     

Are the clock-drawing test and the MMSE combined interchangeable with CAMCOG as a dementia evaluation instrument in a specialized outpatient setting?

This study examines whether the Clock-Drawing Test (CDT) combined with the Mini-Mental State Examination (MMSE) is interchangeable with the more detailed and lengthy Cambridge Cognitive Examination (CAMCOG) as a dementia evaluation instrument in a specialized psychogeriatric outpatient setting: 114 outpatients (88 with dementia, 26 with depressive and anxiety disorders) were included. Each subject underwent a comprehensive evaluation in which the CAMCOG (MMSE included) was administered. DSM-IV diagnoses were independently established. CAMCOG-derived clock drawings were blindly scored according to Freedman's method. The authors found that a combination of CDT and MMSE enhanced the psychometric properties of the above scales approximating them to CAMCOG's. They conclude that CDT in combination with the MMSE is valid for differentiation of dementia sufferers from nondemented psychiatric controls in a specialistic setting and might replace CAMCOG. However, the generalizability of these findings (a wider range of diagnoses, primary care settings) still needs to be verified.