The Colorado Cognitive Assessment (CoCA): Development of an Advanced Test of Cognitive Status

Objective

Current brief tests of cognition provide a rough indication of overall cognitive functioning that assist with making gross clinical judgments (e.g., demented vs. not demented). The purpose of the present study was to develop and preliminarily validate a brief tool, The Colorado Cognitive Assessment (CoCA) to facilitate early and accurate diagnosis of mild and atypical presentations of dementia. A related goal was to compare its psychometric properties with The Montreal Cognitive Assessment (MoCA).

Method

Participants were 150 community dwelling adults over the age of 50 without a known mental health or neurological condition. Confirmatory factor analysis (CFA) was used to assess model fit of the CoCA and MoCA. Measurement invariance (MI) was evaluated using the multiple-indicators multiple-causes modeling (MIMIC) approach.

Results

The CFA model of the CoCA revealed excellent fit; χ2(44) = 47.506, p = .332; CFI = 0.987; TLI = 0.983; RMSEA = 0.023 (90% CI [0.000, 0.061]); SRMR = 0.048. MI analyses revealed that items on the CoCA were invariant to sex, age, education, and mood. In comparison, a CFA model of the MoCA had worse fit; χ2(14) = 28.536, p = .012; CFI = 0.817, TLI = 0.725; RMSEA = 0.083 (90% CI [0.038, 0.127]); SRMR = 0.062; and was biased by age, education, and depressive symptomatology. The global factor score reliability of the CoCA (r = .84) was better than the MoCA (r = .74).

Conclusion

Results provide preliminary evidence for the CoCA as a reliable and comprehensive cognitive instrument with further cross-sectional and longitudinal research needed for its validation.

Mechanisms underlying renoprotection during renin-angiotensin system blockade

Potential determinants of chronic renal disease (CRD) progression were studied in male Munich-Wistar rats subjected to 5/6 nephrectomy and treated with candesartan (Csn; n = 30) or enalapril (Ena; n = 27) from 5 wk postsurgery. Despite control of systolic blood pressure (SBP; 24 wk: Csn = 143 +/- 9; Ena = 148 +/- 8 mmHg), urinary protein excretion rates (U(pr)V) increased over 24 wk (Csn = 92 +/- 10; Ena = 99 +/- 8mg/day). Glomerulosclerosis scores (GS) at 24 wk were similar for Csn (42 +/- 7%) vs. Ena (42 +/- 4%), values close to those of untreated controls at 12 wk (43 +/- 4%). At 24 wk, SBP and UprV correlated strongly with GS, together accounting for 72% of the variance in GS. Renal cortex mRNA levels (determined by competitive RT-PCR) for transforming growth factor (TGF)-beta1 and monocyte chemoattractant protein (MCP)-1 were elevated in Csn and Ena at 12 wk and remained higher at 24 wk vs. sham. Strong correlations were evident among TGF-beta1, MCP-1, and interleukin-1beta and renal injury at 24 wk. Cns and Ena are thus equally effective renoprotective agents in this model. During renin-angiotensin system inhibition, renoprotection is dependent on control of both SBP and UprV. Incomplete suppression of renal cytokine gene expression may also contribute to CRD progression.

Preemptive epidural morphine for postoperative pain relief after lumbar laminectomy

This study was designed to evaluate the efficacy of preemptive epidural morphine for postoperative analgesia after lumbar laminectomy. Thirty ASA physical status I adults undergoing elective lumbar laminectomy under general anesthesia were randomly allocated to one of two groups. Group 1 (study group) received 3 mg epidural morphine preemptively 60 min before surgery, followed by epidural placebo at the end of surgery. Group 2 (control group) received epidural placebo at the same time preoperatively as the study group, followed by 3 mg epidural morphine at the conclusion of surgery. Pain was assessed using visual analog scales (VAS), and sedation was graded on a 4-point rank drowsiness score. Time to first postoperative analgesic (TFA), the supplementary analgesia, and the amount of morphine used over the 24-h period were noted for the groups. VAS pain scores were significantly less in Group 1 (preemptive group) than in Group 2 8 h after surgery (P < 0.05). TFA in the study group (19.9 +/- 2.3 h) was significantly prolonged compared with the control group (8.5 +/- 1.0 h, P < 0.05). The demand for supplementary analgesia and postoperative morphine consumption in the preemptive group was significantly lower than that in control group (P < 0.05). Patients in the control group were significantly sedated after 12 h and had a high incidence of nausea and vomiting (P < 0.05). The study shows that preemptive epidural morphine is superior to epidural morphine given postoperatively for pain relief after lumbar laminectomy.

Analgesia for acute musculoskeletal trauma: low-dose subcutaneous infusion of ketamine

Low-dose ketamine by subcutaneous infusion (0.1 mg/kg/h) was compared in double-blind fashion with intermittent morphine (0.1 mg/kg intravenously, four-hourly) as analgesic regimen in 40 ASA-I adults after acute musculoskeletal trauma. Pain was assessed using visual analogue scales and sedation was graded on a four point rank drowsiness score. Objective cardiovascular and respiratory parameters and patient acceptability in terms of supplementary analgesia and early mobilization were also recorded. Pain relief was better with the ketamine infusion than with intermittent morphine (P < 0.001). Patients were more awake and alert with ketamine infusion as evidenced by the drowsiness score (P < 0.001). Peak expiratory flow rate improved significantly with the ketamine infusion (P < 0.05). None of the patients in ketamine group required supplementary analgesia (P < 0.001) and the patients could be easily mobilized for traction/splintage as compared with patients in the control group (P < 0.001). The incidence of nausea and vomiting in the morphine group was high (P < 0.01). The study shows that subcutaneous infusion of ketamine provides safe and effective analgesia in acute musculoskeletal trauma.

Subcutaneous infusion of ketamine and morphine for relief of postoperative pain: a double-blind comparative study

Low dose ketamine by subcutaneous infusion (0.1 mg.kg-1.h-1) was compared in a double-blind fashion with a similar infusion of morphine (0.03 mg.kg-1.h-1) for postoperative analgesia in 60 ASA-I adults after major abdominal surgery. Pain was assessed using visual analogue scales and sedation was graded on a four-point rank drowsiness score. Cardiovascular and respiratory parameters were also recorded. Pain relief was better with the ketamine infusion than with morphine infusion (P < 0.001). Both tidal and minute volume parameters improved better with ketamine (P < 0.001); patients were more awake and alert as evidenced by the drowsiness score (P < 0.001). Nine out of 30 patients who received morphine required catheterisation for urinary retention (P < 0.05). The study revealed higher analgesic efficacy of a low dose subcutaneous infusion of ketamine with lesser sedation and fewer side effects.

A prospective clinico-bacteriological study of internal jugular cannulation in a critical care unit

The results of 125 consecutive central venous catheterizations during a six-month period in the critical care unit were prospectively studied. All the catheters were inserted percutaneously by internal jugular approach and the placement of catheters was confirmed by chest roentgenography while injecting Conray 420. The safety of the technique was evaluated in terms of success and complication rates. Failure rate was only 0.8 per cent, while overall complication rate was 17.6 per cent. Arterial puncture and hematoma were the commonest complications encountered in 8 and 4 per cent of the patients respectively. Pneumothorax occurred in two patients (1.6%), while misplacement of catheter tip and thrombophlebitis was encountered in 0.8 per cent of all cannulations. No microorganisms were isolated from catheters inserted for less than 5 days. Positive catheter-tip cultures, by quantitative method, were obtained in 41 cases (P < 0.001) of which infected intravenous insert growing > 10(3) colony forming units, was encountered in 36 (P < 0.001) and colonization of the catheter (< 10(3) colony forming units) was seen in 5 cases. Catheter related bacteremia (recovery of the same organism from the catheter tip and peripheral blood cultures) occurred in 31 of these 41 patients (P < 0.01). The study reveals that internal jugular approach is a safe technique for central vein catheterization with very high success rate and fewer complications. However, catheter-related bacteremia is a potential threat which is directly related to the number of days the catheter is in central circulation and is totally preventable.

Acute isoniazid poisoning

We present two cases of acute isoniazid poisoning in patients who ingested 7.5 g and 5.0 g of isoniazid respectively, with the intention of committing suicide. Both were admitted unconscious, with ventilatory insufficiency and convulsions. Hepatic dysfunction and peripheral neuropathy were notable complications.