Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial.

BACKGROUND: Patients with significant multimorbidity and other factors that make healthcare challenging to access and coordinate are at high risk for poor health outcomes. Although most (93%) of Veterans' Health Administration (VHA) patients at high risk for hospitalization or death ("high-risk Veterans") are primarily managed by primary care teams, few of these teams have implemented evidence-based practices (EBPs) known to improve outcomes for the high-risk patient population's complex healthcare issues. Effective implementation strategies could increase adoption of these EBPs in primary care; however, the most effective implementation strategies to increase evidence-based care for high-risk patients are unknown. The high-RIsk VETerans (RIVET) Quality Enhancement Research Initiative (QUERI) will compare two variants of Evidence-Based Quality Improvement (EBQI) strategies to implement two distinct EBPs for high-risk Veterans: individual coaching (EBQI-IC; tailored training with individual implementation sites to meet site-specific needs) versus learning collaborative (EBQI-LC; implementation sites trained in groups to encourage collaboration among sites). One EBP, Comprehensive Assessment and Care Planning (CACP), guides teams in addressing patients' cognitive, functional, and social needs through a comprehensive care plan. The other EBP, Medication Adherence Assessment (MAA), addresses common challenges to medication adherence using a patient-centered approach. METHODS: We will recruit and randomize 16 sites to either EBQI-IC or EBQI-LC to implement one of the EBPs, chosen by the site. Each site will have a site champion (front-line staff) who will participate in 18 months of EBQI facilitation. ANALYSIS: We will use a mixed-methods type 3 hybrid Effectiveness-Implementation trial to test EBQI-IC versus EBQI-LC versus usual care using a Concurrent Stepped Wedge design. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the maintenance/sustainment and spread of both EBPs in primary care after the 18-month implementation period. Our primary outcome will be Reach, measured by the percentage of eligible high-risk patients who received the EBP. DISCUSSION: Our study will identify which implementation strategy is most effective overall, and under various contexts, accounting for unique barriers, facilitators, EBP characteristics, and adaptations. Ultimately this study will identify ways for primary care clinics and teams to choose implementation strategies that can improve care and outcomes for patients with complex healthcare needs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05050643. Registered September 9th, 2021, https://clinicaltrials.gov/study/NCT05050643 PROTOCOL VERSION: This protocol is Version 1.0 which was created on 6/3/2020.

Caring for high-need patients.

OBJECTIVE: We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions. METHODS: We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus. RESULTS: The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately. CONCLUSIONS: Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

High-Risk Patient Experiences Associated With an Intensive Primary Care Management Program in the Veterans Health Administration.

Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85).

Patient selection strategies in an intensive primary care program.

BACKGROUND: Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context. METHODS: This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics. RESULTS: Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM. CONCLUSIONS: A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.

Quality Indicators for High-Need Patients: a Systematic Review.

BACKGROUND: Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. METHODS: This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. RESULTS: The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. DISCUSSION: We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.

Empathy and Impaired Socioemotional Self-Perception in Frontotemporal Dementia.

OBJECTIVE: Impaired empathy is a core feature of behavioral variant frontotemporal dementia (bvFTD). Patients with bvFTD are also prominently impaired in experiencing self-conscious emotions. The investigators explored whether impaired empathy in bvFTD, such as self-conscious emotions, may result from impaired self-consciousness in social situations (socioemotional self-perception). METHODS: This pilot study evaluated 25 patients with bvFTD and compared them with 25 patients with Alzheimer's disease who had comparable dementia severity. Their caregivers completed the Social Dysfunction Scale (SDS), which quantifies empathy, and an extensive intake interview that included questions regarding self-consciousness and insight. The patients completed two measures of self-perception in social situations, the Schutte Self-Report Emotional Intelligence Test (SSEIT) scale and the Embarrassability Scale (EMB). RESULTS: Caregivers of patients with bvFTD, but not of patients with Alzheimer's disease, reported a high correlation between significantly decreased empathy (SDS) and decreased self-consciousness (intake interview questions). Consistent with lack of insight, the patients with bvFTD, unlike the patients with Alzheimer's disease, did not report decreases on the SSEIT and EMB measures. CONCLUSIONS: These preliminary findings suggest that impaired socioemotional self-perception plays a role in the loss of empathy among patients with bvFTD. A lack of self-consciousness in social situations may contribute to a loss of empathy resulting from an inability to co-represent another's emotion in relation to oneself.

Outcomes of a randomized quality improvement trial for high-risk Veterans in year two.

OBJECTIVE: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year. DATA SOURCES: VHA administrative data for five demonstration sites from August 2013 to March 2019. DATA SOURCES: Administrative data extracted from VHA's Corporate Data Warehouse. STUDY DESIGN: Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences. PRINCIPAL FINDINGS: Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73). CONCLUSIONS: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.

Financial Hardship and Health Related Quality of Life Among Older Latinos With Chronic Diseases.

BACKGROUND: Financial hardship influences health-related quality of life (HRQoL) of older adults. However, little is known about the relationship between financial hardship and HRQoL among vulnerable populations. OBJECTIVE: We examined the associations between financial hardship and HRQoL among older Latinos living with chronic disease, including cancer. METHODS: This cross-sectional study included 68 Latinos (age range 50-87) with one or more chronic health conditions who participated in a pilot randomized clinical trial. Participants responded to 11 financial hardship questions. We used factor analysis to explore constructs of financial hardship. HRQoL was assessed using the 27-item Functional Assessment of Cancer Therapy-General (FACT-G). Multiple linear regression examined the associations between financial hardship and HRQoL subscales (physical, social/family, emotional, functional well-being). RESULTS: The factor analysis revealed 3 constructs of financial hardship: medical cost concerns, financial hardship treatment adherence, and financial worry. A 1-point increase in the factor score for financial hardship treatment adherence was associated with a 2.1-point (SE = 0.771) decrease in physical well-being and with a 1.71-point (SE = 0.761) decrease in functional well-being. A 1-point increase in the financial stress factor score was associated with a 2.0-point (SE = 0.833) decrease in social/family well-being, and with a 2.1-point (SE = 0.822) decrease in functional well-being. CONCLUSION: In this study of older Latinos with chronic diseases, financial hardship was associated with worse HRQoL across several domains. Healthcare providers should refer older Latinos living with chronic disease to appropriate support providers, such as care coordinators, social workers, or patient navigators, who can assist them with obtaining financial assistance and other resources.

Neuropsychiatric Effects on Decision-Making in Early Alzheimer Disease.

BACKGROUND: Neuropsychiatric symptoms can impact decision-making in patients with Alzheimer disease (AD). METHODS: Using a simple decision-making task, a variant of the ultimatum game (UG) modified to control feelings of unfairness, this study investigated rejection responses among responders to unfair offers. The UG was administered to 11 patients with AD, 10 comparably demented patients with behavioral variant frontotemporal dementia (bvFTD), and 9 healthy controls (HC). The results were further compared with differences on the caregiver Neuropsychiatric Inventory (NPI). RESULTS: Overall, patients with AD significantly rejected more total offers than did the patients with bvFTD and the HC (P < .01). On the NPI, the only domain that was significantly worse among the patients with AD compared to the other groups was dysphoria/depression. CONCLUSIONS: These results suggest that early AD can be distinguished based on increased rejections of offers in decision-making, possibly consequent to a heightened sense of unfairness from dysphoria/depression.

Frontotemporal asymmetry in socioemotional behavior: A pilot study in frontotemporal dementia.

Clinical studies report abnormal socioemotional behavior in patients with right frontotemporal disease, but neuroimaging studies of socioemotional behavior usually show bilateral activations in normal subjects. This discrepancy suggests that impaired interhemispheric collaboration for socioemotional functions results from asymmetric frontotemporal disease. Behavioral variant frontotemporal dementia (bvFTD) can clarify the contribution of direction-independent frontotemporal asymmetry. In a two-part study, we evaluated bvFTD patients using socioemotional scales and magnetic and resonance imaging measures. Part A compared 18 patients on scales of social dysfunction and emotional intelligence with degree of asymmetry in frontal lobe volumes and analyzed differences between lower and higher asymmetry groups. Part B compared 24 patients on scales of social observation and emotional blunting with degree of asymmetry in frontotemporal cortical thickness using multiple linear regression. Both results showed that left or right hemispheric-specific contributions did not account for all socioemotional differences and that frontal lobe and frontotemporal differences in atrophy between the hemispheres accounted for significant variance in abnormalities in social and emotional behavior. These preliminary results indicate that the degree of frontal lobe and frontotemporal asymmetric involvement, regardless of direction or laterality, significantly contribute to socioemotional dysfunction and support the hypothesis that interhemispheric collaboration is important for complex socioemotional behavior.

Vicarious Embarrassment or "Fremdscham": Overendorsement in Frontotemporal Dementia.

OBJECTIVE: The experience of embarrassment signals violations in social norms, and impairment in this social emotion may underlie much of the social dysfunction in behavioral variant frontotemporal dementia (bvFTD). The authors investigated whether impaired self-awareness of embarrassment may distinguish patients with bvFTD early in the course of disease from healthy control subjects (HCs). METHODS: Self-reported embarrassment was examined among 18 patients with early bvFTD and 23 HCs by using the 36-item Embarrassability Scale, which includes items of situations eliciting embarrassment for oneself ("self-embarrassment") and embarrassment for others ("vicarious embarrassment"). The two study groups were also compared with the Social Norms Questionnaire (SNQ). The analyses included correlations of SNQ results (total score, violations or "break" errors, and overendorsement of social rules or "overadhere" errors) with Embarrassability Scale scores. RESULTS: Patients with bvFTD did not differ from HCs on total or self-embarrassment scores but did have significantly higher vicarious embarrassment scores. Unlike in the HC group, reports of vicarious embarrassment did not differ from reports of self-embarrassment among patients in the bvFTD group. The Embarrassability Score further correlated with overadherence to norms on the SNQ. CONCLUSIONS: In the presence of social dysfunction and emotional blunting, these findings suggest that patients with bvFTD rely on their own perspective for a rule-based application of social norms in reporting vicarious embarrassment. The assessment of reports of embarrassment for others may indicate an early and previously unrecognized clinical measure for detecting bvFTD.

Neuropsychological Similarities and Differences Between Amnestic Alzheimer's Disease and its Non-Amnestic Variants.

BACKGROUND: The neuropsychological recognition of early-onset Alzheimer's disease (AD) can be difficult because of non-amnestic variants such as logopenic variant primary progressive aphasia (lvPPA) and posterior cortical atrophy (PCA). OBJECTIVE: This study evaluated the similarities and differences between typical amnestic AD (tAD) and lvPPA and PCA on a screening neuropsychological battery. METHODS: We enrolled 51 patients meeting NIA-AA criteria for biomarker-supported AD (amnestic or non-amnestic) and having an age of onset of <65 years of age. Based on additional recommended clinical criteria for lvPPA and PCA, the early-onset AD patients were divided into three groups (28 tAD, 9 lvPPA, 14 PCA) of comparable age and dementia severity. We then analyzed their profiles on a focused, screening neuropsychological battery for early-onset AD. RESULTS: In addition to greater variance on the Mini-Mental State Examination, the lvPPA and PCA variants had episodic memory impairment that did not significantly differ from the memory impairment in the tAD patients. Despite differences on language and visuospatial tasks, they did not significantly distinguish the lvPPA and PCA from tAD. The lvPPA group, however, was distinguishable by worse performance on measures reflecting working memory (digit span forward, memory registration). CONCLUSIONS: On neuropsychological screening, all clinical early-onset AD subtypes may have memory impairments. Screening batteries for early-onset AD should also include measures of working memory, which is disproportionately decreased in lvPPA.

Impaired Empathy Versus General Hypoemotionality in Frontotemporal Dementia.

OBJECTIVE: Impaired empathy is a diagnostic feature of behavioral variant frontotemporal dementia (bvFTD), but it is not clear whether it is caused by a primary impairment in empathy or by general emotional blunting. METHODS: Patients with bvFTD who met criteria for loss of empathy (N=10) and patients with Alzheimer's disease (N=15) were assessed with a measure for empathy (Socioemotional Dysfunction Scale [SDS]) and a measure for general emotion (Scale for Emotional Blunting [SEB]). All patients underwent neuroimaging. Both patient groups and a healthy control group (N=18) were evaluated by using autonomic responses (skin conductance responses [SCR]) to pictures from the Internal Affective Picture System (IAPS) (presence or absence of empathy stimuli and high versus low emotion). RESULTS: All participants reported understanding the content and others' perspectives on the empathy pictures; however, only patients with bvFTD showed impaired empathic behavior on the SDS, which persisted after adjusting for measures from the emotion scale (SEB). Patients with bvFTD had significantly lower SCR for all the IAPS stimuli, including for empathy pictures, which also persisted after adjusting for emotional content. On MRI analysis, SCR across groups significantly correlated with the volume of the dorsal anterior cingulate gyrus (dACC). CONCLUSIONS: These results indicate that patients with bvFTD have decreased empathic behavior with or without emotional blunting, and they exhibit decreased psychophysiological responses to empathy stimuli, independent of general emotion. These preliminary findings suggest a specific impairment in emotional empathy, possibly related to impairment of the emotional appraisal role of the dACC.

Skin Conduction Levels Differentiate Frontotemporal Dementia From Alzheimer's Disease.

Patients with behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD) differ in basic emotional tone. Skin conduction levels (SCLs), a measure of sympathetic tone, may be a sensitive test for discriminating these two dementias early in their course. Previous research has shown differences in resting SCLs between patients with bvFTD and AD, but no study has evaluated the discriminability of SCLs during different environmental conditions. The authors compared bvFTD patients (N=8), AD patients (N=10), and healthy control subjects (N=9) on SCL measures pertaining to real-life vignettes or scenarios differing in valence and emotional intensity. The SCLs among the bvFTD patients were decreased across all conditions, whereas the SCLs among the AD patients were increased compared with control participants. On analysis, the SCLs in response to emotional stimuli differentiated bvFTD from AD with an area under the receiver operator characteristic curve of 95.3%. At a cutoff ≤0.77 µS, emotional vignettes distinguished bvFTD from AD with a sensitivity of 86% and a specificity of 96%. These preliminary results indicate the potential utility of SCLs for differentiating bvFTD from AD early in their course, regardless of environmental condition.

Screening for Emotional Expression in Frontotemporal Dementia: A Pilot Study.

OBJECTIVE: Although emotional blunting is a core feature of behavioral variant frontotemporal dementia (bvFTD), there are no practical clinical measures of emotional expression for the early diagnosis of bvFTD. METHOD: Three age-matched groups (bvFTD, Alzheimer's disease (AD), and healthy controls (HC)) of eight participants each were presented with real-life vignettes varying in emotional intensity (high versus low) with either negative or positive outcomes. This study evaluated verbal (self-reports of distress) and visual (presence or absence of facial affect) measures of emotional expression during the vignettes. RESULTS: The bvFTD patients did not differ from the AD and HC groups in reported distress or in the amount of facial affect during vignettes with high emotional intensity or type of outcome. However, the bvFTD patients reported significantly less distress and had correspondingly few facial affective expressions when compared on vignettes of low intensity. CONCLUSIONS: Patients with bvFTD require a high intensity of emotional stimulus and are significantly hyporesponsive to low-intensity stimuli. Simple screening or observations of verbal and facial responsiveness to mildly arousing stimuli may aid in differentiating bvFTD from normal subjects and patients with other dementias. Future studies can investigate whether delivering information with high emotional intensity can facilitate communication with patients with bvFTD.

Initial Heart Rate Reactivity to Socioemotional Pictures in Early-Onset Alzheimer's Disease.

Patients with Alzheimer's disease (AD) often have generalized anxiety, particularly in early-onset AD (EOAD) or the first stages of their disease. This increased anxiety could be associated with decreased sensorimotor gating with increased attention to significant stimuli from AD pathology in the entorhinal cortex. We investigated whether widening initial attention to socioemotional stimuli was association with anxiety among 16 patients with first stage EOAD compared to 19 normal controls (NCs). The participants underwent assessment of their initial heart rate deceleration ("orienting response"; OR), a measure of attentional refocusing, to pictures (International Affective Picture Stimuli) varying in pleasant-unpleasant valence and social-nonsocial content. The results showed group differences; the EOAD patients had significantly larger ORs than the NCs across conditions, with larger ORs in each valence and social condition. In addition, the EOAD patients, but not the NCs, showed ORs to normally less threatening stimuli, particularly pleasant, but also less significantly, social stimuli. On the Neuropsychiatric Inventory, the ORs among the EOAD patients significantly correlated with anxiety scores. Together, these findings suggest that anxiety in mild EOAD may be associated with widening attentional refocusing to socioemotional stimuli, possibly reflecting decreased sensorimotor gating in the entorhinal cortex. This finding could be a potential biomarker for the first stages of AD.

Pavlov's Orienting Response in Frontotemporal Dementia.

Behavioral variant frontotemporal dementia (bvFTD) is a neurodegenerative disorder with initial disturbances in socioemotional behavior in the absence of a sensitive diagnostic test. This study evaluated Pavlov's "orienting response" (OR) or "what is it?" reflex as a measure of their ability to refocus attention on socioemotional stimuli and as a potentially distinguishing measure for bvFTD. Ten patients with bvFTD were compared with 18 normal controls (NC) on ORs (defined as initial heart rate [HR] deceleration) to different pictures based on social and emotional (valence) differences from the International Affective Picture Stimuli. HR was measured while participants viewed pleasant-nonsocial (e.g., food), unpleasant-nonsocial (e.g., garbage), pleasant-social (e.g., babies), and unpleasant-social (e.g., violence) pictures. Participants watched each picture for 6 seconds, and the study examined HR changes during the first 2-second OR interval. The results showed significant differences in valence (pleasant-unpleasant) and valence-group interactions, but no effects of nonsocial-social. Whereas the NCs showed the expected HR deceleration (OR) to unpleasant stimuli, the bvFTD patients showed increased HRs without an initial refocusing. Decreased HR slowing to stimuli among the bvFTD patients correlated with increased scores on an emotional blunting scale. These findings suggest that decreased socioemotional behavior in bvFTD may be associated with decreased appreciation of emotional aspects of stimuli as evidenced by decreased ORs to emotional stimuli, regardless of social content. These findings also suggest further investigation of the OR in bvFTD as an early diagnostic measure for this disorder.

The attribution of animacy and agency in frontotemporal dementia versus Alzheimer's disease.

Impaired attribution of animacy (state of living or being sentient) and of agency (capability of intrinsically-driven action) may underlie social behavior disturbances in behavioral variant frontotemporal dementia (bvFTD). We presented the Heider and Simmel film of moving geometric shapes to 11 bvFTD patients, 11 Alzheimer's disease (AD) patients, and 12 healthy controls (HCs) and rated their recorded verbal responses for animacy attribution and agency attribution. All participants had skin conductance (SC) continuously recorded while viewing the film, and all dementia participants underwent magnetic resonance imaging (MRI) for regions of interest. The bvFTD patients, but not the AD patients, were impaired in animacy attribution, compared to the HCs. In contrast, both bvFTD and AD groups were impaired in agency attribution, compared to the HCs, and only the HCs had increasing SC responsiveness during viewing of the film. On MRI analysis of cortical thicknesses, animacy scores significantly correlated across groups with the right pars orbitalis and opercularis; agency scores with the left inferior and superior parietal cortices and the supramarginal gyrus; and both scores with the left cingulate isthmus involved in visuospatial context. These findings suggest that bvFTD is specifically associated with impaired animacy attribution from right inferior frontal atrophy. In contrast, both dementias may have impaired agency attribution from left parietal cortical atrophy and absent SC increases during the film, a sympathetic indicator of attribution of a social "story" to the moving shapes. These findings clarify disease-related changes in social attribution and corroborate the neuroanatomical origins of animacy and agency.

Testing of mechanical ventilators and infant incubators in healthcare institutions.

The medical device industry has grown rapidly and incessantly over the past century. The sophistication and complexity of the designed instrumentation is nowadays rising and, with it, has also increased the need to develop some better, more effective and efficient maintenance processes, as part of the safety and performance requirements. This paper presents the results of performance tests conducted on 50 mechanical ventilators and 50 infant incubators used in various public healthcare institutions. Testing was conducted in accordance to safety and performance requirements stated in relevant international standards, directives and legal metrology policies. Testing of output parameters for mechanical ventilators was performed in 4 measuring points while testing of output parameters for infant incubators was performed in 7 measuring points for each infant incubator. As performance criteria, relative error of output parameters for mechanical ventilators and absolute error of output parameters for infant incubators was calculated. The ranges of permissible error, for both groups of devices, are regulated by the Rules on Metrological and Technical Requirements published in the Official Gazette of Bosnia and Herzegovina No. 75/14, which are defined based on international recommendations, standards and guidelines. All ventilators and incubators were tested by etalons calibrated in an ISO 17025 accredited laboratory, which provides compliance to international standards for all measured parameters.The results show that 30% of the tested medical devices are not operating properly and should be serviced, recalibrated and/or removed from daily application.