Usefulness of the Montreal Cognitive Assessment in Older Adults With Type 1 Diabetes.

Objective: Older adults with type 1 diabetes are at high risk for cognitive impairment, yet the usefulness of common cognitive screening instruments has not been evaluated in this population. Methods: A total of 201 adults ≥60 years of age with type 1 diabetes completed a battery of neuropsychological measures and the Montreal Cognitive Assessment (MoCA). Receiver operating characteristic (ROC) curves and Youden indices were used to evaluate overall screening test performance and to select an optimal MoCA cutoff score for detecting low cognitive performance, as defined as two or more neuropsychological test performances ≥1.5 SD below demographically corrected normative data. Results: The ROC area under the curve (AUC) was 0.745 (P < 0.001). The publisher-recommended cutoff score of <26 resulted in sensitivity of 60.4% and specificity of 71.4%, whereas a cutoff score of <27 resulted in sensitivity of 75.0% and specificity of 61.0%. The Youden indices for these cutoff scores were 0.318 and 0.360, respectively. Minimally acceptable sensitivity (i.e., >0.80) was obtained when using a cutoff score of <28, whereas >0.80 specificity was obtained with a cutoff score of <25. Conclusions: The MoCA has modest overall performance (AUC 0.745) as a cognitive screening instrument in older adults with type 1 diabetes. The standard cutoff score of <26/30 may not adequately detect individuals with neuropsychological testing-defined abnormal cognition. The optimal MoCA cutoff score (based on the Youden index) was <27/30. A score of <28 resulted in acceptable sensitivity but was accompanied by low specificity (42%). Future studies with a more diverse population are needed to confirm these findings.

Bilobed gallbladder discovered during laparoscopic cholecystectomy: a tale of two lobes and one duct.

Bilobed gallbladder (BG) is a rare congenital anomaly with just 24 cases documented in medical literature in the past 127 years. There are only three documented cases of BG's managed with laparoscopic cholecystectomy, and in all three cases the bilobed anomaly was discovered preoperatively. We present a case of symptomatic cholelithiasis in a BG that was discovered intraoperatively. Both the surgical techniques used to ensure complete and safe removal of all gallbladder components and the elements associated with the preoperative diagnosis of these rare anomalies are discussed.