von Willebrand Factor Antigen, von Willebrand Factor Propeptide, and ADAMTS13 in Carotid Stenosis and Their Relationship with Cerebral Microemboli.

BACKGROUND: The relationship between von Willebrand factor antigen (VWF:Ag), VWF propeptide (VWFpp), VWFpp/VWF:Ag ratio, ADAMTS13 activity, and microembolic signal (MES) status in carotid stenosis is unknown. METHODS: This prospective, multicenter study simultaneously assessed plasma VWF:Ag levels, VWFpp levels and ADAMTS13 activity, and their relationship with MES in asymptomatic versus symptomatic moderate-to-severe (≥50-99%) carotid stenosis patients. One-hour transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES+ve or MES-ve. RESULTS: Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the "early phase" (≤4 weeks) and 37 patients in the "late phase" (≥3 months) after transient ischemic attack (TIA)/ischemic stroke. VWF:Ag levels were higher (p = 0.049) and VWFpp/VWF:Ag ratios lower (p = 0.006) in early symptomatic than in asymptomatic patients overall, and in early symptomatic versus asymptomatic MES-ve subgroups (p ≤0.02). There were no intergroup differences in VWFpp expression or ADAMTS13 activity (p ≥0.05). VWF:Ag levels and ADAMTS13 activity decreased (p ≤ 0.048) and VWFpp/VWF:Ag ratios increased (p = 0.03) in symptomatic patients followed up from the early to late phases after TIA/stroke. Although there were no differences in the proportions of symptomatic and asymptomatic patients with blood group O, a combined analysis of early symptomatic and asymptomatic patients revealed lower median VWF:Ag levels in patients with blood group O versus those without blood group O (9.59 vs. 12.32 µg/mL, p = 0.035). DISCUSSION: VWF:Ag expression, a marker of endothelial ± platelet activation, is enhanced in recently symptomatic versus asymptomatic carotid stenosis patients, including in MES-ve patients, and decreases with ADAMTS13 activity over time following atherosclerotic TIA/ischemic stroke.

Mounier-Kuhn syndrome in an older patient.

Respiratory problems in older adults are frequently labelled as being due to chronic obstructive airways disease (COAD). However where the presentation may be suggestive of another pathology due to the clinical history or type of pathogen isolated from the sputum, then consideration should be given to appropriate imaging. We describe a case of an older lady labelled for many years as COAD but who was a lifelong non-smoker and had Pseudomonas in her sputum. A CT of thorax for suspected bronchiectasis revealed tracheobroncomegaly (Mounier-Kuhn syndrome). This is the oldest case of Mounier-Kuhn syndrome at presentation and highlights the importance of appropriate history taking and investigation of older people.

Stroke in young women: An interpretative phenomenological analysis.

Stroke among adults of working age is increasing. We aimed to explore the experience of stroke among young women in Ireland. In total, 12 women (aged between 18 and 50 years) participated in semi-structured interviews. Data were analysed using interpretative phenomenological analysis. Four super-ordinate themes were identified: stroke as an illness of later life ('obviously it's for older people'), post-stroke selves, a desire for peer support and the impact of stroke on relationships. Findings indicate the importance of addressing the specific needs of younger stroke patients from admission to recovery through provision of inclusive all-age acute stroke services with tailored rehabilitation.

Frequent inaccuracies in ABCD2 scoring in non-stroke specialists' referrals to a daily Rapid Access Stroke Prevention service.

The 'accuracy' of age, blood pressure, clinical features, duration and diabetes (ABCD(2)) scoring by non-stroke specialists referring patients to a daily Rapid Access Stroke Prevention (RASP) service is unclear, as is the accuracy of ABCD(2) scoring by trainee residents. In this prospective study, referrals were classified as 'confirmed TIAs' if the stroke specialist confirmed a clinical diagnosis of possible, probable or definite TIA, and 'non-TIAs' if patients had a TIA mimic or completed stroke. ABCD(2) scores from referring physicians were compared with scores by experienced stroke specialists and neurology/geriatric medicine residents at a daily RASP clinic; inter-observer agreement was examined. Data from 101 referrals were analysed (mean age=60.0years, 58% male). The median interval between referral and clinic assessment was 1day. Of 101 referrals, 52 (52%) were 'non-TIAs': 45 (86%) of 52 were 'TIA mimics' and 7 (14%) of 52 were completed strokes. There was only 'fair' agreement in total ABCD(2) scoring between referring physicians and stroke specialists (κ=0.37). Agreement was 'excellent' between residents and stroke specialists (κ=0.91). Twenty of 29 patients scored as 'moderate to high risk' (score 4-6) by stroke specialists were scored 'low risk' (score 0-3) by referring physicians. ABCD(2) scoring by referring doctors is frequently inaccurate, with a tendency to underestimate stroke risk. These findings emphasise the importance of urgent specialist assessment of suspected TIA patients, and that ABCD(2) scores by non-stroke specialists cannot be relied upon in isolation to risk-stratify patients. Inter-observer agreement in ABCD(2) scoring was 'excellent' between residents and stroke specialists, indicating short-term training may improve accuracy.

Subtle memory and attentional deficits revealed in an Irish stroke patient sample using domain-specific cognitive tasks.

Stroke disrupts motor, sensory, and cognitive systems in survivors. Unlike in physical impairments, assessment of cognitive function is often inadequate, as no standardized procedure to monitor cognitive recovery post stroke exists. We evaluated a number of novel task-orientated tools designed to assess subtle cognitive deficits (including memory, attention, and executive functioning) in a sample of stroke patients. Although unimpaired on MMSE (Mini-Mental State Examination)-based indices of cognition, memory, and intelligence, stroke survivors were significantly impaired on tasks testing visual attention, spatial/relational processing, and associative memory. We recommend a standardized multidomain cognitive assessment and propose that cognitive deficits post stroke require in-depth assessment to inform patient-orientated rehabilitation.

Using support vector machines with multiple indices of diffusion for automated classification of mild cognitive impairment.

Few studies have looked at the potential of using diffusion tensor imaging (DTI) in conjunction with machine learning algorithms in order to automate the classification of healthy older subjects and subjects with mild cognitive impairment (MCI). Here we apply DTI to 40 healthy older subjects and 33 MCI subjects in order to derive values for multiple indices of diffusion within the white matter voxels of each subject. DTI measures were then used together with support vector machines (SVMs) to classify control and MCI subjects. Greater than 90% sensitivity and specificity was achieved using this method, demonstrating the potential of a joint DTI and SVM pipeline for fast, objective classification of healthy older and MCI subjects. Such tools may be useful for large scale drug trials in Alzheimer's disease where the early identification of subjects with MCI is critical.

Using diffusion tensor imaging and mixed-effects models to investigate primary and secondary white matter degeneration in Alzheimer's disease and mild cognitive impairment.

White matter (WM) degeneration in Alzheimer's disease (AD) and mild cognitive impairment (MCI) may be a key indicator of early damage in AD. Here, we analyzed WM diffusion tensor data using Tract-Based Spatial Statistics in conjunction with mixed-effects models. Four indices of diffusion were assessed in 61 healthy control, 19 non-amnestic MCIs, 14 amnestic MCIs, and 9 AD patients. The aim of the study was to use advanced mixed-effects models to investigate the retrogenesis hypothesis of AD, which suggests that tracts that are late to myelinate in ontogenetic development are the earliest to be affected in AD. Our results show that a number of late-myelinating pathways, including the parahippocampal region and the inferior longitudinal fasciculus, were predominantly affected by changes in WM volume. Conversely, early-myelinating pathways were found to be affected by a combination of both WM and gray matter (GM) atrophy. A model of the entire WM structure of the brain returned GM models for two indices of diffusion, suggesting that more complex regional landscapes of diffusion lie hidden beneath a global analysis of the entire brain. Our results warn against an explanation of white matter damage that points simply to one of two mechanisms: secondary degeneration or direct damage of myelin. We suggest that tracts may be affected by both mechanisms, with the balance depending on whether tracts are early or late-myelinating. A greater understanding of the pattern of WM changes in AD may prove useful for the early detection of AD.

Multiple indices of diffusion identifies white matter damage in mild cognitive impairment and Alzheimer's disease.

The study of multiple indices of diffusion, including axial (DA), radial (DR) and mean diffusion (MD), as well as fractional anisotropy (FA), enables WM damage in Alzheimer's disease (AD) to be assessed in detail. Here, tract-based spatial statistics (TBSS) were performed on scans of 40 healthy elders, 19 non-amnestic MCI (MCIna) subjects, 14 amnestic MCI (MCIa) subjects and 9 AD patients. Significantly higher DA was found in MCIna subjects compared to healthy elders in the right posterior cingulum/precuneus. Significantly higher DA was also found in MCIa subjects compared to healthy elders in the left prefrontal cortex, particularly in the forceps minor and uncinate fasciculus. In the MCIa versus MCIna comparison, significantly higher DA was found in large areas of the left prefrontal cortex. For AD patients, the overlap of FA and DR changes and the overlap of FA and MD changes were seen in temporal, parietal and frontal lobes, as well as the corpus callosum and fornix. Analysis of differences between the AD versus MCIna, and AD versus MCIa contrasts, highlighted regions that are increasingly compromised in more severe disease stages. Microstructural damage independent of gross tissue loss was widespread in later disease stages. Our findings suggest a scheme where WM damage begins in the core memory network of the temporal lobe, cingulum and prefrontal regions, and spreads beyond these regions in later stages. DA and MD indices were most sensitive at detecting early changes in MCIa.

"Orthobot, to your station!" The application of the remote presence robotic system in orthopaedic surgery in Ireland: a pilot study on patient and nursing staff satisfaction.

The remote presence robotic system (RPRS) enables an individual to "be in two places at once". Its application includes various uses in medicine and surgery. However, its usefulness in the field of orthopaedic surgery has not been described. The objective of our pilot study was to determine patient and nursing staff satisfaction with the RPRS in an orthopaedic clinical setting in Ireland. We performed evening and weekend ward rounds to gain feedback and determine patient and nursing staff satisfaction with this innovative system. Questionnaires were handed to all patients and staff nurses involved. Both patients and nursing staff had very positive reactions to the RPRS in an orthopaedic postoperative care setting. Potential uses in orthopaedic surgery include clinical outreach in the setting of trauma, supervision in theatre, or watching theatre cases from outside the hospital, providing both patient and parent reassurance in paediatric orthopaedic cases, and, finally, in the setting of outpatient departments. Integration of the RPRS in an orthopaedic clinical setting has exciting and limitless potential. More so in this era in which it would allow trainees to benefit from teaching and training while also cutting down their in-house time and thus hospitals costs.

The penitentiary visit--a new role for geriatricians?

The number of older prisoners is increasing and, with reforms in the prison health service, there is a requirement to provide equity of access to standard healthcare services. The health of older prisoners is often poor, with high levels of psychiatric and physical illnesses, compounded by poor access to appropriate rehabilitation and resettlement services. A recent case presenting to our department highlighted these deficits and illustrated how inputs from a geriatrician could be useful to older prisoners (see Appendix 1, available at www.ageing.oxfordjournals.org). We propose that regular penitentiary visits may be an important new role for geriatricians at a supra-regional level.