Instruments for detection and screening of cognitive impairment for older adults in primary care settings: A review

The Patient Protection and Affordable Care Act requires evaluation for cognitive impairment as part of the Annual Wellness Visit (AWV). Nurses and nurse practitioners in primary care are in a good position to incorporate brief cognitive screens into the AWV. Early recognition of cognitive problems allows clinicians and patients the opportunity to discuss any new or ongoing concerns about cognition, address possible reversible causes, or refer for further evaluation. It should be noted that some patients may prefer not to explore for cognitive impairment.Numerous brief cognitive screens have been developed for primary care, with no one screen being appropriate for all patients or clinicians. This review examines the psychometric properties, usefulness, and limitations of both patient and informant brief (under five minutes) cognitive screens endorsed by the Alzheimer's, National Institute of Aging (NIA), and Gerontological Society (GSA) workgroups, plus a recently developed brief version of the standard MoCA.     

Thrombotic microangiopathy as a cause of dilated cardiomyopathy in HIV-infected patients

Thrombotic microangiopathy is a rare cause of dilated cardiomyopathy. Both entities have been described separately in the setting of HIV infection. However, no patient with these 2 conditions has been reported to date. We report here 2 HIV-infected patients with dilated cardiomyopathy seemingly caused by thrombotic microangiopathy.     

Hemostatic plug formation in normal and von Willebrand pigs: the effect of the administration of cryoprecipitate and a monoclonal antibody to Willebrand factor

Hemostatic plug (HP) formation was investigated in the ear bleeding time incision in normal and von Willebrand pigs. HP volume was calculated by integrating the areas of serial sections. In normal pigs (n = 11), platelets immediately formed a layer on the surface of the cut channel. Platelet aggregates formed at the ends of transected vessels and gradually enlarged. Finally, all transected vessels were occluded by HP and bleeding stopped. In contrast, large HPs were formed in the incision in von Willebrand's disease (vWD) pigs (n = 4); these HPs did not cover the ends of the transected vessels, which continued to bleed, allowing the formation of large hemostatically ineffective platelet aggregates in the incision. Canals traversed these HPs, and bleeding from the open vessels may have continued through them. After infusion of cryoprecipitate into a vWD pig, the bleeding time shortened, and the morphological findings of the HPs were similar to those of normal pigs. In normal pigs (n = 3) infused with an anti- Willebrand factor monoclonal antibody, which prolonged the bleeding time, a large HP formed in the incision, similar to that observed in the vWD pig. The volume of the normal and vWD HPs increased with time. These in vivo findings suggest that Willebrand factor is involved in the localization of the HP to the damaged vessel and may also play a role in platelet-platelet interaction. A computerized morphometric technique was used for measuring the volume of the hemostatic plugs and the distance of sequential points on the perimeter of the HP from the center of selected bleeding vessels.     

Detection of lung perfusion abnormalities using computed tomography in a porcine model of pulmonary embolism

The purpose of this study was to identify perfusion defects of the lung using computed tomography (CT). A balloon catheter was placed in a lobar pulmonary artery of six anesthetized, ventilated, juvenile pigs to simulate occlusive segmental embolus. Contrast medium was injected via a central venous catheter at rates of 1.5, 3, 4.5, and 9 ml/s in each pig. A 40-second single-level cine CT was acquired distal to the inflated balloon during suspended inspiration. Three computer-manipulated images (time to maximal enhancement, change in maximal attenuation, maximal contrast minus precontrast subtraction) were generated using custom software and compared with the unmodified maximal enhancement and precontrast images. Two independent observers identified perfusion defects and scored the level of confidence (5-point scale) on all five images. Regions of interest were drawn in perfused and nonperfused lung and time-attenuation curves were generated. Perfusion defects were accurately (99.8 +/- 0.3%) and confidently (4.5 +/- 0.6) detected and there was excellent interobserver agreement (Kappa 0.99 +/- 0.02) on all computer-manipulated images. There was a significant increase in confidence (p < 0.05) between contrast medium injection rates of 1.5 and 9 ml/s. A linear relationship exists (r = 0.88) between injection rate and change in maximal attenuation. In conclusion, perfusion defects of the lung are seen using computer-manipulated CT images.     

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.