Faculty Bibliography

BACKGROUND: Diabetes mellitus is a risk factor for cognitive changes, but assessment for cognitive disorders in this population is performed infrequently. The present study examined the frequency of cognitive disorders and patterns of deficit in patients enrolled in a specialized clinic for diabetes. METHODS: A cross-sectional study was conducted to assess cognition in Mount Sinai Diabetes Center patients. Thirty eligible subjects aged >/=50 years were assessed and compared with non-diabetic cognitively normal control subjects, as well as non-diabetic subjects with mild cognitive impairment (MCI). The main outcome(s) and measure(s) were obtained through cognitive assessment and diagnosis using the Alzheimer's Disease Centers' uniform data set. RESULTS: Forty percent of subjects were newly diagnosed with a cognitive disorder: 10% were diagnosed with dementia and 30% with MCI. Diabetic subjects performed worse on the Mini-Mental State Examination (27.2 vs 28.4; P = 0.0132), list generation (9.5 vs 12.2; P = 0.0190), Trail Making Test, Parts A (70.1 vs 43.0; P < 0.0001) and B (197.2 vs 123.6; P < 0.0001), and the Digit Symbol test (12.7 vs 40.1; P < 0.0001) than cognitively normal individuals. Compared with subjects with MCI (amnestic type), diabetic subjects performed better on tasks of immediate and delayed recall (11.2 vs 7.3 [P = 0.0048] and 8.4 vs. 4.1 [P = 0.0003], respectively). CONCLUSIONS: Undiagnosed cognitive disorders are common and underappreciated in patients being treated in a specialized diabetes clinic. It may be important to make cognitive assessment a standard part of patient assessments.

Despite many advances in our understanding of ischemic stroke, cryptogenic strokes (those that do not have a determined etiology) remain a diagnostic and therapeutic challenge. Previous classification approaches to cryptogenic stroke have led to inconsistent definitions, and evidence to determine optimal treatment is scarce. These limitations have prompted international efforts to redefine cryptogenic strokes, leading to more rigorous diagnostic criteria, outcome studies, and new clinical trials. Improvement in our ability to detect paroxysmal atrial fibrillation in patients with cryptogenic stroke has strengthened the idea that these strokes are embolic in nature. Further, better understanding of acute biomarkers has helped to identify otherwise occult mechanisms. Together, these strategies will inform long-term outcomes and shape management.

Despite a bevy of options to manage atrial fibrillation, many questions remain

Approximately one third of ischemic strokes are labeled cryptogenic because the etiology is unknown despite a thorough evaluation. Paroxysmal atrial fibrillation carries the same risk of ischemic stroke as persistent atrial fibrillation and has increasingly gained attention as a potential source of cryptogenic stroke. Recent trials utilizing long-term cardiac monitoring devices have demonstrated high rates of previously undetected paroxysmal atrial fibrillation in patients with cryptogenic stroke. Newly detected atrial fibrillation has subsequently changed treatment and increased the use of oral anticoagulation in these studies. Other trials have shown an increased risk of stroke and thromboembolism in patients with device-detected subclinical tachyarrhythmias. Together, these studies suggest an important relationship between episodes of paroxysmal atrial fibrillation and the risk of cryptogenic stroke, but further investigations are needed to guide diagnostic and therapeutic decisions.

Although policies mandating annual influenza vaccination among health care workers (HCWs) are recommended, little is known about which HCWs support mandatory vaccination. We surveyed non-physician, non-nursing HCWs to identify beliefs associated with supporting mandatory HCW vaccination. Although similarities were identified, some beliefs and concerns associated with supporting mandatory vaccination differed among HCW groups. Policy makers should understand these differences and address beliefs and concerns of all HCW groups when attempting to implement a mandatory influenza vaccination policy.

BACKGROUND: Pallidal deep brain stimulation (DBS) is an established treatment for disabling, medication-refractory generalized dystonia. Patients typically regress to their preoperative baseline when stimulation is discontinued. METHODS: Presented are case reports of 2 dystonia patients. RESULTS: Two patients with primary generalized dystonia (1 with the DYT1 mutation) who were treated successfully with bilateral pallidal DBS for periods of 18 months and 5 years retained motor benefit for several months after inadvertent interruption of stimulation. Stimulation was interrupted unilaterally for 3 and 7 months and bilaterally for 2 days and 2 months, respectively. Symptoms of dystonia returned only partially during the period of therapy interruption and rapidly and completely resolved after resuming stimulation. CONCLUSIONS: We report unexpected and prolonged retention of motor benefits despite transient cessation of pallidal DBS in 2 dystonia patients. Factors that appear to differentiate these individuals are young age, short duration of disease, and chronic DBS therapy with relatively low energy of stimulation.