Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes

Describes in detail eight change concepts as a guide to transforming a practice into a patient-centered medical home, including engaged leadership, quality improvement strategy, continuous and team-based healing relationships, and enhanced access

The Contribution of Blood Serum Biomarkers to the Prediction of Cognitive Decline by fMRI and Apolipoprotein-E in Healthy Older Adults

Biomarkers are a promising approach to the prediction and early intervention of Alzheimer\u27s disease. We demonstrated that cortical functional MRI (fMRI) activation during a semantic memory task and apolipoprotein-E ?4 allele inheritance (APOE?4) effectively predicted cognitive decline after 18-months in healthy, asymptomatic elders. Hippocampal volume added modest prediction, while AD family history and demographics were ineffective. Previous studies have linked plasma homocysteine (tHcy), vitamin B12 and creatinine values to cognitive funcitoning, cortical atrophy, hippocampal atrophy and neuropathology, and vascular integrity. Here we incorporated total plasma homocysteine (tHcy), B12 creatinine values into our previous predictive models. Of 78 healthy elders, 27 (34.6%) exhibited significant cognitive decline after 18-months. tHcy, but not B12 or creatinine, was marginally positively correlated with cortical semantic memory fMRI activation, particularly in stable participants. Logistic regression showed that tHcy, when added to APOE?4 and cortical fMRI, was a significant predictor of outcome and strengthed the already significant model (p = .007; C = .80 and R2 = .37). However, control for B12 and creatinine covariates diminished tHcy as a predictor (p = .084), though the model was still stronger than without this factor (C = .78 and R = 31). tHcy did not significantly interact with APOE?4, as has previously been reported. Neither B12 nor creatinine was similarly effective as a predictor. These results suggest that commonly investigated blood serum biomarkers are at best weakly associated with predicting age- and dementia-related cognitive decline in healthy, asymptomatic elders. fMRI and APOE?4 presently provided the best predictive model

The Contribution of Blood Serum Biomarkers to the Prediction of Cognitive Decline by fMRI and Apolipoprotein-E in Healthy Older Adults

Biomarkers are a promising approach to the prediction and early intervention of Alzheimer\u27s disease. We demonstrated that cortical functional MRI (fMRI) activation during a semantic memory task and apolipoprotein-E ?4 allele inheritance (APOE?4) effectively predicted cognitive decline after 18-months in healthy, asymptomatic elders. Hippocampal volume added modest prediction, while AD family history and demographics were ineffective. Previous studies have linked plasma homocysteine (tHcy), vitamin B12 and creatinine values to cognitive funcitoning, cortical atrophy, hippocampal atrophy and neuropathology, and vascular integrity. Here we incorporated total plasma homocysteine (tHcy), B12 creatinine values into our previous predictive models. Of 78 healthy elders, 27 (34.6%) exhibited significant cognitive decline after 18-months. tHcy, but not B12 or creatinine, was marginally positively correlated with cortical semantic memory fMRI activation, particularly in stable participants. Logistic regression showed that tHcy, when added to APOE?4 and cortical fMRI, was a significant predictor of outcome and strengthed the already significant model (p = .007; C = .80 and R2 = .37). However, control for B12 and creatinine covariates diminished tHcy as a predictor (p = .084), though the model was still stronger than without this factor (C = .78 and R = 31). tHcy did not significantly interact with APOE?4, as has previously been reported. Neither B12 nor creatinine was similarly effective as a predictor. These results suggest that commonly investigated blood serum biomarkers are at best weakly associated with predicting age- and dementia-related cognitive decline in healthy, asymptomatic elders. fMRI and APOE?4 presently provided the best predictive model

The Ethical Review of Health Care Quality Improvement Initiatives: Findings From the Field

Based on surveys, examines the review mechanisms of quality improvement initiatives, including frequency; type, such as use of independent review boards; and consideration for ethical issues such as minimal risk and patient privacy and confidentiality

Performance Variability During a Multitrial List-Learning Task as a Predictor of Future Cognitive Decline in Healthy Elders

Introduction: In clinical settings, neuropsychological test performance is traditionally evaluated with total summary scores (TSS). However, recent studies demonstrated that indices of intraindividual variability (IIV) yielded unique information complementing TSS. This 18-month longitudinal study sought to determine whether IIV indices derived from a multitrial list-learning test (the Rey Auditory Verbal Learning Test) provided incremental utility in predicting cognitive decline in older adults compared to TSS. Method: Ninety-nine cognitively intact older adults (aged 65 to 89 years) underwent neuropsychological testing (including the Rey Auditory Verbal Learning Test) at baseline and 18-month follow-up. Participants were classified as cognitively stable (n = 65) or declining (n = 34) based on changes in their neuropsychological test performance. Logistic regression modeling tested the ability of baseline TSS indices (sum of Trials 1–5, immediate recall, and delayed recall) and IIV indices (lost access and gained access) to discriminate between stable and declining individuals. Results: Higher values of both lost access and gained access at baseline were associated with an increased risk for decline at 18-month follow-up. Further, the IIV indices provided predictive utility above and beyond the TSS indices. Conclusion: These results highlight the value of analyzing IIV in addition to TSS during neuropsychological evaluation in older adults. High levels of IIV may reflect impairment in anterograde memory systems and/or executive dysfunction that may serve as a prognostic indicator of cognitive decline

Longitudinal Associations between Physical Activity, Cognitive Status, and Brain Function in Older Adults at Genetic Risk for Alzheimer’s Disease

The apolipoproteinE epsilon4 (APOE-?4) allele is associated with cognitive decline in old age and is a risk factor for Alzheimer\u27s disease (AD). Physical activity (P A) is associated with a reduced risk of incident cognitive impairment, particularly among APOE-?4 carriers. We recently reported greater semantic memory related brain activation in cognitively intact physically active (High P A) APOE-?4 carriers compared to physically inactive (Low PA) ?4 carriers and non-carriers (Smith et al., 2011). Here, we compared longitudinal changes in semantic memory-related brain activation in High PA and Low PA APOE-?4 carriers. Thirty-two older ?4 carriers completed neuropsychological testing and a fMRI semantic memory task (famous name discrimination) at baseline and after 18 months. All participants were cognitively intact at baseline and were classified as High PA (n = 16) or Low PA (n = 16) based on self-report. After 18 months, 5 of 16 High P A and 13 of 16 Low P A were classified as cognitively declining by at least 1 SD decrease in neurocognitive performance (Group difference, p = .011, Fisher\u27s exact test). A fROI analysis of the fMRI data and repeated measures ANOV As revealed significant Group by Time interactions for intensity of semantic memory-related activation. Significantly greater activation at baseline in the High PA group was attenuated over time (no change in Low P A) and resulted in no group differences at the 18-month follow-up. These findings suggest that greater P A at baseline is associated with greater cognitive stability over 18-months in APOE-?4 carriers and reduced neural activation during fame discrimination

Episodic Memory Measures Complement Structural and Functional MRI for Predicting Cognitive Decline in Apolipoprotein E ε4 Carriers

Apolipo-protein E (APOE) ?4 allele carriers demonstrate greater risk for cognitive decline and Alzheimer\u27s disease than non-carriers. However, factors associated with risk of decline among APOE ?4 carriers are not well-known. In this longitudinal study, we investigated whether discrete aspects of baseline episodic memory performance and structural (sMRI) and function (fMRI) magnetic resonance imaging were associated with cognitive decline in older APOE ?4 carriers and non-carriers. Seventy-eight healthy older adults underwent cognitive testing at baseline and after 18 months, baseline serum APOE genotyping, manually-traced hip-pocampal volume measurement from sMRI, and task-activated fMRI. Cognitive decline was defined as a one SD or greater reduction from baseline on at least one of three cognitive measures at follow-up (Rey Auditory Verbal Learning Test [AVLT] Delayed Recall and Trials 1-5 Sum, Mattis Dementia Rating Scale-2 Total Score). Declining APOE ?4 carriers (n=14) exhibited reduced hippocampal volume (

Comparison of Semantic and Episodic Memory BOLD fMRI Activation in Predicting Cognitive Decline in Older Adults

Previous studies suggest that task-activated functional magnetic resonance imaging (fMRI) can predict future cognitive decline among healthy older adults. The present fMRI study examined the relative sensitivity of semantic memory (SM) versus episodic memory (EM) activation tasks for predicting cognitive decline. Seventy-eight cognitively intact elders underwent neuropsychological testing at entry and after an 18-month interval, with participants classified as cognitively “Stable” or “Declining” based on ≥1.0 SD decline in performance. Baseline fMRI scanning involved SM (famous name discrimination) and EM (name recognition) tasks. SM and EM fMRI activation, along with Apolipoprotein E (APOE) ε4 status, served as predictors of cognitive outcome using a logistic regression analysis. Twenty-seven (34.6%) participants were classified as Declining and 51 (65.4%) as Stable. APOE ε4 status alone significantly predicted cognitive decline (R2 = .106; C index = .642). Addition of SM activation significantly improved prediction accuracy (R2 = .285; C index = .787), whereas the addition of EM did not (R2 = .212; C index = .711). In combination with APOE status, SM task activation predicts future cognitive decline better than EM activation. These results have implications for use of fMRI in prevention clinical trials involving the identification of persons at-risk for age-associated memory loss and Alzheimer\u27s disease. (JINS, 2012, 18, 1–11

Facies architecture of Miocene subaqueous clinothems of the New Jersey passive margin: Results from IODP-ICDP Expedition 313

Understanding the history, causes, and impact of sea-level changes is a challenge for our societies that face accelerated global sea-level rise. In this context, improvement of our knowledge of sea-level changes and shoreline migration at geological time scales is critical. The preserved, laterally correlative sedimentary record of continental erosion on passive margins has been used to reconstruct past sea level. However, the detailed nature of a basic clinothem progradational pattern observed on many of these margins is still poorly known. This paper describes the sedimentary facies and interprets the depositional environments and the architecture of the clinothems of the New Jersey shelf (offshore northeastern USA) to depict the origin and controls of the distribution of the sediment on the margin. We analyze 612 cores totaling 1311 m in length collected at three sites 60 km offshore Atlantic City, New Jersey, during International Ocean Discovery Program–International Continental Scientific Drilling Program (IODP-ICDP) Expedition 313. The three sites sampled the lower to middle Miocene passive margin sediments of the New Jersey shelf clinothems. We also collected wireline logs at the three sites and tied the sedimentary architecture to the geometry observed on seismic profiles. The observed sediment distribution in the clinoform complex differs from that of current models based on seismic data, which predict a progressive increase in mud and decrease in sand contents in a seaward direction. In contrast, we observe that the clinoforms are largely composed of muds, with sands and coarser material concentrated at the rollover, the bottomset, and the toe of the slope. The shelf clinothem topsets are storm-influenced mud whereas the foreset slope is composed of a mud wedge largely dominated by density current deposits (e.g., low-density turbidites and debrites). The architecture of the clinothem complex includes a composite stack of ~30-m-thick clinothem units each made up of four systems tracts (Transgressive, Highstand, Forced-Regres­sive, and Lowstand Systems Tract) building individual transgressive-regres­sive sequences. The presence of mud-rich facies deposited during highstands on the topset of the clinoform, 40–60 km offshore from the sand-prone shoreface deposit (observed in the New Jersey onshore delta plain), and the lack of subaerial erosion (and continental depositional environments) point to a depositional model involving a subaerial delta (onshore) feeding a distant subaqueous delta. During forced regressions, shelf-edge deltas periodically overstep the stacks of flood-influenced, offshore-marine mud wedges of the New Jersey subaqueous delta, bringing sand to the rollover and building up the large-scale shelf-prism clinothems. The clinothem complex develops on a gently dipping platform with a ramp-like morphology (apparent dip of 0.75°–0.5°) below mean storm wave base, in 30–50 m of water depth, 40–60 km seaward of the coastal area. Its shape depends on the balance between accom­mo­da­tion and sedimentation rates. Subaqueous deltas show higher accumulation rates than their subaerial counterparts and prograde three times further and faster than their contemporaneous shoreline. The increase in the intensity of waves (height and recurrence intervals) favors the separation between subaqueous and subaerial deltas, and as a consequence, the formation of a flat topset geometry, a decrease in flood events and fluvial discharge, an overall progressive decrease in sediment grain size (from sequence m5.45, ca. 17.8–17.7 Ma, onwards), as well as an increase in sedimentation rates on the foresets of the clinoforms. All of these are recognized as preliminary signals that might characterize the entry into the Neogene icehouse world

Lifestyle and Genetic Contributions to Cognitive Decline and Hippocampal Structure and Function in Healthy Aging

Background: Engagement in cognitively stimulating activities (CA) and leisure time physical activity (PA) have been associated with maintaining cognitive performance and reducing the likelihood of cognitive decline in older adults. However, neural mechanisms underlying protective effects of these lifestyle behaviors are largely unknown. In the current study, we investigated the effect of self-reported PA and CA on hippocampal volume and semantic processing activation during a fame discrimination task, as measured by functional magnetic resonance imaging (fMRI). We also examined whether possession of the apolipoprotein E (APOE) ?4 allele could moderate the effect of PA or CA on hippocampal structure or function. Methods: Seventy-eight healthy, cognitively intact older adults underwent baseline neuropsychological assessment, hippocampal volume measurement via manually-traced structural MRI, and task-activated fMRI. Results: After 18 months, 27 participants declined by one standard deviation or more on follow-up neuropsychological testing. Logistic regression analyses revealed that CA alone or in combination with baseline hippocampal structure or functional activity did not predict the probability of cognitive decline. In contrast, PA interacted with APOE 4 status such that engagement in PA reduced the risk of cognitive decline in APOE 4 carriers only. Furthermore, the benefits of PA appeared to diminish with reduced functional activity or volume in the hippocampus. Conclusions: Our findings suggest that increased leisure time PA is associated with reduced probability of cognitive decline in persons who are at high risk for AD. The beneficial effects of PA in this group may be related to enhancement of the functional and structural integrity of the hippocampus