Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Patients With Cognitive Impairment and Their Caregivers.

BACKGROUND AND OBJECTIVES: Advance care planning (ACP) conversations are important to provide goal-concordant care (i.e., the care that matches the patient's previously stated goals) near end of life. While 31% of older adults presenting to the emergency department (ED) have dementia, only 39% have previously had ACP conversations. We refined and piloted an ED-based, motivational interview designed to stimulate ACP conversations (ED GOAL) for patients living with cognitive impairment and their caregivers. RESEARCH DESIGN AND METHODS: We systematically refined ED GOAL and then conducted an acceptability study in an urban, academic medical center. We prospectively enrolled adults aged 50+ with cognitive impairment and their caregivers. Trained clinicians conducted the intervention. We measured acceptability after the intervention and participants' ACP engagement at baseline and 1-month follow-up. RESULTS: Specific statements to address both the patient and caregiver were added to the ED GOAL script. Of 60 eligible patient/caregiver dyads approached, 26 participated, and 20 (77%) completed follow-up assessments. Patient mean age was 79 years (SD 8.5); 65% were female, 92.3% were White, 96.2% were non-Hispanic, and 69% had moderate dementia. Most patients/caregivers reported feeling completely heard and understood by the study clinician about their future medical care preferences (58%, 15/26). They also reported that the study clinician was very respectful (96%, 25/26) when eliciting those preferences. DISCUSSION AND IMPLICATIONS: Patients living with cognitive impairment and their caregivers found our refined ED GOAL acceptable and respectful. Future studies need to examine the effect of ED GOAL on ACP engagement among these dyads in the ED.

Evaluating older adults with cognitive dysfunction: A qualitative study with emergency clinicians.

BACKGROUND: Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic. METHODS: From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10-20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive-inductive approach. Responses regarding experiences before and during the pandemic were compared. RESULTS: Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic. CONCLUSION: Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.

Emergency Clinicians' Perceptions of Communication Tools to Establish the Mental Baseline of Older Adults: A Qualitative Study.

Background Evaluating older adults with altered mental status in emergency settings can be challenging due to the inability to obtain a history from patients directly and limited collateral information about the change from a patient's mental status baseline. Documents and videos establishing a patient's mental baseline could represent useful communication tools to aid emergency clinicians. Methods Qualitative interviews conducted with 22 emergency clinicians (12 physicians and 10 advanced practice providers) identified methods they use to determine baseline mental status of older adults in the ED and the perceived utility of document- and video-based information about an older adult's baseline mental status. Interview transcripts were coded for dominant themes using deductive and inductive approaches. Results Participants determine an older adult's baseline mental status by obtaining information about the patient's baseline cognition (memory and communication) and function (activities of daily living and mobility). The techniques they use include 1) reviewing the electronic medical record, 2) speaking with family members or caregivers by phone or in person, and 3) obtaining verbal or phone reports from emergency medical services personnel or health care providers from short- or long-term care facilities. The majority of participants thought that a document or video with information about a patient's baseline mental status would be useful (n=15, 68%), qualifying that content ought to be brief, clearly dated, and periodically updated. Conclusions Documents or videos could assist emergency clinicians in establishing baseline cognitive function when evaluating geriatric patients and may have implications for improving the detection of delirium.

The response of Escherichia coli to the alkylating agents chloroacetaldehyde and styrene oxide.

DNA damage is ubiquitous and can arise from endogenous or exogenous sources. DNA-damaging alkylating agents are present in environmental toxicants as well as in cancer chemotherapy drugs and are a constant threat, which can lead to mutations or cell death. All organisms have multiple DNA repair and DNA damage tolerance pathways to resist the potentially negative effects of exposure to alkylating agents. In bacteria, many of the genes in these pathways are regulated as part of the SOS reponse or the adaptive response. In this work, we probed the cellular responses to the alkylating agents chloroacetaldehyde (CAA), which is a metabolite of 1,2-dichloroethane used to produce polyvinyl chloride, and styrene oxide (SO), a major metabolite of styrene used in the production of polystyrene and other polymers. Vinyl chloride and styrene are produced on an industrial scale of billions of kilograms annually and thus have a high potential for environmental exposure. To identify stress response genes in E. coli that are responsible for tolerance to the reactive metabolites CAA and SO, we used libraries of transcriptional reporters and gene deletion strains. In response to both alkylating agents, genes associated with several different stress pathways were upregulated, including protein, membrane, and oxidative stress, as well as DNA damage. E. coli strains lacking genes involved in base excision repair and nucleotide excision repair were sensitive to SO, whereas strains lacking recA and the SOS gene ybfE were sensitive to both alkylating agents tested. This work indicates the varied systems involved in cellular responses to alkylating agents, and highlights the specific DNA repair genes involved in the responses.

Determinants of False-Negative Fine-Needle Aspirates of Axillary Lymph Nodes in Women with Breast Cancer: Lymph Node Size, Cortical Thickness and Hilar Fat Retention.

OBJECTIVE: Ultrasound-guided fine-needle aspiration (UG-FNA) is utilized to sample axillary lymph nodes in breast cancer patients. Diagnostic sensitivity is good but few data exist regarding the causes of false-negative results. STUDY DESIGN: Fifty-four UG-FNAs of sentinel lymph nodes with histologic follow-up were identified. Gross and radiographic lymph node size, the percentage replaced by carcinoma and the cortical thickness were correlated with false-negative rates. RESULTS: Thirty-seven aspirates were negative, 5 of these being false-negative (9%). True-positive lymph nodes averaged 1.3 cm in dimension while false-negatives averaged 0.92 cm. Percentage involvement by carcinoma for true-positive FNAs averaged 69% while false-negatives averaged 25%. Cortical thickness averaged 5.6 mm in true-positive FNAs but 2.9 mm in false-negatives. CONCLUSION: A relationship exists between lymph node size and the likelihood of a false-negative FNA. Lymph nodes <1.2 cm have a higher incidence of false-negative results. Lymph nodes with <30% involvement demonstrated a higher percentage of false-negatives than those with >30% replacement. Sentinel lymph nodes <1 cm appear to be relatively poor candidates for UG-FNA. Lymph nodes with a cortical thickness <3.5 mm are more often associated with a false-negative result than nodes with a thicker cortex.

Leukoencephalopathy, cerebral calcifications, and cysts in two sisters.

BACKGROUND: The triad of leukoencephalopathy with cerebral calcifications and cysts is a rare syndrome consisting of these three radiographic findings first described by Labrune et al. in 1996. The inheritance pattern and genetic mutation responsible for this syndrome (if any) have not been determined. PATIENT DESCRIPTION: We report the occurrence of this syndrome in siblings. Two sisters presented with leukoencephalopathy, cerebral calcifications, and cysts approximately 10 years apart, one at 18 years with longstanding epilepsy and the other at 25 years with postpartum stroke-like signs. In both individuals, computed tomography revealed calcifications in the basal ganglia and subcortical white matter as well as supratentorial cysts. Magnetic resonance imaging demonstrated diffuse white matter increased T2 signal and bilateral supratentorial cysts with enhancing walls. Both patients underwent biopsy, one an open biopsy and the other a stereotactic biopsy, with sections of the resected tissue revealing gliosis with Rosenthal fibers, myelin loss, and calcifications, plus in the larger sample cystic spaces and thick-walled abnormal blood vessels with hemosiderin deposition in the adjacent tissues. CONCLUSION: In these siblings, the triad of radiological findings, histopathologic findings, and lack of extraneurological findings on physical examination suggest an occurrence of familial leukoencephalopathy, cerebral calcifications, and cysts with probable autosomal recessive inheritance.