Use of Alzheimer's Disease Cerebrospinal Fluid Biomarkers in A Tertiary Care Memory Clinic.

INTRODUCTION: Alzheimer's disease (AD) cerebrospinal fluid (CSF) biomarkers are promising tools to help identify the underlying pathology of neurocognitive disorders. In this manuscript, we report our experience with AD CSF biomarkers in 262 consecutive patients in a tertiary care memory clinic. METHODS: We retrospectively reviewed 262 consecutive patients who underwent lumbar puncture (LP) and CSF measurement of AD biomarkers (Aß1-42, total tau or t-tau, and p-tau181). We studied the safety of the procedure and its impact on patient's diagnosis and management. RESULTS: The LP allowed to identify underlying AD pathology in 72 of the 121 patients (59%) with early onset amnestic mild cognitive impairment (aMCI) with a high probability of progression to AD; to distinguish the behavioral/dysexecutive variant of AD from the behavioral variant of frontotemporal dementia (bvFTD) in 25 of the 45 patients (55%) with an atypical neurobehavioral profile; to identify AD as the underlying pathology in 15 of the 27 patients (55%) with atypical or unclassifiable primary progressive aphasia (PPA); and to distinguish AD from other disorders in 9 of the 29 patients (31%) with psychiatric differential diagnoses and 19 of the 40 patients (47%) with lesional differential diagnoses (normal pressure hydrocephalus, encephalitis, prion disease, etc.). No major complications occurred following the LP. INTERPRETATION: Our results suggest that CSF analysis is a safe and effective diagnostic tool in select patients with neurocognitive disorders. We advocate for a wider use of this biomarker in tertiary care memory clinics in Canada.

The Dépistage Cognitif de Québec: A New Clinician's Tool for Early Recognition of Atypical Dementia.

INTRODUCTION: Early recognition of atypical dementia remains challenging partly because of lack of cognitive screening instruments precisely tailored for this purpose. METHODS: We assessed the validity and reliability of the Dépistage Cognitif de Québec (DCQ; www.dcqtest.org), a newly developed cognitive screening test, to detect atypical dementia using a multicenter cohort of 628 participants. Sensitivity and specificity were compared to the Montreal Cognitive Assessment (MoCA). A predictive diagnostic algorithm for atypical dementia was determined using classification tree analysis. RESULTS: The DCQ showed excellent psychometric properties. It was significantly more accurate than the MoCA to detect atypical dementia. All correlations between DCQ indexes and standard neuropsychological measures were significant. A statistical model distinguished typical from atypical dementia with a predictive power of 79%. DISCUSSION: The DCQ is a better tool to detect atypical dementia than standard cognitive screening tests. Expanding the clinician's tool kit with the DCQ could reduce missed/delayed identification of atypical dementia and accelerate therapeutic intervention.

Evaluation of a continuous quality improvement program in anticoagulant therapy: Feasibility, satisfaction and perception.

BACKGROUND: The ACO Program (Programme ACO), a continuous quality improvement program (CQIP) in anticoagulation therapy, was offered in community pharmacies as a pilot project. OBJECTIVE: To evaluate the participants' appreciation for the various activities of the program. METHODS: Participants had access to training activities, including an audit with feedback, online training activities (OTA), clinical tools and support from facilitators. Cognitive behavioural learning determinants were evaluated before and 5 months after the beginning of the program. Participants' satisfaction and perception were documented via online questionnaires and a semistructured interview. RESULTS: Of the 52 pharmacists in the ACO Program, 47 participated in this evaluation. Seventy-seven percent of the participants completed at least 1 OTA and 6% published on the forum. The feeling of personal effectiveness rose from 8.01 (7.67-8.35) to 8.62 (8.24-8.99). The audit and feedback, as well as the high-quality OTA and their lecturers, were the most appreciated elements. DISCUSSION: There was a high OTA participation rate. The facilitators seemed to play a key role in the CQIP. The low level of participation in the forum reflects the known phenomenon of social loafing. Technical difficulties affecting the platform and data collection for the audit with feedback constituted limitations. CONCLUSION: The CQIP in anticoagulation therapy is appreciated by community pharmacists and is associated with an improved feeling of personal effectiveness.

Clinical Assessment of Judgment in Adults and the Elderly: Development and Validation of the Three Domains of Judgment Test-Clinical Version (3DJT-CV).

(1) Background: This article discusses the first two phases of development and validation of the Three Domains of Judgment Test (3DJT). This computer-based tool, co-constructed with users and capable of being administered remotely, aims to assess the three main domains of judgment (practical, moral, and social) and learn from the psychometric weaknesses of tests currently used in clinical practice. (2) Method: First, we presented the 3DJT to experts in cognition, who evaluated the tool as a whole as well as the content validity, relevance, and acceptability of 72 scenarios. Second, an improved version was administered to 70 subjects without cognitive impairment to select scenarios with the best psychometric properties in order to build a future clinically short version of the test. (3) Results: Fifty-six scenarios were retained following expert evaluation. Results support the idea that the improved version has good internal consistency, and the concurrent validity primer shows that 3DJT is a good measure of judgment. Furthermore, the improved version was found to have a significant number of scenarios with good psychometric properties to prepare a clinical version of the test. (4) Conclusion: The 3DJT is an interesting alternative tool for assessing judgment. However, more studies are needed for its implementation in a clinical context.

Implementation and evaluation of a pharmacy-led thromboprophylaxis campaign in a community hospital.

In hospitalized patients, venous thromboembolism (VTE) is an important cause of morbidity and mortality. Despite evidence demonstrating efficacy and safety of pharmacological thromboprophylaxis in the prevention of VTE, its use remains low. The aim of this study is to compare the incidence of use of thromboprophylaxis before and after a pharmacy-led thrombosis prevention campaign in medical patients hospitalized in a community hospital. A pharmacy-led multifaceted thromboprophylaxis campaign including continuing education activities for physicians and pharmacists and individualized academic detailing activities supported by clinical tools were implemented over an 8-week period. In a quasi-experimental study, the incidence of pharmacological thromboprophylaxis was evaluated using a retrospective chart review and compared before and after the campaign in medical patients at high and non-high risk of VTE as defined by the American College of Chest Physicians criteria. The medical charts of 461 patients were reviewed; 66 and 58 patients were at high-risk of VTE prior to and after the campaign, respectively. After the campaign, thromboprophylaxis ordering in high-risk patients increased from 15.2 to 43.1% (adjusted OR: 6.8; 95% CI: 2.5-18.0). Thromboprophylaxis ordering in non-high risk patients was 1.8% before the campaign and 6.0% after. This increase was not statistically significant (adjusted OR: 4.6; 95% CI: 1.0-20.4). The incidence of pharmacologic thromboprophylaxis in hospitalized medical patients at high-risk of VTE increased significantly after the campaign but remained sub-optimal. Longer or a different campaign may be needed to ensure long-term optimal thromboprophylaxis use.

Dosage of enoxaparin among obese and renal impairment patients.

BACKGROUND: Enoxaparin dosage for obese patients and patients with renal impairment remains controversial. OBJECTIVE: To compare anti-factor Xa activity (anti-Xa) among obese and renal impairment patients to patients with healthy weight and adequate renal function. DESIGN: Open, prospective, nonrandomized clinical trial. SETTING: A major community teaching hospital. PATIENTS: A total of 233 patients with prescription of enoxaparin. INTERVENTIONS: Enoxaparin 1.5 mg/kg once daily or 1 mg/kg twice daily except those on dialysis, who received 75% of the dose. MEASUREMENTS: Anti-Xa was measured 4 h post-injection on day 2 or 3. RESULTS: Mean (95% confidence interval (95% CI)) anti-Xa was equal to 1.14 IU/mL (1.07-1.21) and 1.14 IU/mL (1.08-1.20) among patients who received one (n=92) and two injections (n=122) per day, respectively. Anti-Xa increases with body mass index (BMI) (0.01 IU/mL for each kg/m2; 95% CI: 0.002-0.017), but the increase is insufficient to reach supratherapeutic anti-Xa. Anti-Xa decreases with higher creatinine clearance (CrCl) (-0.003 IU/mL for each mL/min; 95% CI: -0.006 to -0.001). On the twice-daily regimen, this is sufficient to reach supratherapeutic anti-Xa. The odd ratio (OR) (95% CI) of having a nontherapeutic anti-Xa is equal to 2.28 (1.25-4.16) when enoxaparin is administered twice daily and to 3.03 (1.16-7.86) among severe renal impairment patients (< or =30 mL/min). CONCLUSIONS: Based on Anti-Xa, no dosage adjustments are required in obese patients. In renally impaired patients, adjustments may be necessary when enoxaparin is administered twice daily.

Reliability, validity and ease of use of a portable point-of-care coagulation device in a pharmacist-managed anticoagulation clinic.

UNLABELLED: In a pharmacist-managed anticoagulation clinic, portable point-of-care coagulation devices may facilitate patient monitoring by providing rapid INR measurement. Few studies, however, have validated this type of device. OBJECTIVE: To evaluate the reliability, validity and ease of use of the CoaguChek S, a new portable coagulation device. METHODS: A total of 100 patients followed at a pharmacist-managed anticoagulation clinic attended two study visits. INRs were measured using the CoaguChek S and the standard laboratory technique. RESULTS: Reliability: The test-retest reliability (precision) of the CoaguChek S, estimated by the intraclass correlation coefficient (ICC) and a 95% confidence interval (95% CI), was high (0.98 (0.98-0.99)) and comparable to the standard laboratory technique (0.99 (0.98-0.99)). Interrater reliability was also high (0.97 (0.95-0.98)). Reliability coefficients did not vary with the test-strip lot number nor the CoaguChek S operator. VALIDITY: When compared with standard laboratory procedure, the ICC (95% CI) was equal to 0.93 (0.91-0.95). The mean difference (95% CI) between INR measured by the laboratory and the CoaguChek S was equal to -0.02 units (-0.06-0.03). The mean absolute and relative absolute differences (95% CI) were equal to 0.24 units (0.21-0.27) and 9% (8%-10%), respectively. Differences tended to increase for INRs greater than 3 units as seen by a mean difference (95% CI) of -0.17 units (-0.35-0.02). This represented a mean absolute difference (95% CI) of 0.44 units (0.33-0.55) and a mean relative absolute difference of 12% (9%-15%). Concordance between therapeutic decisions based on CoaguChek S and laboratory results was high (Kappa = 0.68). In 34 cases (18%), the therapeutic decision would have been different. However, in 15 of these discordant observations, the difference between the CoaguCheck S and laboratory INR was