Ernström, Karin

Importance Alzheimer disease (AD) biomarker and genetic testing results are increasingly disclosed to cognitively unimpaired adults in research and could in the future inform clinical treatment decisions in this population. Objectives To assess psychological outcomes after returning 3 categories of amyloid biomarker results as well as apolipoprotein E ( APOE ) genotypes. Design, Setting, and Participants This cohort study was a secondary analysis of data collected as part of screening for the multisite AHEAD preclinical AD trial. Participants were individuals aged 55 to 80 years undergoing screening from July 14, 2020, to October 15, 2024. Exposure Participants were informed whether they had not-detected, intermediate, or elevated amyloid positron emission tomography levels, as well as their APOE genotype, which were categorized as noncarrier, ε4 heterozygote, or ε4 homozygote. Main outcomes and measures Impact of Events Scale (IES; 15 items to assess intrusive thoughts and avoidance; each item is scored as not at all [0], rarely [1], sometimes [3], or often [5]; total range, 0-75), collected 24 to 72 hours after disclosure, and change in a scale measuring concerns about AD dementia (adapted scale using 6 items in which participants indicated their level of agreement with statements related to their perceived probability of developing AD dementia; items scored as strongly disagree [1] through strongly agree [5]; total range, 6-30), calculated by subtracting the score collected before biomarker testing from 1 collected after biomarker and genetic test results disclosure. Results Among 3414 included individuals, the mean (SD) age was 68.8 (6.0) years and 2116 (62%) were female. Group mean IES scores were below clinically significant thresholds. Nevertheless, across genetic groups, learning an elevated amyloid result (1184 participants) was associated with higher IES (mean [SD], 10.5 [10.9]) than intermediate amyloid (482 participants; mean [SD] IES, 8.8 [9.8]), and intermediate amyloid was associated with higher scores than not-detected amyloid (1748 participants; mean [SD] IES, 6.5 [8.4]). Across amyloid groups, learning APOE ε4 homozygosity (337 participants) was associated with higher mean (SD) IES (12.7 [11.6]) than heterozygosity (1609 participants; 9.1 [10.2]), and heterozygosity was associated with higher IES than noncarrier status (1468 participants; mean [SD] IES, 6.2 [8.1]). Both types of information were significant in an analysis of covariance model; no interaction effect was observed. In contrast, only biomarker disclosure was associated with differential change in concerns about AD dementia. Those with elevated amyloid showed a mean (SD) increase in concern (0.8 [3.5]), those with intermediate amyloid showed a smaller increase (0.4 [3.7]), and those with not-detected amyloid showed decreased concerns (−1.1 [4.2]). Conclusions and Relevance In this cohort study of cognitively unimpaired adults, associations with intrusive thoughts were observed to differ among genetic and biomarker subgroups; such associations were limited to biomarker subgroups for measures of perceived dementia risk.

Introduction: "Mild" stroke is not well defined, but is a relative contraindication for the administration of IV rtPA. Advances in telemedicine have allowed for specialized practitioners to observe the examination, rather than rely on the on-scene examiner. We investigated whether there were differences in rates of identification, treatment, and outcomes of mild stroke patients in the phone compared to the video arms of a telestroke network. Methods: The STRokE DOC trials were prospective, randomized, outcome-blinded trials comparing video telemedicine to phone-only evaluations, which assessed eligibility for IV rtPA and correctness of decision-making for 2 hubs and 6 spokes. This analysis included all adult acute ischemic stroke patients from the STRokE DOC trials who were defined as “mild” using a recent definition from the TREAT Task Force. Rates of ICH, mortality, and dichotomized 90-day mRS scores were compared between the video and phone arms. Results: Mild stroke accounted for 32% and 29% of the video and phone arms, respectively. The two groups had similar baseline characteristics except hypertension (higher rate in video arm). Of the video mild stroke patients, 13% had poor outcome (mRS>1) compared to 24% of the phone arm (p=0.45). There were no symptomatic ICH or deaths. Among IV rtPA treated mild stroke patients, all of the video arm had good outcome, versus 25% of the phone arm. Of 100 non-treated patients, 34 were excluded because of "too mild" a deficit (TMT). In the phone arm, 7 of these did not meet the TREAT-derived criteria for mild stroke (p=0.03). One TMT patient in the phone arm had poor outcome. Conclusions: Mild stroke made up a third of the patients in each group. Some TMT patients in the phone arm did not meet the criteria for mild stroke; their subtle findings may not have been conveyed adequately over the phone. Among IV rtPA treated patients, the phone arm had worse outcomes. The results raise concern regarding accuracy of predicting outcomes for mild stroke patients, especially when based on a phone description. The study numbers were small, so conclusions cannot be definitively made. Future studies are necessary to determine decision making factors within the telemedicine process that influence treatment outcomes among mild stroke patients.

Background and Purpose— The American Stroke Association guidelines emphasized the need for further high-quality studies that assess agreement by radiologists and nonradiologists engaged in emergency telestroke assessments and decision-making. Therefore, the objective of this study was to determine the level of agreement of baseline brain CT scan interpretations of patients with acute stroke presenting to telestroke spoke hospitals between central reading committee neuroradiologists and each of 2 groups, spoke hospital radiologists and hub hospital vascular neurologists (telestrokologists). Methods— The Stroke Team Remote Evaluation Using a Digital Observation Camera Arizona trial was a prospective, urban single-hub, rural 2-spoke, randomized, blinded, controlled trial of a 2-way, site-independent, audiovisual telemedicine and teleradiology system designed for remote evaluation of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis. In the telemedicine arm, the subjects’ CT scans were interpreted by the hub telestrokologist and in the telephone arm by the spoke radiologist. All subjects’ CT scans were subsequently interpreted centrally, independently, and blindly by 2 hub neuroradiologists. The primary CT outcome was determination of a CT-based contraindication to thrombolytic treatment. Kappa statistics and exact agreement rates were used to analyze interobserver agreement. Results— Fifty-four subjects underwent random assignment. The overall agreement for the presence of radiological contraindications to thrombolysis was excellent (0.91) and did not differ substantially between the hub telestrokologist to neuroradiologist and spoke radiologist to neuroradiologist (0.92 and 0.89, respectively). Conclusions— In the context of a telestroke network designed to assess patients with acute stroke syndromes, agreement over the presence or absence of radiological contraindications to thrombolysis was excellent whether the comparisons were between a telestrokologist and neuroradiologist or between spoke radiologist and neuroradiologist. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00623350.