Tablet-Based Cognitive Impairment Screening for Adults With HIV Seeking Clinical Care: Observational Study

BACKGROUND

Neurological complications including cognitive impairment persist among people with HIV on antiretrovirals; however, cognitive screening is not routinely conducted in HIV clinics.

OBJECTIVE

Our objective for this study was 3-fold: (1) to determine the feasibility of implementing an iPad-based cognitive impairment screener among adults seeking HIV care, (2) to examine the psychometric properties of the tool, and (3) to examine predictors of cognitive impairment using the tool.

METHODS

A convenience sample of participants completed Brain Baseline Assessment of Cognition and Everyday Functioning (BRACE), which included (1) Trail Making Test Part A, measuring psychomotor speed; (2) Trail Making Test Part B, measuring set-shifting; (3) Stroop Color, measuring processing speed; and (4) the Visual-Spatial Learning Test. Global neuropsychological function was estimated as mean T score performance on the 4 outcomes. Impairment on each test or for the global mean was defined as a T score ≤40. Subgroups of participants repeated the tests 4 weeks or >6 months after completing the first test to evaluate intraperson test-retest reliability and practice effects (improvements in performance due to repeated test exposure). An additional subgroup completed a lengthier cognitive battery concurrently to assess validity. Relevant factors were abstracted from electronic medical records to examine predictors of global neuropsychological function.

RESULTS

The study population consisted of 404 people with HIV (age: mean 53.6 years; race: 332/404, 82% Black; 34/404, 8% White, 10/404, 2% American Indian/Alaskan Native; 28/404, 7% other and 230/404, 58% male; 174/404, 42% female) of whom 99% (402/404) were on antiretroviral therapy. Participants completed BRACE in a mean of 12 minutes (SD 3.2), and impairment was demonstrated by 34% (136/404) on Trail Making Test A, 44% (177/404) on Trail Making Test B, 40% (161/404) on Stroop Color, and 17% (67/404) on Visual-Spatial Learning Test. Global impairment was demonstrated by 103 out of 404 (25%). Test-retest reliability for the subset of participants (n=26) repeating the measure at 4 weeks was 0.81 and for the subset of participants (n=67) repeating the measure almost 1 year later (days: median 294, IQR 50) was 0.63. There were no significant practice effects at either time point (P=.20 and P=.68, respectively). With respect for validity, the correlation between global impairment on the lengthier cognitive battery and BRACE was 0.63 (n=61; P<.001), with 84% sensitivity and 94% specificity to impairment on the lengthier cognitive battery.

CONCLUSIONS

We were able to successfully implement BRACE and estimate cognitive impairment burden in the context of routine clinic care. BRACE was also shown to have good psychometric properties. This easy-to-use tool in clinical settings may facilitate the care needs of people with HIV as cognitive impairment continues to remain a concern in people with HIV.

[Hemodynamic effects of a single intravenous administration of prostaglandin E1 in a patient sample with chronic NYHA-stage II/III heart failure]

We investigated the hemodynamic effects of a single infusion of PGE1 (60 micrograms infused over a period of 2 h--this is the single dose used in courses of treatment for peripheral occlusive arterial disease) in patients with chronic heart failure NYHA class II-III. The ejection fraction of these patients was < 55%, their average age was 58.4 years (standard deviation 10 years), and their condition was stable. Nineteen of the patients had coronary heart disease and one patient had myocarditis. The hemodynamic data were obtained invasively by catheterization of the right and left heart. Blood pressure and pulse rate were measured manually. Intravenous infusion of 60 micrograms PGE1 over a period of 2 hours did not significantly alter contractility or hemodynamics. Dp/dtmax, dp/dtmax/p, and dp/dt DP40, which are parameters of left ventricular contractility, determined with the aid of a catheter-tip manometer, did not differ significantly over time from those in the placebo control group. Similarly, the other data furnished no evidence that administration of PGE1 had any hemodynamic or myocardial effects. Hence, it is reasonable to state that it is safe to administer PGE1 to patients with peripheral occlusive arterial disease.

Hemodynamic effects of a single intravenous infusion of prostaglandin E1 in patients with clinically moderate to severe chronic heart failure

In a placebo-controlled, double-blind study, we investigated the hemodynamic effects of a single infusion of prostaglandin E ( 1 ) (PGE ( 1 ); 60 microg infused over a period of 2 hours, the unit dosage used in courses of treatment for peripheral occlusive arterial disease) in 20 patients with moderate to severe chronic heart failure (New York Heart Association functional class II or III). Ejection fraction before therapy was less than 55%, and average age was 58.4 +/- 10 years in these clinically stable patients. Nineteen patients had coronary heart disease and one patient had had myocarditis underlying heart failure. Hemodynamic data were obtained by right- and left-heart catheterization and by Doppler echocardiography. Blood pressure and pulse rate were measured manually. Intravenous infusion of 60 microg PGE ( 1 ) over a period of 2 hours did not significantly alter contractility or hemodynamics. Dp/dt max, dp/dt max/p and dp/dt DP40, measures of left ventricular contractility determined with a catheter-tip manometer, did not differ significantly over time in PGE ( 1 ) -treated patients and those who received placebo. Other measures also failed to reveal PGE ( 1 ) -induced myocardial effects. We conclude that it is safe to administer PGE ( 1 ) to patients with peripheral occlusive arterial disease irrespective of heart failure.

Changes in left ventricular filling during follow-up study in survivors and nonsurvivors of idiopathic dilated cardiomyopathy

The assessment of left ventricular diastolic function by Doppler echocardiography shows both a nonrestrictive and restrictive type of filling in idiopathic dilated cardiomyopathy. These different filling patterns are related to the symptoms of cardiac failure and the prognosis. It remains to be established whether changes of Doppler parameters during follow-up procedures were of clinical relevance. Doppler echocardiography of left ventricular filling was done in 45 patients with idiopathic dilated cardiomyopathy at the time of their diagnosis and repeatedly during a follow-up study of 38 +/- 19 months. The deceleration time of early filling, the maximum early and atrial Doppler velocities and their ratios, as well as echocardiographic parameters of cardiac dimensions and systolic function, were measured. During the follow-up period, seven patients died and four patients underwent heart transplantation because of progressive heart failure. The deceleration time was shorter in patients who died or had to undergo heart transplantation as compared with survivors (119 +/- 43 ms vs 188 +/- 63 ms; P < .005). There was no difference in changes of clinical symptoms in survivors and nonsurvivors. The systolic function improved only in survivors. The difference in deceleration time remained significant between both groups, and it also remained a prognostic discriminator. Peak early velocity increased in nonsurvivors (from 0.66 +/- 0.20 m/s to 0.95 +/- 0.21 m/s; P < .01), while it remained constant in survivors (0.65 +/- 0.17 m/s and 0.67 +/- 0.25 m/s). The peak early/atrial velocity ratio varied widely in either group during the follow-up study, its changes were closely related to the concomitant changes of clinical symptoms (r = .59; P < .005) with a decrease of the peak early/atrial velocity ratio in patients with clinical improvement and an increase of the peak early/atrial velocity ratio in those without clinical improvement. The Doppler echocardiographic deceleration time discriminated between survivors and nonsurvivors in idiopathic dilated cardiomyopathy at the time of the initial diagnostic procedure, and this difference was persistent during the follow-up study. The serial evaluation of patients with idiopathic dilated cardiomyopathy showed a close association of changes in diastolic filling with changes in clinical symptoms.

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990's

Prosthetic valve endocarditis is considered to be associated with a more severe prognosis than native valve endocarditis. Among other factors, inappropriate visualization of vegetations in prosthetic valve endocarditis by transthoracic echocardiography is responsible for this observation. Since the introduction of transoesophageal echocardiography into clinical practice the diagnostic sensitivity and specificity of the detection of vegetations located on prosthetic valves have been enhanced. Therefore we aimed to determine and compare the prognosis of prosthetic valve endocarditis and native valve endocarditis in the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104 patients were seen at our institution between 1989 and 1993. Eighty patients (77%) had native valve endocarditis and 24 (23%) had late prosthetic valve endocarditis. In the latter group two patients had recurrent infective endocarditis. Patients with prosthetic valve endocarditis were older (mean age 64 vs 54 years in native valve endocarditis; P < 0.001) and the majority was female (62% vs 38% in native valve endocarditis; P < 0.05). In prosthetic valve endocarditis, infection of a valve in the mitral position predominated (65% vs 30% in native valve endocarditis; P < 0.01), whereas in native valve endocarditis more than half the cases had isolated aortic valve endocarditis (51% vs 27% in prosthetic valve endocarditis; P < 0.01). In prosthetic valve endocarditis more cases were caused by Staphylococcus aureus (31% vs 14% in native valve endocarditis; P = 0.08), whereas in native valve endocarditis the most frequent organisms were streptococci (29% vs 19% in prosthetic valve endocarditis; P = 0.12). Differences in the clinical features of native valve endocarditis and prosthetic valve endocarditis could not be found except for a higher rate of embolism in native valve endocarditis (40% vs 19% in prosthetic valve endocarditis; P < 0.05). Vegetations could be detected by transthoracic echocardiography more frequently in native valve endocarditis (71% vs 15% in prosthetic valve endocarditis; P < 0.0001). Transoesophageal echocardiography visualized vegetations in 95% of the episodes of native valve endocarditis and in 80% of the episodes of prosthetic valve endocarditis (P = 0.09). Thus, the diagnostic gain by transoesophageal echocardiography was greatest in prosthetic valve endocarditis. Patients with native valve endocarditis had significantly larger vegetations than patients with prosthetic valve endocarditis (P < 0.05 for length, P < 0.001 for width). The median time to diagnosis was similar in native valve endocarditis and prosthetic valve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditis and in 58% of those with prosthetic valve endocarditis; the median time delay between the diagnosis of infective endocarditis and surgery tended to be shorter in prosthetic valve endocarditis than in native valve endocarditis (45 vs 60 days). The in-hospital mortality and the mortality during a follow-up of 22 +/- 10 months did not significantly differ between native valve endocarditis and prosthetic valve endocarditis (21% vs 17%; 28% vs 25%). In summary in the era of transoesophageal echocardiography, late prosthetic valve endocarditis does not seem to carry a worse prognosis than native valve endocarditis. This can be attributed in part to the improved diagnostic accuracy achieved by transoesophageal echocardiography leading to comparable diagnostic latency periods in both patient groups. Finally, better characterization of vegetations on prosthetic valves by transoesophageal echocardiography allows early lifesaving surgery in patients with prosthetic valve endocarditis.

Infective endocarditis in the elderly in the era of transesophageal echocardiography: clinical features and prognosis compared with younger patients

PURPOSE

Advanced age is considered to be associated with a more severe prognosis in infective endocarditis (IE), which is relevance in view of a change in epidemiology of the disease with an increasing proportion of elderly people. We wanted to examine whether in the era of improved diagnostic sensitivity for IE by transesophageal echocardiography the clinical course in elderly persons would be still more severe than in younger patients.

PATIENTS

During the period from 1989 to 1993, 104 patients with 106 episodes of IE were treated at our university hospital. Three groups were compared: group A with 28 patients younger than 50 years, group B with 58 patients aged 50 to 70, and group C with 20 patients older than 70. Transesophageal echocardiography was performed in 78% of the patients; it was not performed in 22% of the patients with a conclusive transthoracic examination. The patients were followed up for an average of 25 months after the diagnosis.

RESULTS

No significant differences were observed among the age groups with respect to the possible source of infection, the frequency of positive blood cultures, and the type of infective organisms. Elderly patients more often had predisposing valvular conditions (eg, degenerative and calcified lesions and prosthetic valves), which decreased the sensitivity of transthoracic echocardiography to 45% as compared with 75% in group A. Transesophageal echocardiography improved the diagnostic yield by 45% in group C and by 47% in group B. Vegetations were smaller in group C and B as compared with group A, whereas other echocardiographic characteristics were similar. Fever and leukocytosis were less frequent in group C (55% and 25%, respectively) than in group A (82% and 61%, respectively). The interval between the onset of symptoms and the diagnosis of IE was similar in all groups. Elderly patients underwent surgical therapy as frequently (65%) as the other groups. The 1-year survival in group C (26%) was comparable with that in group A (22%) and group B (22%). The major determinant of survival was the occurrence of embolic complications.

CONCLUSION

Infective endocarditis in elderly patients caused less severe clinical symptoms than in young patients. The early diagnosis in elderly patients was facilitated by the high sensitivity of transesophageal echocardiography, which enabled the timely initiation of an appropriate medical and surgical therapy. This led to a clinical outcome similar to that for younger patients.

[Prognostic significance of changes in left ventricular diastolic function in follow-up of dilatative cardiomyopathy]

A total of 39 patients with idiopathic dilated cardiomyopathy (IDC) and sinus rhythm were examined for correlations between clinical course, systolic/diastolic cardiac function, and clinical status according to NYHA class (I-IV). Patients were divided in two groups: group 1 included survivors (n = 28, 49 +/- 11 years) and group 2 the nonsurvivors (n = 7) and transplanted patients (n = 4 transplanted; 48 +/- 10 years). Both groups were examined several times, and data at baseline were compared with those of the last examination. The follow-up period was about 3 years (group 1: 41 +/- 22 months, group 2: 24 +/- 13). Baseline conditions were defined at the time when the diagnosis of IDC was established. Diastolic cardiac function was evaluated by Doppler echocardiography parameters of early (VE) and late diastolic peak velocity (VA), the ratio of VE/VA and early deceleration time (EDT). Data for clinical symptoms (NYHA group 1: 2.5 +/- 0.9 vs. group 2: 2.7 +/- 1.3, NS) systolic [fractional shortening (FS) group 1: 0.17 +/- 0.06 vs. group 2: 0.16 +/- 0.06, NS], and diastolic function (VE, VA, VE/VA) showed no differences between the two groups. Only the EDT was significantly shorter in group 2 (group 1: 196 +/- 64 ms vs. group 2: 119 +/- 43 ms, P < 0.001) when diagnosis was established. During the follow-up period there was an improvement in both groups concerning NYNA class (group 1 from 2.5 +/- 0.9 to 1.9 +/- 0.7, P < 0.005; group 2 from 2.7 +/- 1.3 to 2.1 +/- 0.9, NS). There was a nonsignificant deterioration in systolic function in group 2 (FS, from 0.16 +/- 0.06 to 0.15 +/- 0.06, P = 0.07), which contrasted to an improvement in group 1 (from 0.17 +/- 0.06 to 0.20 +/- 0.08, P = 0.06). VE/VA increased in group 2 (from 1.24 to 1.67 +/- 1.21, P = 0.09) essentially due to a significantly increased VE (from 0.66 +/- 0.2 m/s to 0.85 +/- 0.27 m/s, P < 0.05). EDT remained shorter in group 2 (group 1.198 +/- 55 ms vs. 149 +/- 84 ms, P < 0.05). In conclusion, values of VE > 0.8 m/s, VE/VA > 1.6, and EDT < 150 ms during follow-up were predictors of poor prognosis in patients with IDC. Patients with a long EDT (> 150 ms) had a favorable prognosis for survival.

[Doppler echocardiographic analysis of diastolic function in dilatative cardiomyopathy for the evaluation of its progression and prognosis]

The relationship between left-ventricular diastolic function and the course of the disease was investigated in a prospective study of 61 patients (44 men, 17 women; median age 51 [26-74] years) with dilated cardiomyopathy. The diastolic function was measured by recording the transmitral Doppler flow profile. During a follow-up period of 33 +/- 23 months, 15 patients died (twelve of progressive heart failure, three suddenly without previous heart failure). Cardiac transplantation was performed in four patients. The overall 1-year mortality rate was 14%. A "restrictive" Doppler echocardiographic filling pattern with a steep early-diastolic maximum and a small atrial filling component predominated in the patients who died from progressive heart failure or had a cardiac transplantation because of it. The deceleration of the early diastolic velocity maximum was clearly shorter than in the survivors (111 +/- 32 ms vs 194 +/- 62 ms; P < 0.001). In a Cox proportional hazard model the deceleration time was the best prognosticator, followed by the end diastolic left-ventricular diameter (LVD). The group of patients with a short deceleration time (< or = 140 ms) had a significantly higher 1-year mortality rate (28% [confidence interval 9-47%]) than those in whom it was longer (3% [0-11%]; P < 0.0001). Taking into account LVD it proved possible to identify a prognostically especially unfavourable group with a 1-year mortality rate of 53% (26-80%), characterized by a LVD > 70 mm and a deceleration time < or = 140 ms. Repeated echocardiography in 26 survivors and nine patients who died later or had been operated on showed that the deceleration time did not change significantly in the course of the disease. On the other hand, the systolic function, as measured by the echocardiographically determined shortening fraction, improved in the survivors (from 0.18 +/- 0.07 to 0.22 +/- 0.08; P < 0.05), but not in those who later on died.