The N E W E N G L A N D J O U R N A L of M E D I C I N E

proving delivery of primary care.1 However, we are sensitive to the fact that this testing can add time and complexity to the visit, and commu­ nity resources to support patients with cognitive impairment may be limited. Support for this important work and appropriate time allotted for clinicians to engage in conversations with patients and families must be prioritized in all efforts to redesign primary care.

Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695-9. D O t: 10.1056/NEJMC1500324







Brown and Steinman are correct to highlight medication nonadherence as an early indicator of cognitive impairment. We concur that medica­ tion nonadherence can be an early signal of im­ paired executive functioning and should prompt Leigh H. Simmons, M.D. appropriate evaluation. Christiana A. lyasere, M.D. Physicians in primary care practices, including Kathleen L. Hamilton, N.P. those affiliated with our own hospital, are en­ Massachusetts General Hospital couraged to perform routine screening of older Boston, MA Ms. Hamilton reports no potential conflict of interest rele­ adults for cognitive impairment at the time of vant to this letter. Since publication of their article, Drs. Sim­ the Medicare Annual Wellness Visit or at other mons and lyasere report no further potential conflict of interest. periodic intervals. Models of team-based care such as the patient-centered medical home are 1. Rich E, Lipson D, Libersky J, Parchman M. Coordinating care for adults with complex care needs in the patient-centered proposed to ensure that comprehensive exami­ medical home: challenges and solutions. Rockville, MD: Agency nations that include screening for cognitive im­ for Healthcare Research and Quality. January 2012 (AHRQ pub­ pairment are delivered routinely in primary care; lication no. 12-0010-EF). we believe these models hold promise for im­ D O I: 10.1056/N EJM cl500324

Infection with a Chlorophyllic Eukaryote after a Traumatic Freshwater Injury t h e e d i t o r : We present two cases of softtissue infection caused by the chlorophyll-con­ taining alga Desmodesmus arm atus in immuno­ competent adults. Patient 1, a 24-year-old man who had no underlying medical conditions, sus­ tained a deep puncture wound to the right foot in a freshwater lake in Texas. Patient 2, a 30-yearold man who also had no clinically significant medical history, received a traumatic freshwater injury while jet-skiing in Missouri; the injury re­ sulted in open dislocation of the right knee and a coronal unicondylar fracture of the distal right femur. After each patient was admitted to the hospi­ tal, there was a clinical impression of infection, and tissue specimens obtained intraoperatively (from the tissue of the right foot in Patient 1 and from the adipose tissue of the right knee and the vastus medialis muscle o f the thigh in Patient 2) were sent for microbiologic examination. Gram’s staining revealed polymorphonuclear leukocytes

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but no organisms. Routine bacterial and myco­ bacterial cultures were unremarkable except for a single colony of a coagulase-negative staphylo­ coccus species isolated on the bacterial culture of the adipose tissue obtained from Patient 2. However, fungal cultures of tissue from the right foot (in Patient 1) and adipose tissue (in Patient 2) grew green colonies consistent with a chloro­ phyllic organism that was subsequently identi­ fied as the alga D. armatus. Both patients required surgical debridement, and although they did not receive antifungal therapy, which may be active against some algae,1 both recovered without recurrence of D. armatus infection. Patient 1 had a full recovery without se­ quelae. However, beginning approximately 1 year after his initial presentation, Patient 2 had recur­ rent methicillin-susceptible Staphylococcus aureusassociated septic arthritis. The isolates obtained from both patients pro­ duced green colonies on Sabouraud’s dextrose

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Case 38-2014: A man with sore throat, hoarseness, fatigue, and dyspnea.

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