Subtle Cognitive Decline predicts progression to Mild Cognitive Impairment Above and Beyond Alzheimer’s Disease Risk Factors

Objective

Early identification of those at risk for mild cognitive impairment (MCI) and Alzheimer’s disease (AD) is critical for early intervention. Recent work shows that subtle cognitive decline (SCD), operationally-defined using sensitive neuropsychological scores, predicts progression to MCI/AD and is associated with AD biomarkers. We aimed to determine whether SCD adds unique value in predicting progression to MCI/AD above and beyond other AD risk factors.

Method

547 cognitively unimpaired participants from the Alzheimer’s Disease Neuroimaging Initiative (359 without SCD; 188 with SCD) underwent neuropsychological testing and lumbar puncture. Participants were classified as SCD if they performed >1 SD below the demographically-adjusted mean on 1) two neuropsychological total scores in different cognitive domains, or 2) two memory test process scores (e.g., intrusion errors), or 3) one total score and one process score. Cox regressions examined whether SCD status predicted progression to MCI and AD within 5 years after adjusting for age, education, sex, MMSE, depressive symptoms, ischemia risk, apolipoprotein E genotype, and AD biomarker “positivity” based on the cerebrospinal fluid phosphorylated tau-to-β-amyloid ratio.

Results

SCD status predicted progression to MCI (HR = 2.74, 95% CI = 2.07-3.63, p < .001) and AD (HR = 2.20, 95% CI = 1.04-4.65, p = .04) within 5 years, even after including known AD risk factors in the model.

Conclusion

SCD conveys a 2-3 fold increased risk of progression to MCI/AD and is a unique predictor above and beyond risk factors that are commonly used in preclinical AD research. These findings support our novel SCD criteria as a cost-effective and non-invasive method for identifying those at risk for future cognitive decline.

A highly immunogenic trivalent T cell receptor peptide vaccine for multiple sclerosis

Background: T cell receptor (TCR) peptide vaccination is a novel approach to treating multiple sclerosis (MS). The low immunogenicity of previous vaccines has hindered the development of TCR peptide vaccination for MS. Objective: To compare the immunogenicity of intramuscular injections of TCR BV5S2, BV6S5 and BV13S1 CDR2 peptides in incomplete Freund’s adjuvant (IFA) with intradermal injections of the same peptides without IFA. Methods: MS subjects were randomized to receive TCR peptides/IFA, TCR peptides/saline or IFA alone. Subjects were on study for 24 weeks. Results: The TCR peptides/IFA vaccine induced vigorous T cell responses in 100% of subjects completing the 24-week study (9/9) compared with only 20% (2/10) of those receiving the TCR peptides/saline vaccine (P =0.001). IFA alone induced a weak response in only one of five subjects. Aside from injection site reactions, there were no significant adverse events attributable to the treatment. Conclusions: The trivalent TCR peptide in IFA vaccine represents a significant improvement in immunogenicity over previous TCR peptide vaccines and warrants investigation of its ability to treat MS.

Managing unstable angina and coronary care beds effectively

This article is an evaluation of a new chest pain admission policy at Western Hospital. Our aim was to determine the clinical outcomes of patients with unstable angina treated according to this new policy. It involved attempting to identify a group at low risk of serious complications and to manage them in a general ward area without cardiac monitoring, to reduce the pressure on coronary care unit beds. We conducted a retrospective case note review and concluded that that selected patients with an admission diagnosis of unstable angina can be safely managed in unmonitored medical beds provided mechanisms are in place for their transfer to the coronary care unit if recurrent pain or a complication occurs.

Telephone triage: 5 years' experience

Triaging by telephone has long been a 'bone of contention' among emergency nurses in Victoria, Australia, with some nurses adamant that telephone advice is appropriate and other nurses equally adamant that telephone advice should not be given at all. Almost unanimously agreed upon by both groups is that documentation of the call, and/or the advice given, is time consuming and may pose a legal risk to the nurse if something untoward should happen to the patient. This paper relates our experience including our policy on telephone triage with an analysis of 5 years of documented telephone calls from January 1991 to January 1996.

Managing potentially ischaemic chest pain and coronary care beds effectively

One of the most common reasons why patients attend emergency departments in Australia is chest pain that is potentially due to coronary artery disease (myocardial infarction, unstable or stable angina pectoris). A number of models for the investigation and treatment of these patients have been employed over the last five to ten years. This paper describes the evolution of a model for managing ischaemic chest pain that aims to avoid potentially preventable deaths from undiagnosed myocardial infarction, to admit to hospital patients who could benefit from inpatient treatment, to admit to a coronary care unit patients at significant risk of complications, and to avoid inter-hospital transfer of patients. Introduction of the model has led to an increase in the appropriate hospital admission of patients with ischaemic chest pain, a marked reduction in inter-hospital transfers, and better utilisation of coronary care beds. Unmonitored, general ward management of low risk patients with clinical unstable angina has not resulted in compromised outcomes.

Human-computer interface evaluation: not user-friendliness but design for operation

This paper considers human-computer interface evaluation in the context of design and development. It is argued that it is not helpful to view evaluation as a method for achieving user-friendliness, rather it should be seen as a participating activity within design and development. The centre of concern is the operation of the system when employed in practice. Such evaluation is not necessarily to be conducted by independent observation and experiment, but may be closely integrated with other design activities. In fact the very theory underlying the evaluation finds its embodiment in the artifact of the user interface. Taking this view has technical, as well as human factors, implications.