Background Cognitive impairment is common in patients treated with hemodialysis. The trajectory of cognitive function and risk factors for cognitive decline remain uncertain in this population. Study Design Longitudinal cohort Setting & Participants Three hundred fourteen prevalent hemodialysis patients Predictors Age, sex, race, education level, hemodialysis vintage, cause of end-stage renal disease, and baseline history of cardiovascular disease (CVD). Outcomes Cognitive function as determined by a comprehensive neurocognitive battery, administered at baseline and yearly whenever possible. Individual cognitive test results were reduced into two domain scores using principal components analysis, representing memory and executive function, which were used as our co-primary outcomes, and by definition have a mean of zero and standard deviation of one. Results Mean age was 63 years; 54% were men, 22% were black and 90% had at least a high school education. During median follow up of 2.1 (IQR, 0.9–4.2) years, 196 had at least one follow up test, 156 died and 43 received a kidney transplant. Linear mixed models and joint models, which accounted for competing risks from death, dropout, or kidney transplantation, showed nearly identical results. The joint model demonstrated a decline in executive function (−0.09 [95% confidence interval, −0.13 to −0.05] SD per year), while memory improved slightly (0.05 [95% CI, 0.02 to 0.08] SD per year). A significant yearly decline was also seen in the Mini-Mental State Examination (median change of −0.41; 95% CI, −0.57 to −0.25). Older age was the only significant risk factor for steeper executive function decline (−0.04 [95% CI, −0.06 to −0.02] SD steeper annual decline for each 10 years of age). Limitations Prevalent hemodialysis patients only, limited follow up testing due to high mortality rate, and exclusion of participants with severe cognitive deficits or dementia Conclusions Prevalent hemodialysis patients demonstrate significant cognitive decline, particularly within tests of executive function. Older age was the only statistically significant risk factor for steeper cognitive decline, which may have important clinical consequences for patient management and education. Future studies should evaluate strategies to maintain or improve cognitive function.

A naturally luminescent bacterium, Vibrio harveyi, and two bacteria, Escherichia coli and Pseudomonas fluorescens, which had been genetically marked with luminescence were starved in liquid medium at 4 and 30°C for 54 days. Total cell concentrations and concentrations of culturable and viable cells were determined by acridine orange staining, dilution plate counting, and direct viable counting, respectively, and population activity was measured by luminometry. V. harveyi became nonculturable but maintained viability during starvation at 4°C and maintained both culturability and viability at 30°C. In contrast, E. coli became viable but nonculturable during starvation at 30°C but not at 4°C. Luminescence of nonculturable cells of both strains, and culturable cells of V. harveyi, decreased to background levels during starvation. Luminescence of starved culturable cells of E. coli also fell below background levels but occasionally increased to detectable values. Viable, nonculturable forms of P. fluorescens were not detected at either temperature, and cells starved at 4°C showed no decrease in luminescence measured during incubation of samples at 25°C. Following incubation of late-log-phase cells with yeast extract and nalidixic acid, changes in light output directly paralleled changes in cell length, as observed during direct viable counting. Quantification of changes in luminescence following incubation of starved cells with yeast extract enabled measurement of the activity of both culturable and viable but nonculturable cells. Measurement of luminescence was significantly more sensitive, rapid, and convenient in quantifying activity following nutrient amendment than measurement of changes in cell length. Luminescence-based marker systems potentially provide a selective means of detecting the presence and activity of viable but nonculturable cells in the soil and freshwater environments, where indigenous luminescent populations are negligible, and enable assessment of the activity and environmental impact of such

BackgroundNeurocognitive testing shows that cognitive impairment is common among patients receiving maintenance hemodialysis. Identification of a well performing screening test for cognitive impairment might allow for broader assessment in dialysis facilities and thus optimal delivery of education and medical management.MethodsFrom 2015 to 2018, in a cohort of 150 patients on hemodialysis, we performed a set of comprehensive neurocognitive tests that included the cognitive domains of memory, attention, and executive function to classify whether participants had normal cognitive function versus mild, moderate, or severe cognitive impairment. Using area-under-the-curve (AUC) analysis, we then examined the predictive ability of the Mini Mental State Examination, the Modified Mini Mental State Examination, the Montreal Cognitive Assessment, the Trail Making Test Part B, the Mini-Cog test, and the Digit Symbol Substitution Test, determining each test’s performance for identifying severe cognitive impairment.ResultsMean age was 64 years; 61% were men, 39% were black, and 94% had at least a high-school education. Of the 150 participants, 21% had normal cognitive function, 17% had mild cognitive impairment, 33% had moderate impairment, and 29% had severe impairment. The Montreal Cognitive Assessment had the highest overall predictive ability for severe cognitive impairment (AUC, 0.81); a score of ≤21 had a sensitivity of 86% and specificity of 55% for severe impairment, with a negative predictive value of 91%. The Trails B and Digit Symbol tests also performed reasonably well (AUCs, 0.73 and 0.78, respectively). The other tests had lower predictive performances.ConclusionsThe Montreal Cognitive Assessment, a widely available and brief cognitive screening tool, showed high sensitivity and moderate specificity in detecting severe cognitive impairment in patients on maintenance hemodialysis.

Objectives Maladaptive cognitions related to loss are thought to contribute to development of complicated grief and are crucial to address in treatment, but tools available to assess them are limited. This paper introduces the Typical Beliefs Questionnaire (TBQ), a 25-item self-report instrument to assess cognitions that interfere with adaptation to loss. Design Study participants completed an assessment battery during their initial evaluation and again after completing treatment at 20 weeks. Test-retest reliability was assessed on a subsample of the participants who did not show change in complicated grief severity after the first four weeks of treatment. To examine latent structure of the TBQ, an exploratory factor analysis (EFA) was performed. Setting Academic medical centers in Boston, New York, Pittsburgh and San Diego from 2010–2014. Participants 394 bereaved adults who met criteria for complicated grief. Measurements The TBQ along with assessments of complicated grief symptoms and related avoidance, depression symptoms, functional impairment, and perceived social support. Results The TBQ exhibited good internal consistency (α= .82) and test-retest reliability (n=105; ICC= .74). EFA indicated a five-factor structure: “Protesting the Death,” “Negative Thoughts About the World,” “Needing the Person,” “Less Grief is Wrong” and “Grieving Too Much.” The total score and all factors showed sensitivity to change with treatment. Conclusions This new tool allows a clinician to quickly and reliably ascertain presence of specific maladaptive cognitions related to complicated grief, and subsequently, to use the information to aid a diagnostic assessment, to structure the treatment, and to measure treatment outcomes.

BackgroundPatients treated with dialysis have high rates of brain infarcts, brain atrophy, and white matter disease. There are limited data regarding the presence of more subtle damage to brain white matter.MethodsIn the Cognition and Dialysis Study, we compared brain structure using diffusion tensor imaging in hemodialysis (HD) patients to individuals without known kidney disease, using tract based spatial statistics (TBSS) to compare Fractional Anisotropy (FA) and Mean Diffusivity (MD). Statistical comparison of each overlaid voxel was age controlled using a permutation based corrected p value of <0.05.ResultsThirty-four HD patients and twenty six controls (52 vs 51 years for HD vs control) had adequate magnetic resonance imaging for analysis. The HD group had fewer women (38% vs 23%) and a higher prevalence of diabetes (29% vs 8%), heart failure (29% vs 0%) and clinical stroke (15% vs 0%). Hemodialysis patients had significantly lower FA across multiple white matter fiber tracts, with fronto-temporal connections, the genu of the corpus callosum and the fornix more significantly affected than posterior regions of the brain. Similarly, HD patients had significantly higher mean diffusivity in multiple anterior brain regions. Results remained similar when those with a prior history of stroke were excluded.ConclusionsIn HD patients, there is more white matter disease in the anterior than posterior parts of the brain compared to controls without kidney disease. This pattern of injury is most similar to that seen in aging, suggesting that developing chronic kidney disease and ultimately kidney failure may result in a phenotype consistent with accelerated aging.