Characterization of dementia with Lewy bodies (DLB) and mild cognitive impairment using the Lewy body dementia module (LBD-MOD).

INTRODUCTION: The National Institute on Aging Alzheimer's Disease Research Center program added the Lewy body dementia module (LBD-MOD) to the Uniform Data Set to facilitate LBD characterization and distinguish dementia with Lewy bodies (DLB) from Alzheimer's disease (AD). We tested the performance of the LBD-MOD. METHODS: The LBD-MOD was completed in a single-site study in 342 participants: 53 controls, 78 AD, and 110 DLB; 79 mild cognitive impairment due to AD (MCI-AD); and 22 MCI-DLB. RESULTS: DLB differed from AD in extrapyramidal symptoms, hallucinations, apathy, autonomic features, REM sleep behaviors, daytime sleepiness, cognitive fluctuations, timed attention tasks, and visual perception. MCI-DLB differed from MCI-AD in extrapyramidal features, mood, autonomic features, fluctuations, timed attention tasks, and visual perception. Descriptive data on LBD-MOD measures are provided for reference. DISCUSSION: The LBD-MOD provided excellent characterization of core and supportive features to differentiate DLB from AD and healthy controls while also characterizing features of MCI-DLB.

Safety, efficacy, and clinical applicability of pulmonary vein isolation with circular multi-electrode ablation systems: PVAC® vs. nMARQ™ for atrial fibrillation ablation.

AIMS: We compare our experience with available circular multi-electrode catheters for atrial fibrillation (AF) ablation: PVAC(®), a phased radiofrequency system, and nMARQ™, an irrigated tip-CARTO-based technology. METHODS AND RESULTS: Prospective observational study of 175 consecutive patients with follow-up duration of at least 5 months who underwent pulmonary vein isolation (PVI) for symptomatic AF using PVAC(®) (n = 93, age 61.4 ± 9.8 years; 60% male, 13% persistent AF) vs. nMARQ™ (n = 82, age 63.2 ± 10.6 years; 67% male, 24% persistent AF). Procedure and radiation times were 94 ± 27 and 33 ± 13 min for PVAC(®) and 81 ± 18 and 30 ± 8.5 for nMARQ™ (P = 0.0008 and P = 0.18), respectively. The number of applications and the total burning time (min) were 20 ± 7 and 19 ± 6.7 for PVAC(®) and 16 ± 5.6 and 11 ± 4 for nMARQ™ (P < 0.0001 for both), respectively. In two nMARQ™ patients with small atria and pulmonary veins (PVs) and in two PVAC(®) patients with large PVs, the procedure failed; switching to the alternative technology was successful. Acute success rate was 97% for PVAC(®) and 95% for nMARQ™. There was one tamponade in nMARQ™ group and non-significant different minor complications for both techniques. One-year freedom from AF was 79 and 80.7% with PVAC(®) vs. nMARQ™, after one PVI, and 88 vs. 87.7% after two PVIs. CONCLUSION: Both technologies have short procedure and fluoroscopy times, comparable complication rates, and comparable acute and 1-year success rates. The number of applications and total procedure and burning times were shorter with nMARQ™. nMARQ™ was more suitable for larger atria and PVs. Thus, a patient-based pre-ablation anatomy definition is probably warranted for appropriate selection of technology type.

Comprehensive annular and subvalvular repair of chronic ischemic mitral regurgitation improves long-term results with the least ventricular remodeling.

BACKGROUND: Undersized ring annuloplasty for ischemic mitral regurgitation (MR) is associated with variable results and >30% MR recurrence. We tested whether subvalvular repair by severing second-order mitral chordae can improve annuloplasty by reducing papillary muscle tethering. METHODS AND RESULTS: Posterolateral myocardial infarction known to produce chronic remodeling and MR was created in 28 sheep. At 3 months, sheep were randomized to sham surgery versus isolated undersized annuloplasty versus isolated bileaflet chordal cutting versus the combined therapy (n=7 each). At baseline, chronic myocardial infarction (3 months), and euthanasia (6.6 months), we measured left ventricular (LV) volumes and ejection fraction, wall motion score index, MR regurgitation fraction and vena contracta, mitral annulus area, and posterior leaflet restriction angle (posterior leaflet to mitral annulus area) by 2-dimensional and 3-dimensional echocardiography. All groups were comparable at baseline and chronic myocardial infarction, with mild to moderate MR (MR vena contracta, 4.6±0.1 mm; MR regurgitation fraction, 24.2±2.9%) and mitral annulus dilatation (P<0.01). At euthanasia, MR progressed to moderate to severe in controls but decreased to trace with ring plus chordal cutting versus trace to mild with chordal cutting alone versus mild to moderate with ring alone (MR vena contracta, 5.9±1.1 mm in controls, 0.5±0.08 with both, 1.0±0.3 with chordal cutting alone, 2.0±0.4 with ring alone; P<0.01). In addition, LV end-systolic volume increased by 108% in controls versus 28% with ring plus chordal cutting, less than with each intervention alone (P<0.01). In multivariate analysis, LV end-systolic volume and mitral annulus area most strongly predicted MR (r(2)=0.82, P<0.01). CONCLUSIONS: Comprehensive annular and subvalvular repair improves long-term reduction of both chronic ischemic MR and LV remodeling without decreasing global or segmental LV function at follow-up.

Mindfulness and Care Experience in Family Caregivers of Persons Living with Dementia.

Background: Greater mindfulness, the practice of awareness and living in the moment without judgement, has been linked to positive caregiving outcomes in dementia caregivers and its impact attributed to greater decentering and emotion regulation abilities. Whether the impact of these mindfulness-based processes varies across caregiver subgroups is unclear. Objective: Analyze cross-sectional associations between mindfulness and caregiver psychosocial outcomes, considering different caregiver and patient characteristics. Methods: A total of 128 family caregivers of persons living with Alzheimer's disease and related disorders were assessed on several mindfulness measures (i.e., global; decentering, positive emotion regulation, negative emotion regulation) and provided self-reported appraisals of caregiving experience; care preparedness; confidence, burden, and depression/anxiety. Bivariate relationships between mindfulness and caregiver outcomes were assessed with Pearson's correlations and stratified by caregiver (women versus men; spouse versus adult child) and patient (mild cognitive impairment (MCI) versus Dementia; AD versus dementia with Lewy bodies; low versus high symptom severity) characteristics. Results: Greater mindfulness was associated with positive outcomes and inversely associated with negative outcomes. Stratification identified specific patterns of associations across caregiver groups. Significant correlations were found between all mindfulness measures and caregiving outcomes in male and MCI caregivers while the individual mindfulness component of positive emotion regulation was significantly correlated to outcomes in most caregiver groups. Conclusion: Our findings support a link between caregiver mindfulness and improved caregiving outcomes and suggest directions of inquiry into whether the effectiveness of dementia caregiver-support interventions may be improved by targeting specific mindfulness processes or offering a more inclusive all-scope approach depending on individual caregiver or patient characteristics.

Serum Cholesterol Concentration on Admission in 415 Dogs Envenomated by Daboia (Vipera) palaestinae as a Marker of Envenomation Severity and Outcome-A Retrospective Study.

Daboia (Vipera) palaestinae (Dp), accounts for most envenomations in humans and dogs in Israel. In humans envenomed by Dp, serum cholesterol concentration (sChol) is inversely correlated with envenomation severity. This study examined the utility of sChol upon admission in dogs envenomed by Dp as an envenomation severity and outcome marker. Data upon admission, including sChol, were retrospectively collected from the medical records of dogs with proven Dp envenomation. The study included 415 dogs. The mortality rate was 11%. The heart rate upon admission was higher in non-survivors than in survivors. Signs of bleeding or hematoma and circulatory shock signs were more frequent among non-survivors compared to survivors. sChol, the platelet count, and serum albumin concentration (sAlb) were lower, while serum creatinine concentration was higher among non-survivors. sChol and sAlb were moderately, positively, and significantly correlated. sChol was significantly, negatively, albeit weakly, correlated with the length of hospitalization and the heart rate. sChol was lower in dogs admitted >12 h post-envenomation than in those admitted later. In dogs, sChol upon admission is a potential marker of severity and outcome of Dp envenomation. The platelet count, sAlb, and sCreat might also be potential markers.

The Frontal Behavioral Battery: A Measure of Frontal Lobe Symptoms in Brain Aging and Neurodegenerative Disease.

BACKGROUND: Approximately 90%of persons living with dementia experience behavioral symptoms, including frontal lobe features involving motivation, planning, social behavior, language, personality, mood, swallowing, and gait. OBJECTIVE: We conducted a two-stage study with a development sample (n = 586) and validation sample (n = 274) to evaluate a brief informant-rated measure of non-cognitive features of frontal lobe dysfunction: the Frontal Behavioral Battery (FBB). METHODS: In the development sample, internal consistency, principal factor analysis, and correlations between the FBB and outcomes were evaluated. In the validation sample, we examined (a) FBB scores by diagnosis, (b) known-group validity by demographics, subjective complaints, and dementia staging, and (c) correlation between FBB and MRI volumes. Receiver operator characteristic curves assessed the ability of the FBB to discriminate individuals with frontal lobe features due to a neurodegenerative disease. RESULTS: The FBB characterized 11 distinct frontal lobe features. Individuals with dementia with Lewy bodies and frontotemporal degeneration had the greatest number of frontal lobe features. Premorbid personality traits of extroversion, agreeableness, and openness were associated with fewer frontal lobe behavioral symptoms, while subjective cognitive complaints were associated with greater symptoms. The FBB provided very good discrimination between individuals with and without cognitive impairment (diagnostic odds ratio: 13.1) and between individuals with and without prominent frontal lobe symptoms (diagnostic odds ratio: 84.8). CONCLUSION: The FBB may serve as an effective and efficient method to assess the presence of non-cognitive symptoms associated with frontal lobe dysfunction, but in a brief fashion that could facilitate its use in clinical care and research.

Efficacy of augmented visual environments for reducing sickness in autonomous vehicles.

The risk of motion sickness is considerably higher in autonomous vehicles than it is in human-operated vehicles. Their introduction will therefore require systems that mitigate motion sickness. We investigated whether this can be achieved by augmenting the vehicle interior with additional visualizations. Participants were immersed in motion simulations on a moving-base driving simulator, where they were backward-facing passengers of an autonomous vehicle. Using a Head-Mounted Display, they were presented either with a regular view from inside the vehicle, or with augmented views that offered additional cues on the vehicle's present motion or motion 500ms into the future, displayed on the vehicle's interior panels. In contrast to the hypotheses and other recent studies, no difference was found between conditions. The absence of differences between conditions suggests a ceiling effect: providing a regular view may limit motion sickness, but presentation of additional visual information beyond this does not further reduce sickness.

The Resilience Index: A Quantifiable Measure of Brain Health and Risk of Cognitive Impairment and Dementia.

BACKGROUND: There is increasing interest in lifestyle modification and integrative medicine approaches to treat and/or prevent mild cognitive impairment (MCI) and Alzheimer's disease and related dementias (ADRD). OBJECTIVE: To address the need for a quantifiable measure of brain health, we created the Resilience Index (RI). METHODS: This cross-sectional study analyzed 241 participants undergoing a comprehensive evaluation including the Clinical Dementia Rating and neuropsychological testing. Six lifestyle factors including physical activity, cognitive activity, social engagements, dietary patterns, mindfulness, and cognitive reserve were combined to derive the RI (possible range of scores: 1-378). Psychometric properties were determined. RESULTS: The participants (39 controls, 75 MCI, 127 ADRD) had a mean age of 74.6±9.5 years and a mean education of 15.8±2.6 years. The mean RI score was 138.2±35.6. The RI provided estimates of resilience across participant characteristics, cognitive staging, and ADRD etiologies. The RI showed moderate-to-strong correlations with clinical and cognitive measures and very good discrimination (AUC: 0.836; 95% CI: 0.774-0.897) between individuals with and without cognitive impairment (diagnostic odds ratio = 8.9). Individuals with high RI scores (> 143) had better cognitive, functional, and behavioral ratings than individuals with low RI scores. Within group analyses supported that controls, MCI, and mild ADRD cases with high RI had better cognitive, functional, and global outcomes than those with low RI. CONCLUSION: The RI is a brief, easy to administer, score and interpret assessment of brain health that incorporates six modifiable protective factors. Results from the RI could provide clinicians and researchers with a guide to develop personalized prevention plans to support brain health.

Improving stress echocardiography accuracy for detecting left circumflex artery stenosis: a new echocardiographic sign?

BACKGROUND: The accuracy and reproducibility of stress echocardiography (SE) for the detection of coronary artery lesions requires improvement, particularly in the left circumflex artery (LCx). AIMS: To evaluate the feasibility and diagnostic value of a new sign: Rise of the Apical lateral wall and/or Horizontal displacement of the Apex toward the septum ("RA-HA") in apical echocardiographic views. METHODS: Consecutive patients with normal left ventricular function at rest, positive SE and an indication for coronary angiography were included. SEs were analysed blindly by three independent cardiologists: two seniors (S1 and S2) and one junior (J). RESULTS: Of 81 patients, 58 had an exercise SE and 23 had a dobutamine SE. Significant coronary stenosis was found in 59 of 77 patients who underwent coronary angiography (76.6%). Interobserver reproducibility for the presence of RA-HA was very good between S1 and S2 (κ = 0.86), and good between S1 and J (0.67) and S2 and J (0.70). The sensitivity, specificity and positive and negative predictive values of RA-HA for the detection of significant coronary artery stenosis were, respectively, 39-41%, 83-89%, 88-92% and 29-31% for S1/S2; and 29%, 83%, 85% and 26% for J. To predict LCx stenosis (single or multivessel): 67-70%, 89%, 80-81% and 80-82% for S1/S2, respectively, and 50%, 89%, 75% and 74% for J. CONCLUSION: With a short learning curve, RA-HA is easily diagnosed with a very good interobserver reproducibility. It has high specificity and PPV for the detection of a coronary artery stenosis, particularly in the LCx artery, during exercise or dobutamine SE.

Relief of mitral leaflet tethering following chronic myocardial infarction by chordal cutting diminishes left ventricular remodeling.

BACKGROUND: one of the key targets in treating mitral regurgitation (MR) is reducing the otherwise progressive left ventricular (LV) remodeling that exacerbates MR and conveys adverse prognosis. We have previously demonstrated that severing 2 second-order chordae to the anterior mitral leaflet relieves tethering and ischemic MR acutely. The purpose of this study was to test whether this technique reduces the progression of LV remodeling in the chronic ischemic MR setting. METHODS AND RESULTS: a posterolateral MI was created in 18 sheep by obtuse marginal branch ligation. After chronic remodeling and MR development at 3 months, 6 sheep were randomized to sham surgery (control group) and 12 to second-order chordal cutting (6 each to anterior leaflet [AntL] and bileaflet [BiL] chordal cutting, techniques that are in clinical application). At baseline, chronic infarction (3 months), and follow-up at a mean of 6.6 months post-myocardial infarction (MI) (euthanasia), we measured LV end-diastolic (EDV) and end-systolic volume (ESV), ejection fraction, wall motion score index, and posterior leaflet (PL) restriction angle relative to the annulus by 2D and 3D echocardiography. All measurements were comparable among groups at baseline and chronic MI. At euthanasia, AntL and BiL chordal cutting limited the progressive remodeling seen in controls. LVESV increased relative to chronic MI by 109±8.7% in controls versus 30.5±6.1% with chordal cutting (P<0.01) (LVESV in controls, 82.5±2.6 mL; in AntL, 60.6±5.1 mL; in BiL, 61.8±4.1 mL). LVEDV increased by 63±2.0% in controls versus 26±5.5% and 22±3.4% with chordal cutting (P<0.01). LV ejection fraction and wall motion score index were not significantly different at follow-up among the chordal cutting and control groups. MR progressively increased to moderate in controls but decreased to trace-mild with AntL and BiL chordal cutting (MR vena contracta in controls, 5.9±1.1 mm; in AntL, 2.6±0.1 mm; in BiL, 1.7±0.1 mm; P<0.01). BiL chordal cutting provided greater PL mobility (decreased PL restriction angle to 54.2±5.0° versus 83±3.2° with AntL chordal cutting; P<0.01). CONCLUSIONS: reduced leaflet tethering by chordal cutting in the chronic post-MI setting substantially decreases the progression of LV remodeling with sustained reduction of MR over a chronic follow-up. These benefits have the potential to improve clinical outcomes.

Diagnosis of proximal pulmonary embolism by transthoracic echocardiography.

To date, few cases giving detailed visual descriptions of a thrombus in the pulmonary arteries or its branches in transthoracic echocardiography have been reported. We report the case of a 67-year-old man who was admitted to a hospital emergency department with a thrombus in the right pulmonary artery diagnosed by transthoracic echocardiography. The specificity of echocardiography in pulmonary embolism varies between 80% and 90% according to the series. The direct visualization of a thrombus is sometimes possible, permitting a faster diagnosis in patients with compromised hemodynamic status.