Transient ischemic attack: Part I. Diagnosis and evaluation.

Transient ischemic attack is defined as transient neurologic symptoms without evidence of acute infarction. It is a common and important risk factor for future stroke, but is greatly underreported. Common symptoms are sudden and transient, and include unilateral paresis, speech disturbance, and monocular blindness. Correct and early diagnosis of transient ischemic attack versus mimicking conditions is important because early interventions can significantly reduce risk of future stroke. Nonspecific symptoms and gradual onset are more likely with mimics than with true transient ischemic attacks. Transient ischemic attacks are more likely with sudden onset, focal neurologic deficit, or speech disturbance. Urgent evaluation is necessary in patients with symptoms of transient ischemic attack and includes neuroimaging, cervicocephalic vasculature imaging, cardiac evaluation, blood pressure assessment, and routine laboratory testing. The ABCD(2) (age, blood pressure, clinical presentation, diabetes mellitus, duration of symptoms) score should be determined during the initial evaluation and can help assess the immediate risk of repeat ischemia and stroke. Patients with higher ABCD(2) scores should be treated as inpatients, whereas those with lower scores are at lower risk of future stroke and can be treated as outpatients.

Transient ischemic attack: Part II. Risk factor modification and treatment.

Interventions following a transient ischemic attack are aimed at preventing a future episode or stroke. Hypertension, current smoking, obesity, physical inactivity, diabetes mellitus, and dyslipidemia are all well-known risk factors, and controlling these factors can have dramatic effects on transient ischemic attack and stroke risk. For patients presenting within 48 hours of resolution of transient ischemic attack symptoms, advantages of hospital admission include rapid diagnostic evaluation and early intervention to reduce the risk of stroke. For long-term prevention of future stroke, the American Heart Association/American Stroke Association recommends antiplatelet agents, statins, and carotid artery intervention for advanced stenosis. Aspirin, extended-release dipyridamole/aspirin, and clopidogrel are acceptable first-line antiplatelet agents. Statins have also been shown to reduce the risk of stroke following transient ischemic attack, with maximal benefit occurring with at least a 50 percent reduction in low-density lipoprotein cholesterol level or a target of less than 70 mg per dL (1.81 mmol per L). For those with transient ischemic attack and carotid artery stenosis, carotid endarterectomy is recommended if stenosis is 70 to 99 percent, and perioperative morbidity and mortality are estimated to be less than 6 percent.

Evaluation of suspected dementia.

As the proportion of persons in the United States older than 65 years increases, the prevalence of dementia will increase as well. Risk factors for dementia include age, family history of dementia, apolipoprotein E4 genotype, cardiovascular comorbidities, chronic anticholinergic use, and lower educational level. Patient history, physical examination, functional assessment, cognitive testing, laboratory studies, and imaging studies are used to assess a patient with suspected dementia. A two-visit approach is time-effective for primary care physicians in a busy outpatient setting. During the first visit, the physician should administer a screening test such as the verbal fluency test, the Mini-Cognitive Assessment Instrument, or the Sweet 16. These tests have high sensitivity and specificity for detecting dementia, and can be completed in as little as 60 seconds. If the screening test result is abnormal or clinical suspicion of another disease is present, appropriate laboratory and imaging tests should be ordered, and the patient should return for additional cognitive testing. A second visit should include a Mini-Mental State Examination, Geriatric Depression Scale, and verbal fluency and clock drawing tests, if not previously completed.

Impact and Reception of a Required 4-Week Palliative Medicine Rotation.

BACKGROUND AND OBJECTIVES: Hospice and palliative medicine (HPM) is one of three Accreditation Council for Graduate Medical Education accredited clinical subspecialties available to family medicine graduates for fellowship training. Despite this, training is not currently a curriculum requirement. We have pioneered a required 4-week palliative medicine rotation into the curriculum. METHODS: Twenty-eight residents who completed the palliative medicine rotation across four classes were surveyed to assess how the rotation improved their level of comfort with providing end-of-life (EOL) care and to demonstrate the need of formal palliative medicine training. Wilcoxon signed ranks test was used to detect statistical differences between the mean level of comfort of residents pre- and postrotation with providing the basic skills needed to practice HPM. RESULTS: The HPM rotation significantly improved the residents' level of comfort in all areas of measured EOL care (P<0.001). All residents surveyed strongly agreed that the rotation was valuable to their future and 100% of residents strongly agreed that an HPM rotation should be required. CONCLUSIONS: Formal HPM training should be a required component in residency education and considerations should be given to the 4-week format. This rotation provides a model that can be implemented in other residency programs nationally. Implementation of this rotation may help close the enormous gap of patients not receiving quality EOL care.

End-of-life care in advanced dementia.

In the next 30 years, the average age of the population will continue to increase, as will the prevalence of dementia. The management of advanced dementia requires the careful orchestration of communication, prognostication, patient care, and caregiver education. Understanding the specific tools available to establish prognosis and guide medical management in these complicated medical patients greatly improves patient and caregiver satisfaction at the end of the patient's life. In caring for patients with advanced-stage dementia, providers should be knowledgeable regarding the terminal nature of the condition and its common comorbid diseases, and should be prepared to educate the patients' caregivers, building a structure of support for the patient's benefit and navigating the complexities of end-of-life care.

Delirium superimposed on dementia and mild cognitive impairment.

Dementia is an illness that progressively affects cognition, emotion, and functional status. It can be complicated by delirium, an acute disturbance of consciousness and cognition that develops over a short course with fluctuating symptoms. Patients with dementia who experience delirium tend to have slower resolution of symptoms, more adverse events, and poorer outcomes. There are significant health care expenditures associated with delirium. Many health care providers fail to recognize and diagnose delirium. The confusion assessment method is a suggested tool for diagnosing delirium. Delirium is multifactorial, occurring in an individual who has a predisposing factor (dementia is the number 1 risk factor) and is exposed to further precipitating risk factors that are often preventable. The main focus of treatment and management of delirium should be on prevention, which can be achieved through assessing patients for predisposing and precipitating factors. If a patient does develop delirium, a reassessment of precipitating factors is the first step in treatment, and then nonpharmacologic or pharmacologic treatment can be considered. The use of antipsychotics or melatonin to treat delirium in dementia is considered off-label.

Managing patients on antipsychotics: your domain, too.

Primary care physicians are increasingly likely to care for patients taking antipsychotics. Here's what you need to know about the common adverse effects, major risks, and monitoring required.

Current guidelines on antiplatelet agents for secondary prevention of noncardiogenic stroke: an evidence-based review.

Antiplatelet therapy is a mainstay of secondary prevention of ischemic strokes. Recent studies, such as Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS), the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial, and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT), have added much to our understanding about how best to utilize the various antiplatelet agents available. Aspirin has been shown to reduce the risk of recurrent strokes, and the combination of aspirin and dipyridamole has repeatedly been shown to outperform aspirin alone. Recently, clopidogrel was demonstrated to be "noninferior" to an aspirin/dipyridamole combination, and can be considered as a first-line agent. The American Stroke Association and American Heart Association have clear recommendations on how to utilize these agents.

Students who participate in a student-run free health clinic need education about access to care issues.

We surveyed first-year medical students about preparedness for work at student-run clinics, and for addressing patients' access to care, and social issues. Most students did not know how to get uninsured patients ongoing care or medications outside of the student-run clinic. A large majority of students desired an orientation addressing these issues.

Intracerebral hemorrhage for the palliative care provider: what you need to know.

Intracerebral hemorrhage (ICH) makes up 10%-30% of all strokes. Palliative care providers are often asked to get involved with ICH cases to aid with development of short-term and long-term goals. Prognosis can be calculated using the ICH score (based on Glasgow Coma Score score, ICH volume, presence of intraventricular hemorrhage, age, and location of origin) or the Essen score (based on age, NIH Stroke Scale [NIHSS], and level of consciousness). Do-not-resuscitate (DNR) status is important to discuss with families. Expert consensus states DNR is appropriate if the patient has two of the following: severe stroke, life-threatening brain damage, or significant comorbidities. The process of withdrawing ventilatory support can differ greatly from that of a medical intensive care unit (ICU) patient. Most ICH patients die within 24 hours following extubation. Symptoms of dyspnea and pain warrant use of opioids before and after terminal extubation. In addition, treating death rattle and postextubation stridor are important interventions. Family meetings are a vital intervention to help explain prognosis, establish a plan of care, and to get all family members on the same page. Family meetings can have a rapid effect, with 66% of families opting for withdrawal of life support to decide within 24 hours of such a meeting.

Angioedema after local trauma in a patient on angiotensin-converting enzyme inhibitor therapy.

Angioedema is a side effect that is often associated with the use of angiotensin-converting enzyme (ACE) inhibitor medications. These medications result in increased levels of circulating bradykinins. This case illustrates the result of a local traumatic event to the upper lip, presumably causing marked bradykinin release in a patient who was taking an ACE inhibitor. The local release of bradykinin from trauma, in addition to decreased bradykinin catabolism secondary to ACE inhibitor therapy, resulted in angioedema predominantly in the upper lip. The angioedema resolved with discontinuation of the ACE inhibitor.