Tuesday, July 9, 2024
Pathogenic mutation in ARPP21 in patients with amyotrophic lateral sclerosis
Details Emerge About Participants in Dementia Alternative Payment Model
On July 1, the Centers for Medicare & Medicaid Services (CMS) Innovation Center launched the Guiding an Improved Dementia Experience (GUIDE) Model, with 390 participating organizations building dementia care programs that will serve hundreds of thousands of people with Medicare nationwide.
CMS said the GUIDE Model, which will run for eight years, will be one of the first Innovation Center care models to focus on longitudinal, condition-specific comprehensive care, a key element of the Innovation Center’s 2022 Specialty Strategy. Today, nearly 7 million Americans live with Alzheimer’s disease or another form of dementia, and, by 2060 the number of Americans living with dementia is expected to double to 14 million.
Details about many of the model participants are starting to emerge. Participants represent a wide range of healthcare providers, including large academic medical centers, small group practices, community-based organizations, health systems, hospice agencies, and other practices.
UConn Health in Connecticut shared details about how its program is set up. Patients eligible for the pilot program at UConn Health are those who visit with a UConn Center on Aging geriatrician and have a diagnosis of dementia. UConn Health will be proactively contacting its patients who may be eligible for the program, along with CMS. The UConn Center on Aging geriatricians will also accept new patients into the GUIDE Model Program.
Patients enrolled in the GUIDE program will receive a comprehensive assessment by UConn Health geriatricians and a home visit from a UConn Health navigator to identify any at home safety risks and needs. The multidisciplinary care team at UConn Health will also work with caregivers to develop a coordinated care plan and medication schedule and provide caregiver skills training, and referrals to helpful services such as home-delivered meals and transportation, along with 24/7 access to their UConn Health GUIDE care team’s phone support line. Access to respite services will be available so caregivers have time to care for themselves, too.
“This program will allow UConn Health to provide vital care coordination services to address social, environmental, and emotional concerns and help people living with dementia remain in their own homes, said Khadija Poitras-Rhea, L.C.S.W., associate vice president of population health at UConn Health, in a statement. “GUIDE combines comprehensive medical care for patients with additional services like support groups, respite care, community resources and education to support person-centered care. The program has a focus on health equity and our team will work closely with senior centers, faith communities and others in underserved areas to offer the benefits of GUIDE to help reduce health disparities when it comes to memory care for marginalized groups and promote greater health equity.”
Emory Integrated Memory Care in Atlanta is participating in GUIDE. A joint initiative between the Emory University Nell Hodgson Woodruff School of Nursing and Emory Healthcare, Emory Integrated Memory Care offers geriatric primary care, dementia care, and caregiver education and support. The nurse-managed practice is available as an outpatient clinic at the Emory Brain Health Center in Brookhaven and at select Atlanta-area senior living communities.
Emory Integrated Memory Care is the only primary care practice in the U.S. specifically designed for people living with dementia and their care partners. The practice operates under the management of nurse practitioners with advanced training and specialization in dementia, geriatrics and palliative care.
Among the GUIDE participants are virtual care providers. The CareAtHome Medical Group, a national independent medical group that provides clinical care via telemedicine to patients with chronic conditions and home-based care needs, is partnering with Vesta Healthcare, a healthcare services organization and its network of home-based care providers to deliver the GUIDE program in 11 states.
“CMS is excited to partner with CareAtHome and Vesta Healthcare under the GUIDE Model,” said CMS Administrator Chiquita Brooks-LaSure, in a statement. “GUIDE is a new approach to how Medicare will pay for the care of people living with dementia. The GUIDE participants are envisioning new ways to support not only people living with dementia but also to reduce strain on the people who care for them so that more Americans can remain in their homes and communities, rather than in institutions.”
Watch live: Biden speaks at NATO summit as questions swirl around campaign
President Biden is delivering an address Tuesday for the 75th anniversary of the North Atlantic Treaty Organization (NATO) during the organization’s summit in Washington.
NATO has several urgent items on its current agenda, although viewers at home and abroad will also evaluate Biden’s demeanor and apparent mental sharpness. The president received support from House Democrats earlier in the day, but the incumbent’s fitness to stand for reelection in the fall remains a pressing question both within his party and among the public as a whole.
The status of NATO, formed initially as a transatlantic counterweight to the Soviet Union, had been somewhat in doubt following the end of the Cold War.
But as several former Soviet satellites, Warsaw Pact nations, including Czechia (Czech Republic), Slovakia, and Hungary, and former Baltic republics of the U.S.S.R. itself signed onto the alliance, Russia came to see the alliance as a renewed threat.
The U.S.-backed war in Ukraine is the most critical flashpoint in the current tensions between Russia and the West. The bid by Ukraine itself to join NATO is still pending, although current member states are in agreement that the war-ravaged country will in time follow several of its neighbors in signing on.
Biden is scheduled to speak at 5 p.m. EDT.
Watch the live video above.
https://thehill.com/video-clips/4762445-biden-nato-speech-watch-live/
'AI-based differential diagnosis of dementia etiologies on multimodal data'
Abstract
Differential diagnosis of dementia remains a challenge in neurology due to symptom overlap across etiologies, yet it is crucial for formulating early, personalized management strategies. Here, we present an artificial intelligence (AI) model that harnesses a broad array of data, including demographics, individual and family medical history, medication use, neuropsychological assessments, functional evaluations and multimodal neuroimaging, to identify the etiologies contributing to dementia in individuals. The study, drawing on 51,269 participants across 9 independent, geographically diverse datasets, facilitated the identification of 10 distinct dementia etiologies. It aligns diagnoses with similar management strategies, ensuring robust predictions even with incomplete data. Our model achieved a microaveraged area under the receiver operating characteristic curve (AUROC) of 0.94 in classifying individuals with normal cognition, mild cognitive impairment and dementia. Also, the microaveraged AUROC was 0.96 in differentiating the dementia etiologies. Our model demonstrated proficiency in addressing mixed dementia cases, with a mean AUROC of 0.78 for two co-occurring pathologies. In a randomly selected subset of 100 cases, the AUROC of neurologist assessments augmented by our AI model exceeded neurologist-only evaluations by 26.25%. Furthermore, our model predictions aligned with biomarker evidence and its associations with different proteinopathies were substantiated through postmortem findings. Our framework has the potential to be integrated as a screening tool for dementia in clinical settings and drug trials. Further prospective studies are needed to confirm its ability to improve patient care.
The 988 Crisis Lifeline Callback Enigma
"We should project our thoughts ahead of us at every turn and have in mind every possible eventuality instead of only the usual course of events." -- Lucius Annaeus Seneca
The launch of the 988 Suicide & Crisis Lifeline in July 2022 reminds us of the urgency of mental health crisis care. As a physician-scientist who has practiced emergency department psychiatry for decades, I would be interested to know what actually happens in these short, highly vulnerable moments immediately before and during crisis calls. Although this new entry point holds the potential for advancement in the field, concerns around the training and effectiveness of this new "comprehensive" crisis service continue to be raised and are likely valid.
More research is needed beyond general acceptance, case reports, some favorable numbers, and clinical anecdotal literature. Improvements to the lifeline are necessary to better understand local mental health needs, to evaluate the clinical expectations of intake counselors, to increase the visibility of existing resources, and to improve access where the primary barrier is clear and convincing pathology, not social determinants.
For example, there is no bias-free validity evidence demonstrating the crisis line's hypothesized efficacy in high-risk encounters. High-quality evidence demonstrating crisis line effectiveness during imminent risk of suicide is limited. Furthermore, concerns regarding the thoroughness of crisis call counselors' specific assessment of risk utilizing the Applied Suicide Intervention Skills Training (ASIST) are significant.
On the one hand, ASIST states that it develops "nonjudgmental attitudes" and "...focuses not on the complexity of suicide and its causes, but on the simple concept and achievable goal of safety for now." However, in this prehospital setting, acuity must be determined by the patient's complaints at the intake dispatch level. As 988 counselors receive calls, they should not only identify a patient's acuity level through their complaints, primary symptoms, and comorbidities, but also route the call appropriately.
While 988 advisers may diligently answer high-volume calls, engage with non-emergent clients utilizing several communication preferences, and help devise a safety plan, it is the prioritization of calls and call-backs to address those with the most pressing needs that is particularly important. Without knowing what takes place during these calls or if there is any triage protocol in place, I'm at a loss over whether this resource is being appropriately deployed.
Callbacks
Callbacks must be performed within a specific window of time based on the initial triage evaluation of a person's complaint.
For example, crisis counselors should understand that some non-urgent callers who need help in a time of crisis may not answer a timely callback due to fear of police contact, stigmatization, involuntary hospitalization, or other severe personal or financial consequences from the call. In situations where individuals need immediate attention, the call should be transferred without delay to specifically trained triage counselors. In this way, the proper level of care can be customized. Unfortunately, with some stress-induced, rapidly progressive, often unobvious suicidal conditions, destructive behavior may occur during the crisis call itself or before the call-back is attempted.
Some proximal real-life traumatic events, imagined or threatened with unique personal salience or vulnerability, may expose persons to a singular and particularly life-threatening event for whom ASIST is not helpful -- no matter how the 988 hotline is currently used. This is descriptively termed extrapyramidal induced or autonomous suicidality with both motor and mental manifestations, and often characterized by the person's belief that they are in the process of dying (Latin, angor = distress, animi = animated).
This dynamic angor animi is equivalent to near-death, acute coronary persons gasping and in poor clinical status requiring heroic intervention. In the interval before irretrievable slowed reaction time, difficulty initiating and prioritizing tasks, and internal preoccupation occur, there is a therapeutic window through which the person may still be psychologically available and accessible by phone. But it will close rapidly. Immediate transfer to specifically trained triage counselors or prompt call-back is essential here.
Focused Factors
Beyond randomized trials or nonrandomized designs with some form of control to identify best assessment practices, only focused factors that influence outcomes of crisis conversations will begin to improve crisis care. The evaluation of focused factors of risk is complex but essential. Observational studies to examine effectiveness should also be conducted.
What represents a focused, goodness-of-fit factor of importance and survival in these highly vulnerable moments immediately before and during a crisis call? It is the early identification of seized neurocognitive capacity characterized by inhibition or loss of verbal or symbol fluency, i.e., phonological recoding to connect letters and numbers.
Enigmatically, it is the 988 string of numbers itself. Here's why it is important. During a psychological crisis, cognitive functions can be significantly affected. Acute stress can lead to mental slowing, impaired task switching, difficulty concentrating, reduced processing speed, and diminished comprehension.
Thus, for some during a disorganizing crisis, the 988 digital dialing code may not be an easy number to remember. Individuals in greatest need may not be able to access it cognitively at a certain point during their crisis. Therefore, the impact on the thoroughness of current, phenotype-specific risk training and assessment becomes essential with a pointed index of suspicion for unusual high-risk cases.
I understand the challenge and complexity. Identifying cognitive impairment is one thing, but then considering potential etiologies and intervening is a whole other thing.
Conclusion
It should now be obvious that suicide risk determinations require examination of intricate sensory processing. What is the requisite process? In simpler terms, these findings speak to the importance of crisis counselors, during initial call and timely callback, to suspect and understand rapid transitioning and autonomous suicide probabilities. Counselors must assess neurocognitive functioning, regardless of ideation, early and quickly in these crisis encounters. Well-timed tests of executive function, such as the 1-minute phonic alpha-numeric trail-making examination, are additional, easy-to-learn and easy-to-administer tools for the identification of risk acuity in a distribution of high-risk callers.
Future 988 training efforts and implementation need to focus on improving consistency and effectiveness of currently inadequate ASIST-like assessments of risk. In-depth training on focused factors, clinical guidelines, and suicide prevention strategies should be based on emerging high-quality evidence in the field of clinical usefulness. This should include empirical decision trees and differential diagnosis of extreme risk distribution phenotypes with intricate probability models.
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