How effective is the Trail Making Test (Parts A and B) in identifying cognitively impaired drivers?

BACKGROUND: the medical community plays an important role in identifying drivers who may no longer be competent to drive due to illnesses such as dementia. Several office-based cognitive screening tools are currently used by the medical community, e.g. Mini-Mental State Examination, Trail Making Test (TMT), to assist in the identification of cognitively impaired (CI) at-risk drivers. However, the predictive validity of these tools is questionable. OBJECTIVE: to examine the predictive power of the TMT for on-road driving performance. METHODS: data from a prospective sample of CI and healthy older drivers were collected. TMT-A and -B (time and errors) served as predictor variables, with pass/fail on a scientifically based on-road assessment used as the criterion variable. Receiver operating characteristic (ROC) curve analysis was used to assess overall 'diagnostic' accuracy of TMT-A and -B for driving competency. Cut points from previous studies/guidelines were used to assess predictive power. FINDINGS: a total of 134 older drivers (mean age = 75.30; SD = 7.83) participated: 87 healthy controls and 47 CI individuals. All predictor variables, with the exception of TMT-A errors, were significantly correlated with driving outcome. However, results from ROC curve analyses indicated that only TMT-A and -B total time had moderate discriminative abilities. Results also indicate that the power of the TMT is the lowest where physicians need it most (e.g. identifying CI patients whose driving skills have declined to an unsafe level). CONCLUSION: TMT-A and -B outcomes are most likely to be inaccurate in those whose driving competency has declined to an unsafe level, resulting in risks to both individual and public safety.

Tipping the balance: Chronic superior vena cava thrombosis resulting in an aberrant and inefficient venous circuit.

Given there was no direct flow into the right atrium from the SVC, we deemed this inefficient venous circuit responsible for her breathlessness, with a small reduction in cardiac function 'tipping the balance' and producing symptoms this late in life. The patient opted for conservative management with the risk of intervention outweighing her currently manageable symptoms.

Mesalazine-induced myopericarditis: a case report.

BACKGROUND: Mesalazine is a well-established 1st line treatment for inflammatory bowel disease (IBD). Cardiotoxicity following 5-aminosalicyclic-acid therapy remains a rare yet serious complication and can often be challenging to distinguish from myocarditis presenting as an extra-intestinal manifestation of IBD. CASE SUMMARY: We present a case of a 22-year-old man with a background of ulcerative colitis commenced on a mesalazine preparation for disease progression. He presented to our hospital 12 days following drug initiation with acute chest pain, peak troponin-T of 242 ng/L, dynamic electrocardiogram changes, and severe left ventricular systolic dysfunction on transthoracic echocardiogram. The clinical diagnosis of myopericarditis was suspected and mesalazine was stopped shortly after. Outpatient cardiac magnetic resonance performed 2 weeks following mesalazine cessation demonstrated a recovery of cardiac function with associated symptom and biochemical resolution. DISCUSSION: Clinicians should be aware of this potentially fatal adverse effect of a commonly prescribed medication. Symptoms of myocarditis often occur within the early stages of mesalazine initiation, which aids the clinical diagnosis. The mainstay of treatment is to simply discontinue the drug with rapid resolution of symptoms seen without any permanent or long-term cardiac dysfunction. Close liaison with the gastroenterology team is key, as 2nd line IBD therapies are often required for the ongoing management of the patient's colitis.

Effusive-constrictive cholesterol pericarditis: a case report.

BACKGROUND: Cholesterol pericarditis (CP) remains a rare pericardial disease characterized by chronic pericardial effusions with high cholesterol concentrations with or without the formation of cholesterol crystals. Effusions are often large and can cause ventricular compression and subsequent pericardial adhesion formation. CP can be idiopathic but has associations with rheumatoid arthritis (RA), tuberculosis and hypothyroidism. CASE SUMMARY: We present a case of a 72-year-old male with a background of seropositive RA with a finding of an incidental pericardial effusion on computed tomography thorax abdomen and pelvis. Transthoracic echocardiogram demonstrated a large effusion with echocardiographic features of tamponade. On review, he was breathless with a raised venous pressure, bilateral ankle oedema, and pulsus paradoxus was present. Pericardial drainage was performed with fluid analysis demonstrating a cholesterol concentration of 8.3 mmol/L and numerous cholesterol crystal formation. Interval imaging demonstrated recurrence of the effusion with pericardial thickening and progressive constriction. He remained asymptomatic and underwent a successful pericardial window. At present, he is under close clinical outpatient surveillance with symptoms guiding a future pericardiectomy if warranted. DISCUSSION: CP can present as an emergent situation with signs and symptoms of acute heart failure with prompt pericardiocentesis required in cases of clinical tamponade. However, the disease course is often one of chronicity with relapsing large effusions that tend to recur following drainage, with the development of pericardial constriction necessitating pericardiectomy for definitive management.

Mapping catheter-related mitral valve injury: a case report.

BACKGROUND: An increasing number of catheter ablations are performed for symptomatic tachyarrhythmias and commonly involve the left atrium, increasing the risk of catheter interaction with the mitral valve (MV) complex. Mitral valve trauma at the time of atrial fibrillation (AF) ablations remains a rare yet emergent situation that requires prompt diagnosis and management to prevent the long-term sequelae of heart failure secondary to MV dysfunction. CASE SUMMARY: We present a case of a 69-year-old female with symptomatic paroxysmal AF and atrial flutter who underwent a combined ablation procedure. During the pulmonary vein isolation procedure, the mapping catheter became entangled within the MV apparatus but was freed. She presented to our hospital 2 weeks later with dyspnoea, lethargy, and a cough. Clinical examination revealed a pansystolic murmur and right moderate pleural effusion. Transthoracic echocardiogram (TTE) demonstrated a flail posterior MV leaflet with severe eccentric mitral regurgitation (MR). She underwent urgent valve repair at the regional cardiothoracic centre. Upon review 2 months later, she was symptom free with surveillance TTE demonstrating a preserved left ventricular systolic function with a trace of MR. DISCUSSION: Mitral valve injury secondary to catheter entrapment at the time of left-sided ablations is a rare yet serious complication and can present as an emergent situation requiring prompt recognition and early surgical management to salvage valve and cardiac function.

King Devick computerized neurocognitive test scores in professional football players with learning and attentional disabilities.

OBJECTIVE: This study examined outcomes from the King Devick (K-D) in athletes with Learning Disabilities (LD) and attention disorders (ADHD). METHODS: A total of 574 professional football players from the Canadian Football League (CFL) completed baseline evaluations with computerized neurocognitive testing (CNT) prior to the 2016 competitive season. Player age, education, history of concussion, LD, and ADHD were analyzed for K-D and Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) performance. A series of analyses of co-variance (ANCOVA's) were used to compare participants with a history of LD and ADHD with history of concussion as a co-variate. RESULTS: Approximately 5% of participants reported a diagnosed history of LD and 13% with ADHD. Performance on the K-D test was not significantly correlated with age, education, or history of concussion but was significantly correlated with history of LD and ADHD. Participants with LD performed approximately 6.9 s slower on the K-D test (t[563] = 4.70, p. = 0.0003) and participants with ADHD were approximately 2 s slower (t[572] = 2.04, p. = 0.04). CONCLUSIONS: Results indicated that players with a history of diagnosed LD and ADHD performed slower on the K-D test in comparison to athletes with no history of diagnoses. The results of this study underscore the importance of recognizing individualized outcomes when using the K-D.