The diagnosis of "mixed" dementia in the Consortium for the Investigation of Vascular Impairment of Cognition (CIVIC)

If vascular risk factors are risk for Alzheimer's disease (AD), and if "pure" vascular dementia (VaD) is less common than has been thought, what do we make of the diagnosis of mixed dementia? We report characteristics of those with mixed dementia in a prospective, seven center, clinic-based Canadian study. Of 1,008 patients, 372 were diagnosed with AD, 149 with vascular cognitive impairment (VCI) including 76 with mixed AD/VaD, and 82 with other types of dementia. The mean age of patients with mixed AD/VaD was 78.0 +/- 7.6 years; 49% were female. These proportions differed significantly between dementia diagnosis subgroup (p < 0.001) showing a trend which is evident in all comparisons--AD/VaD patients fall in between AD and VaD. Vascular risk factors were present significantly more often in mixed AD/VaD than in AD (p < 0.001). More mixed AD/VaD (20%) than AD patients (4%) had focal signs, compared with 38% of those with vascular dementia and 12% with other types of dementia. Between the initial clinical diagnosis and the final diagnosis (which utilized neuroimaging and neuropsychological data) AD/VaD was the least stable diagnosis. Neuroimaging of ischemic lesions was the most common reason for reassignment from AD to the mixed AD/VaD diagnosis (17 cases). These data suggest that an operational definition of mixed AD/VaD can be proposed on presentation and clinical/radiographic findings, but indifferent to vascular risk factors. The concept of mixed dementia should be extended to include vascular dementia in combination with dementias, other than Alzheimer's disease.

Online measures of basic language skills in children with early focal brain lesions

Twenty children with early focal lesions were compared with 150 age-matched control subjects on 11 online measures of the basic skills underlying language processing, a digit span task, and 6 standardized measures. Although most of the children with brain injury scored within the normal range on the majority of the tasks, they also had a disproportionately high number of outlier scores on the reaction time tests. This evidence for a moderate impairment of the basic skills underlying language processing contrasts with other evidence suggesting that these children acquire normal control of the functional use of language. Furthermore, these children scored within the normal range on a measure of general cognitive ability, suggesting that there is no particular sparing of linguistic functions at the expense of general cognitive functions. Using the MPD procedure (Valdés-Pérez & Pericliev, 1997), we found that the controls and the five clinical groups could be best distinguished with two measures of online processing (word repetition and visual number naming) and one standardized test subcomponent (the CELF Oral Directions subtest). The 12 children with left hemisphere lesions scored significantly lower than the 8 other children on the CELF-RS measure. Within the group of children with cerebral infarct, the nature of the processing disability could be linked fairly well to site of lesion. Otherwise, there was little relation between site or size of lesion and the pattern of deficit. These results support a model in which damage to the complex functional circuits subserving language leads to only minor deficits in process efficiency, because of the plasticity of developmental processes.

Causes of Alzheimer's disease

It is now understood that genetic factors play a crucial role in the risk of developing Alzheimer's disease (AD). Rare mutations in at least 3 genes are responsible for early-onset familial AD. A common polymorphism in the apolipoprotein E gene is the major determinant of risk in families with late-onset AD, as well as in the general population. Advanced age, however, remains the major established risk factor for AD, although environmental variables may also have some role in disease expression. Some pathogenic factors directly associated with aging include oxidative damage and mutations in messenger RNA. Other factors unrelated to the aging process may, in the future, be amenable to therapeutic intervention by way of estrogen replacement therapy for postmenopausal women, anti-inflammatory drug therapy and reducing vascular risk factors. Older theories, such as aluminum playing a role in the pathogenesis of AD, have been mostly discarded as our understanding of pathogenic mechanisms of AD has advanced.

Outcome measures for the study of activities of daily living in vascular dementia

Decline in functional abilities is a major component of the dementia syndrome. The definition of dementia in the International Classification of Diseases (10th rev.) requires a cognitive impairment sufficient to impair personal activities of daily living (ADL). The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) also requires cognitive deficits sufficiently severe to cause impairment in occupational or social functioning and must represent a decline from a higher level of functioning. However, the term disability is more appropriate than impairment to describe a loss in activities, as opposed to a loss of elementary functions, and is consistent with World Health Organization definitions of impairment, disability, and handicap. There is no doubt that ADL outcomes are required in therapeutic drug studies on vascular dementia, and there is a good rationale and some evidence for the use of ADL scales developed for therapeutic research in Alzheimer disease, favoring scales devoid of items sensitive to physical disabilities. Similarly, ADL-related clinical milestones could be used for longer-term studies aiming predominantly at slowing progression of disease in both early and later stages of dementia. Slower decline in ADL and delay in reaching ADL-related clinical milestones should be considered as valid outcomes by regulatory bodies in the process of dementia drug approval.

Seizure control and mortality in epilepsy

Mortality rates are increased among people with epilepsy, and may be highest in those with uncontrolled seizures. Because epilepsy surgery eliminates seizures in some people, we used an epilepsy surgery population to examine how seizure control influences mortality. We tested the hypothesis that patients with complete seizure relief after surgery would have a lower mortality rate than those who had persistent seizures. Three hundred ninety-three patients who had epilepsy surgery between January 1986 and January 1996 were followed after surgery to assess long-term survival; 347 had focal resection or transection, and 46 had anterior or complete corpus callosotomy. A multivariate survival analysis was performed, contrasting survival in those who had seizure recurrence with survival of those who remained seizure free. Standardized mortality ratios and 95% confidence intervals were calculated. Overall, seizure-free patients had a lower mortality rate than those with persistent seizures. This was true for the subset of patients with localized resection or multiple subpial transection. No patients died among 199 with no seizure recurrence, whereas of 194 patients with seizure recurrence, 11 died. Six of the deaths were sudden and unexplained. Most patients who died had a substantial reduction in postoperative seizure frequency. The standardized mortality ratio for patients with recurrent seizures was 4.69, and the risk of death in these patients was 1.37 in 100 person-years, whereas among patients who became seizure free, there was no difference in mortality rate compared with the age- and sex-matched population of the United States. Elimination of seizures after surgery reduces mortality rates in people with epilepsy to a level indistinguishable from that of the general population, whereas patients with recurrent seizures continue to suffer from high mortality rates. This suggests that uncontrolled seizures are a major risk factor for excess mortality in epilepsy. Achieving complete seizure control with epilepsy surgery in refractory patients reduces the risk of death, so the long-term risk of continuing medical treatment appears to be higher than the risk of epilepsy surgery in suitable candidates.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia

OBJECTIVE

To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians toward the recognition, assessment and management of dementing disorders and to disseminate and evaluate the impact of these statements and guidelines built on these statements.

OPTIONS

Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral, management of complications (especially behavioural problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations; neuroimaging and referrals; and appropriate use of cognitive enhancing agents.

EVIDENCE

Authors of each background paper were entrusted to perform a literature search, discover additional relevant material, including references cited in retrieved articles, consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based on this evidence, consensus statements were developed by a group of experts, guided by a steering committee of 8 individuals, from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems.

VALUES

Recommendations have been developed with particular attention to the context of primary care, and are intended to support family physicians in their ongoing assessment and care of patients with dementia. BENEFITS HARM AND COSTS: Potential for improved clinical care of people with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations.

RECOMMENDATIONS

Forty-eight recommendations are offered that address the following aspects of dementia care: early recognition; importance of careful history and examination in making a positive diagnosis; essential laboratory tests; rules for neuroimaging and referral; disclosure of diagnosis; importance of monitoring and providing support to caregivers; cultural aspects; detection and treatment of depression; observation and management of behavioural disturbances; detection and reporting of unsafe motor vehicle driving; genetic factors and opportunities for preventing dementia; pharmacological treatment with particular emphasis on cognitive enhancing agents.

VALIDATION

Four other sets of consensus statement or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

First International Pharmacoeconomic Conference on Alzheimer's Disease: report and summary

The First International Pharmacoeconomic Conference on Alzheimer's Disease (AD) was held in Amsterdam in July 1998. The meeting was held under the auspices of the International Working Group for Harmonization of Dementia Drug Guidelines (http://dementia.ion.ucl.ac.uk/harmon), bringing together academics, clinicians, purchasers, and representatives from industry. Presentations were given on the methodology of pharmacoeconomic studies in AD, particularly focusing on caregiver burden, quality of life (QOL), and resource utilization. Three economic models of AD were presented based on data from the United States, Canada, and the United Kingdom. In two studies, these data were then used to model the cost-effectiveness and effect on cost of treatment with donepezil. Both studies suggested a possible cost advantage for the use of donepezil, when compared with no placebo or treatment, particularly when donepezil is used appropriately in mild-to-moderate AD. These data need to be interpreted with care, as none of the cost or utility information were collected during the clinical trials. Additional data from a 2-year clinical trial of selegiline and vitamin E suggest that cognitive measures may be poor predictors of economic outcome, which is better measured directly. Both economic models of donepezil rely on short-term cognitive data to predict long-term outcome, a methodf that may not be useful in predicting economic savings. The issues facing pharmacoeconomists, researchers, clinicians, and families in the future were addressed in a series of workshops using a method of strategic futuring. The workshops attempted to see 7 years into the future for a range of areas, including consumer and caregiver use of pharmacoeconomic data; early detection and prevention; Japanese perspectives; activities of daily life and what will be daily life activities; caregiver burden; QOL at the end of life; new uses for new information and communication technology in clinical research; and physicians' use of pharmacoeconomic data. A range of exciting futures were predicted, although common themes that arose when considering barriers to achieving these futures included cost, education, political will, confidentiality, privacy, and ethics. The first conference was deemed to have been a success, having attracted more than 160 delegates and many distinguished speaker. A second conference is planned for the year 2000. Over the next 2 years, research needs to be broadened particularly in the methodological areas of resource utilization, QOL, and caregiver burden. Data from clinical trials with relevant economic and QOL outcomes will be needed by purchasers if drug treatments for dementia are to gain widespread use. It is also hoped that the models described at the meeting may become more freely available to politicians, purchasers, clinicians, and caregivers to help them make better decisions about treatment.

A playroom observation procedure to assess children with mental retardation and ADHD

Forty-two children (ages 6 to 12 years old) with moderate mental retardation to borderline intellectual functioning were studied in a laboratory playroom setting to determine whether children identified as ADHD (attention deficit hyperactivity disorder) or controls differed on activity and attentional measures. Children with ADHD were further divided into ADHD + conduct problems (ADHD + CD) and ADHD-only subgroups (with an ADHD-combined group comprising children of both subgroups). An interval recording system was used to code observations of independent play and a restricted academic task. Results indicated that the ADHD-combined group was significantly more vocal and engaged in a significantly greater number of toy changes than controls during independent play. Significant group differences were also noted during the restricted academic task, with the ADHD-combined and ADHD + CD groups more off-task and engaging in a greater number of toy touches than controls. Discriminant analyses found independent play measures to predict group membership in 70 percent of cases (ADHD-combined vs. controls), but in only 64 percent of cases using measures from the restricted academic task. No significant findings resulted when the ADHD subjects were further divided into two subgroups. Despite some inconsistent findings, such laboratory-based observations may be of value in the diagnosis of ADHD in children with moderate mental retardation to borderline intellectual functioning.

Predictors of overweight and overfatness in a multiethnic pediatric population. Child and Adolescent Trial for Cardiovascular Health Collaborative Research Group

The goal of the study was to determine whether overweight or overfatness were predicted from sex, race or ethnicity, school site, and intervention or control status for children who were 9 y old at the outset of the Child and Adolescent Trial for Cardiovascular Health (CATCH). In this ethnically and geographically diverse group of 5106 students, height, weight, and triceps skinfold thickness were measured at 9 (baseline) and 11 y (follow-up) of age. The strongest predictors of status at follow-up were baseline overweight (odds ratio: 69.0; 95% CI: 54.9, 96.3) and overfatness (odds ratio: 27.4; 95% CI: 22.4, 33.4); site, African American race or ethnicity, and male sex were also significant independent associations. Children in the overweight (> 85th percentile for body mass index) group had significantly higher adjusted means for total blood cholesterol, higher apolipoprotein B concentrations, lower mean HDL-cholesterol concentrations, and lower performance on the 9-min run than those in other groups (< 15th, 15-49th, or 50-85th body mass index percentiles). Similar results were found for these factors for those subjects with greater triceps skinfold-thickness measurements. Groups of children who were overweight and overfat at baseline were more likely to be overweight and overfat at follow-up and to have more cardiovascular risk factors than their peers.

Gastrointestinal tract bleeding associated with naproxen sodium vs ibuprofen

BACKGROUND

The risk of gastrointestinal tract bleeding requiring hospitalization associated with naproxen sodium was compared with that with ibuprofen, using a prescription database to approximate over-the-counter dosing.

OBJECTIVE

To evaluate the safety of naproxen sodium.

METHODS

A claims database containing Ohio Medicaid data from January 1986 through February 1993 and Michigan Medicaid data from April 1983 through July 1993 was used to compare 101,318 patients dispensed naproxen sodium with 277,601 patients dispensed ibuprofen. Using a case-cohort design, all 59 patients from the full cohort who had been hospitalized with upper gastrointestinal tract bleeding (UGIB) that developed within 14 days after the first prescription for the study drugs were compared with a subcohort made up of a 10% random sample of subjects selected from the combined drug cohorts.

RESULTS

The incidence of UGIB occurring within 14 days after the first prescription in the naproxen sodium cohort was 26 (0.026%) of 101,318 (95% confidence interval [CI], 0.017%-0.038%), compared with 33 (0.012%) of 277,601 patients (95% CI, 0.008%-0.017%) in the ibuprofen cohort. Overall, the use of naproxen sodium vs ibuprofen was associated with an adjusted relative risk of 2.0 (95% CI, 1.1-3.8). Among people with multiple prescriptions, the crude relative risk for those receiving therapy in a dose typical of over-the-counter use was 4.1 (95% CI, 1.2-13.8).

CONCLUSIONS

The overall incidence of UGIB is low with both drugs. There is little additional absolute risk posed by the use of low-dose naproxen sodium, compared with low-dose ibuprofen, despite an increased relative risk. However, given the widespread use of these drugs, a substantial number of additional cases of UGIB could result from use of naproxen sodium. This increased risk should be considered, especially for patients whose baseline risk of UGIB is elevated.

Teaching pediatric residents about early intervention and special education

We compared two educational interventions (didactic lecture with handouts vs guidelines placed in patient charts) and assessed their impact on knowledge of early developmental services and identification of children eligible for these services. Forty-nine pediatric residents participated in preintervention and postintervention tests of knowledge of such services. Mean scores for all residents were 54% (pre-test) and 60% (post-test). First-year residents scored significantly lower than 2nd- and 3rd-year residents on pre- (p = .0001) and post-tests (p < .02). From our convenience sample of 1204 patients, ages newborn to 6 years, seen in the resident continuity clinic during the study period, residents identified children eligible for early developmental services. The mean percentage of identifying eligible children was 13% (range, 0-40%). We did not detect a statistically significant impact of either educational strategy. We conclude, therefore, that more comprehensive strategies are needed to change physician knowledge of and behavior toward early developmental services.

Physician characteristics: do they influence the evaluation and treatment of breast cancer in older women?

BACKGROUND

To determine if physician specialty, length of time in practice, and fear of malpractice influence the diagnosis and management of breast cancer in older women.

METHODS

We used a fractional factorial design that controlled for patient age (65 or 80 years), race, socioeconomic status, mobility, comorbidity, and assertive behavior through 2 videotaped scenarios (a potential breast cancer [no. 1] and a known stage IIA breast cancer [no. 2]). One hundred twenty-eight white male physicians equally divided by specialty (surgeon versus nonsurgeon) and time in practice (< or = 15 or >15 years) viewed the videotapes and made recommendations.

RESULTS

The physician subjects saw 46 patients per week, 59% female, and 47% age > or = 65. Their concern over malpractice was 4.7 (on a 10-point Likert scale with a higher score indicating more concern) and did not differ by specialty or time in practice (P values > 0.7). After viewing scenario no. 1, surgeons were less likely than nonsurgeons to consider breast cancer as the principal diagnosis (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2 to 0.9) and to obtain a tissue diagnosis (OR = 0.3, 95% CI = 0.1 to 0.9). However, in scenario no. 2, surgeons were more likely to offer reconstruction (OR = 3.8, 95% CI = 1.4 to 10.4). Physicians in practice < or = 15 years were more likely than those in practice <15 years to obtain a tissue diagnosis in scenario no. 1 (OR = 6.1, 95% CI = 1.9 to 19.2) and to perform full primary therapy in scenario no. 2 (OR = 2.8, 95% CI = 1.2 to 6.9). Physicians who performed an extensive metastatic evaluation (bone or computer tomography [CT] scan) had greater concern over malpractice than those who did not, as did physicians who performed an axillary node dissection (OR = 2.1, 95% CI 1.3 to 3.4 and OR = 1.8, 95% CI = 1.1 to 3.0).

CONCLUSIONS

With the uncertainty of how to diagnose and treat older women with breast cancer, physician specialty, length of time in practice, and concern over malpractice do influence clinical decisions.

Clinical global measures of dementia. Position paper from the International Working Group on Harmonization of Dementia Drug Guidelines

Following is the report of the committee working on clinical global measures for antidementia drug guidelines. The concepts involved in global scales, the distinctions between change and severity scales, advantages and disadvantages of structured interviews, and anchoring of change scores are discussed, and selected existing clinical global scales are described. In addition, the committee assessed the utility of global scales in clinical trials for antidementia drugs. There was a consensus among the members of the working group on the following: (1) Clinical global scales are interview based; in most cases, they include information obtained from caregivers as well as directly from patients, but they can rely on information from the subject only. (2) Clinicians' global ratings are intended to assess clinically meaningful change based on multidimensional clinical assessment and take into account the clinical heterogeneity of dementia by assessing at least cognition, behavior, and functioning. (3) There are two distinct types of clinical global measures: (a) clinicians' interview-based global severity scales, which generally incorporate classification by stage or severity of illness and (b) clinicians' interview-based global change scales, which incorporate global assessment ratings of clinical change. The committee could not reach a consensus on whether global scales should be required in phase II and phase III clinical trials, or whether other specific assessments such as well-designed activities of daily living, cognition, and behavior measures could, when used in appropriate combinations, replace the global as assessments of clinical meaningfulness.

Protein kinase C activity and protein levels in Alzheimer's disease

Patients with Alzheimer's disease (AD) have been reported to have abnormalities in the levels and activities of protein kinase C (PKC) in brain and other tissues. We have measured Ca2+-activated, phospholipid-dependent PKC activities and levels in cerebral cortex from frontal, motor, temporal and parietal regions, as well as in leukocytes and platelets from AD patients and controls. No significant differences in PKC histone H1 phosphotransferase activity were seen in frontal, motor, temporal or parietal cortex, or in leukocytes and platelets from AD patients and controls. Elevated PKC protein was present in cytosolic fractions from frontal cortex, but not in other brain regions, or in leukocytes and platelets. These data suggest that abnormalities of PKC phosphorylating activity are absent in AD.

A randomized, controlled trial of linopirdine in the treatment of Alzheimer's disease

OBJECTIVES

We tested the efficacy and safety of linopirdine, a novel phenylindolinone, in the treatment of Alzheimer's disease.

METHODS

A multicentre, randomized, double-blind, parallel group, placebo-controlled trial of linopirdine (30 mg three times per day or placebo). Patients (n = 382, 55% male, 98% Caucasian, age range 51-95 years) with mild or moderate Alzheimer's disease, of whom 375 received at least one treatment dose were analysed. There were no important differences between the groups at baseline.

RESULTS

No difference was seen in Clinical Global Impression scores between patients receiving placebo and those receiving linopirdine (n = 189). Small differences in the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores were seen throughout the study favouring linopirdine; at 6 months the ADAS-Cog scores were 20.2 (linopirdine) and 22.1 (placebo) p = 0.01.

CONCLUSIONS

This trial did not detect clinically meaningful differences in patients receiving linopirdine for 6 months, despite evidence of a small degree of improved cognitive function. Further studies may benefit from more sensitive tests of treatment effects in Alzheimer's disease.

An evaluation of a nurse extern program

Externships are meant to bridge the gap between the educational and practice setting for nursing. This project began with discussions of outcomes for nurse extern programs. The Schutzenhofer Nurse Activity Scale and the Meleis Nurse Self-Description Form were used to measure identified outcomes of professional activities and autonomy. Forty-one participants began the study, but 33 completed the pretest and posttest both. Analysis of data showed a positive correlation in Posttest 1 between age and the Meleis Nurse Self-Description Form (NSDF). Dimensions of professional activity changed most in older students. At the end of Phase 2, analysis of data showed significantly greater professional autonomy. However, no significant change in NSDF was seen throughout time. Participants reported increased self confidence.

Regional HmPAO SPECT and CT measurements in the diagnosis of Alzheimer's disease

BACKGROUND

This study investigated the hypothesis that the combination of regional CT brain atrophy measurements and semiquantitative SPECT regional blood flow ratios could produce a diagnostic test for Alzheimer's disease (AD) with an accuracy comparable to that achieved with the present clinical gold standard of the NINCDS-ADRDA criteria.

METHODS

Single proton emission computed tomography (SPECT) and CT head scans were performed on 122 subjects referred an UBC Alzheimer clinic and diagnosed as either 'not demented' (ND-37) or 'possible/probable AD' (AD-85) by the NINCDS-ADRDA criteria. Stepwise discriminant analysis (SDA) was performed on the bilateral SPECT regions of interest and compared to bilateral CT qualitative/quantitative assessment in the frontal, parietal and temporal lobes to determine which were most accurate at ND/AD distinction. Receiver operating curves (ROC) were then constructed for these variables individually and for their combined discriminant function.

RESULTS

The left temporal qualitative cortical atrophy score (CT) and left temporal perfusion ratio (SPECT) were selected in the SDA. The combined discriminant function was more specific at AD/ND distinction than either of CT or SPECT alone. The accuracy of AD/ND distinction with the combined discriminant function was below that achieved by clinical diagnosis according to the NINCDS-ADRDA criteria and was not significantly different from that achieved with SPECT or CT alone as defined by ROC curve analysis.

CONCLUSION

The measurements of left temporal cortical atrophy and regional cerebral blood flow were most indicative of AD; however they lacked the sensitivity and specificity to recommend their use as a diagnostic test for AD.

Serum levels of the iron binding protein p97 are elevated in Alzheimer's disease

Alzheimer's disease is a progressive and incurable disease whose prevalence increases dramatically with age. A biochemical marker for monitoring the onset and progression of the disease would be a valuable tool for disease management. In addition, such a marker might be used as an end point in clinical intervention protocols. Here we provide evidence that the soluble form of the iron binding protein p97 is found in elevated amounts in the serum of Alzheimer's patients compared with healthy controls. This biochemical marker has the potential for identifying subjects afflicted with the disease and possibly for monitoring the onset and longitudinal progression of the disease.

Tobacco use measurement, prediction, and intervention in elementary schools in four states: the CATCH Study

BACKGROUND

The Child and Adolescent Trial for Cardiovascular Health (CATCH) is a multistate field trial examining the effects of school environment, classroom curricula, and family intervention components in promoting the cardiovascular health of elementary school students. The purpose of this paper is to describe the CATCH tobacco use intervention and measurement, including the adoption of tobacco-free school policies.

METHODS

In this study, changes in school tobacco use policies and smoking experimentation among students were assessed. Smoking experimentation was measured in all CATCH schools when the students were in their fifth-grade year. A total of 6,527 subjects in 96 schools in California, Louisiana, Minnesota, and Texas answered questions about behaviors and potential correlates of smoking as part of the CATCH health behavior questionnaire in Spring 1994. School tobacco use policy, an important complement to classroom- and home-based prevention efforts, was promoted as part of the CATCH intervention. The degree to which such policy was implemented was measured using surveys of school officials.

RESULTS

At the end of fifth grade, only 4.8% of the subjects indicated that they had experimented with tobacco. School intervention condition was not a factor in the prediction of experimentation. Those whose best friend or sibling smoked, or who had ready access to cigarettes in the home, were more likely to have experimented with smoking. In the 3 years of the study, the percentages of tobacco-free schools went up from 49.7 to 76.8%. Though differences in the rate of policy adoption could not be directly attributed to the CATCH intervention, the implementation of the tobacco-free schools' policies did vary substantially from state to state. Minnesota and Texas, with stronger state laws supporting local policy, had nearly completely smoke-free schools. In spite of a statewide tobacco control initiative, California was slower to implement school policies. Louisiana, which allows local decision making regarding smoking policy, had the most difficulty establishing a policy for all districts.

CONCLUSION

Future studies should examine the impact of parallel policy interventions that are ongoing at both school and state levels. Tobacco-free policies appear to be a crucial part of school-based interventions and must be tailored to political and regional factors affecting a given school district.

Consequences of success: do more teeth translate into more disease and utilization?

OBJECTIVES

Increased tooth retention coupled with increased numbers of older adults means that the actual number of teeth at risk to dental disease will increase sharply. Whether this increase in the number of teeth will translate into more disease and utilization in unknown. The purpose of this study was to test this "more teeth, therefore more dental disease" theory using cross-sectional data.

METHODS

In-home personal interview and oral examination data were obtained on a probability sample of elders aged 70 years and older living in the six New England states using the Medicare beneficiary list as a sampling frame. Data on dental utilization, number of teeth, dental caries, and periodontal disease were included in the current analysis.

RESULTS

Analysis of variance on subjects with 1-10 (Group 1), 11-24 (Group 2), and 25-32 (Group 3) teeth show that the extent of bleeding on probing, pocket depth, and loss of attachment all increase as numbers of teeth increase. Similarly, a greater number of restored coronal and root surfaces were found in Group 3 relative to the other two groups. Mean numbers of decayed and filled coronal surfaces were 8.4 in Group 1.33.0 in Group 2, and 50.3 in Group 3. In contrast, unrestored coronal and root surface were significantly higher in Group 1 (mean root DS = 1.3) than Group 3 (mean root DS = 0.3). Utilization patterns of those with successful aging dentitions (Group 3) show that they are visiting dentists more frequently than the compromised group (Group 1).

CONCLUSIONS

These cross-sectional data obtained from a probability sample of New England elders show that subjects who retained higher numbers of teeth have more periodontal disease and dental caries experience, and visit the dentist more frequently.

Acute histamine-induced flux of airway liquid: role of neuropeptides

The role of capsaicin-sensitive neuropeptides in the accumulation of airway wall liquid observed 30 s after histamine infusion was investigated in guinea pigs. Two groups were studied: normal animals and animals in which endogenous neuropeptides had been depleted by capsaicin pretreatment. A rapid intravenous infusion of saline or histamine (11 micrograms/kg resulted in marked but similar changes in pulmonary mechanics in normal and capsaicin-pretreated animals. To assess liquid accumulation in airway wall compartments, the lungs were frozen 30 s after histamine infusion; airways from these lungs, 0.15-2.44 mm in internal perimeter, were imaged by low-temperature scanning electron microscopy. There was no difference in average airway surface liquid thickness (hASL) in normal or capsaicin-pretreated airways in response to saline. In capsaicin-pretreated animals, histamine infusion was associated with a significantly decreased hASL (hASL, cap11/hASL,cap0 = 0.58, P < 0.04). Capsaicin pretreatment, without histamine exposure, caused significant increases in epithelial and submucosal areas (Aepi,cap0/Aepi,norm0 = 1.23, P < 0.06; Asub,cap0/Asub,norm0 = 1.40, P < 0.01). The notation cap0 and cap11 indicates capsaicin-pretreated airways given 0 or 11 micrograms/kg histamine, respectively; similarly, norm0 and norm11 indicate normal airways given 0 and 11 micrograms/kg histamine, respectively. Histamine infusion in capsaicin-pretreated animals was associated with liquid shifts from epithelium to lamina propria and from submucosa to adventitia; however, the total wall area was similar to, if not smaller than, that in capsaicin-pretreated animals without histamine treatment. In contrast, histamine infusion in normal animals resulted in significant increases in the areas of the epithelial and lamina propria compartments (Aepi,norm11/Aepi,norm0 = 1.25, P < 0.05; Alp,norm11/Alp,norm0 = 2.19, P < 0.001) as well as a substantial increase in adventitial area, which was significantly attenuated by capsaicin pretreatment (Aadv,cap11/Aadv,norm11 = 0.40, P < 0.001). The resulting total wall area was more than twice that in normal animals without histamine treatment. Our data indicate that histamine-induced accumulation of liquid in the epithelium, lamina propria, and adventitia of normal airways is rapid in onset, most likely derives from a leaky bronchial microvasculature, and is mediated by the secondary release of neurokinins.

Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A postmarketing surveillance study

OBJECTIVE

To evaluate the risk of gastrointestinal and operative site bleeding associated with the use of parenteral ketorolac tromethamine.

DESIGN

Postmarketing surveillance inception cohort study.

SETTING

A total of 35 hospitals throughout the Philadelphia, Pa, region, 1991 to 1993.

PATIENTS

Patients administered 10,272 courses of parenteral ketorolac therapy were compared with patients administered 10,247 courses of a parenteral opiate who were matched to the ketorolac patients by hospital, admitting service, and date of initiation of study drug.

MAIN OUTCOME MEASURES

Medical records were reviewed for demographics, medical history, doses and duration of study drug, various aspects of the hospital course including surgery and concomitant medications, and adverse events.

RESULTS

The multivariate adjusted odds ratio (OR) comparing ketorolac with opiates for gastrointestinal bleeding was 1.30 (95% confidence interval [CI], 1.11 to 1.52); for operative site bleeding, the OR was 1.02 (95% CI, 0.95 to 1.10). The OR was elevated further in subjects 75 years of age or older for both gastrointestinal bleeding (OR = 1.66; 95% CI, 1.23 to 2.25) and operative site bleeding (OR = 1.12; 95% CI, 0.94 to 1.35). A dose-response relationship was evident between average daily ketorolac dose and both gastrointestinal bleeding and operative site bleeding (trend test P < .001 for both). When analgesic therapy lasted 5 or fewer days, ketorolac was associated with only a small increased risk of gastrointestinal bleeding (OR = 1.17; 95% CI, 0.99 to 1.30); when therapy was prolonged beyond 5 days, the OR was 2.20 (95% CI, 1.36 to 3.57). The association of ketorolac with operative site bleeding was not affected by duration of therapy.

CONCLUSIONS

The overall associations between ketorolac use and both gastrointestinal bleeding and operative site bleeding are small. However, the risk associated with the drug is larger and clinically important when ketorolac is used in higher doses, in older subjects, and for more than 5 days. Improving physicians' prescribing practices by limiting the dose and duration of ketorolac use, especially in the elderly, should enhance its overall risk-benefit balance.

Reduced stomach capacity in obese subjects after dieting

The objective of the study was to assess the change in gastric capacity of obese subjects consuming a hypoenergetic diet. Otherwise healthy, obese subjects participated in a prospective controlled study as hospital outpatients. Fourteen (11 females, 3 males) subjects were assigned to the diet group and 9 (7 females, 2 males) were assigned to the control group. Subjects in the diet group were provided a 2508-kJ/d(600 kcal/d) formula diet for 4 wk. Subjects in the control group ate ad libitum for 4 wk. Gastric capacity was determined before the study and 4 wk later by oral insertion of a latex gastric balloon after an overnight fast. The balloon was infused with water at a rate of 100 mL/min, with pauses for measuring intragastric pressure, until no further distension was tolerated. Two indexes for estimating gastric capacity were used based on subjective and objective criteria: 1) the maximal volume that could be tolerated, and 2) the volume required to produce a rise in water pressure of 5 cm. Subjects in the diet group, who lost a mean of 9.1 kg, showed a 27% reduction in gastric capacity based on the first index (P = 0.004) and a 36% reduction based on the second index (P = 0.006). For the control subjects, gastric capacity did not change significantly with use of either index. The results demonstrate a reduction in gastric capacity in obese subjects after a restricted diet.

Outcome variables in presymptomatic individuals at higher risk of developing Alzheimer disease

The treatment of individuals at risk of Alzheimer disease is feasible in well-designed, placebo-controlled, double-blind studies. The favored design would be life survival for cognitive impairment, alterations in instrumental ADL, and selected biological variables.

Children's activity levels and lesson context during third-grade physical education

Little is known about children's activity levels during physical education classes and how they relate to the national health objectives for the year 2000 (U.S. Public Health Service, 1991). We systematically observed students' physical activity and associated variables in 293 third-grade physical education lessons in 95 schools in 4 Child and Adolescent Trial for Cardiovascular Health (CATCH) centers in California, Louisiana, Minnesota, and Texas. The influence of independent variables was assessed simultaneously by analysis of variance. Significant differences among study centers were evidenced for both physical activity and lesson context variables. Additionally, there were differences among variables for lesson location and teacher specialty, but not for teacher gender. Boys were more active than girls, but only during free play opportunities. The findings have widespread implications for educators responsible for developing and implementing health-related physical education programs, as well as for designing and conducting staff development.

High-performance liquid chromatographic determination of iobitridol in plasma, urine and bile

Iobitridol is a new non-ionic, low-osmolality contrast medium for urography and angiography. We have developed a method for determining iobitridol in body fluids using high-performance liquid chromatography with ultraviolet detection. The method, which is specific and reproducible, does not require an internal standard. Determinations can be carried out in body fluids against a set of standards in ethanol. The method was validated for the quantification of iobitridol in biological samples obtained during pharmacokinetic studies.

Canadian guidelines for the development of antidementia therapies: a conceptual summary

The magnitude of the problems faced by Canadian society as a result of an aging population has been identified. Perhaps the most important concern related to this greying of Canada is the increasing incidence of dementia and Alzheimer's disease. Therapeutic options for these disorders have been limited to date. Advances in biotechnology and molecular biology will offer novel approaches to treatment. These and the expansion of more traditional therapeutic avenues require guidelines with the aim of optimizing their development.

Airway surface liquid thickness as a function of lung volume in small airways of the guinea pig

The average thickness and distribution of airway surface liquid (ASL) on the luminal surface of peripheral airways were measured in normal guinea pig lungs frozen at functional residual capacity (FRC) and total lung capacity (TLC). Tissue blocks containing cross sections of airways of internal perimeter 0.188-3.342 mm were cut from frozen lungs and imaged by low-temperature scanning electron microscopy (LTSEM). Measurements made from LTSEM images were found to be independent of freezing rate by comparison of measurements at rapid and slow freezing rates. At both lung volumes, the ASL was not uniformly distributed in either the circumferential or longitudinal direction; there were regions of ASL where its thickness was < 0.1 micron, whereas in other regions ASL collected in pools. Discernible liquid on the surfaces of airways frozen at FRC followed the contours of epithelial cells and collected in pockets formed by neighboring cells, a geometry consistent with a low value of surface tension at the air-liquid interface. At TLC airway liquid collected to cover epithelial cells and to form a liquid meniscus, a geometry consistent with a higher value of surface tension. The average ASL thickness (h) was approximately proportional to the square root of airway internal perimeter, regardless of lung volume. For airways of internal perimeter 250 and 1,800 microns, h was 0.9 and 1.8 microns at FRC and 1.7 and 3.7 microns at TLC, respectively. For a given airway internal perimeter, h was 1.99 times thicker at TLC than at FRC; the difference was statistically significant (P < 0.01; 95% confidence interval 1.29-3.08).(ABSTRACT TRUNCATED AT 250 WORDS)

Reducing the fat content of ground beef in a school foodservice setting

OBJECTIVE

The objective was to develop and test the nutrient results of a two-step defatting procedure with ground beef in a school foodservice setting as part of the Eat Smart school lunch component of the Child and Adolescent Trial for Cardiovascular Health (CATCH).

SETTING AND DESIGN

The procedure was tested in a school foodservice setting to determine the effect of cooking, draining, and subsequent rinsing with hot water on nutrient composition of ground beef. Samples of raw; cooked and drained; and cooked, drained, and rinsed ground beef were collected and chemically analyzed for total fat, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, cholesterol, iron, and niacin content.

RESULTS

The results indicated that the total fat and the saturated, monounsaturated, and polyunsaturated fatty acids were significantly reduced 31% to 35% from cooking and draining (P < .005) and reduced by an additional 25% to 30% from rinsing (P < .0001). Cholesterol content was not affected. Iron content increased after the cooking and rinsing, although not significantly. Niacin content significantly decreased during rinsing by 28% (P < .005), but the mean value of the cooked, drained, and rinsed ground beef still met the criteria of the Food and Drug Administration for a good source of niacin.

APPLICATION

The two-step defatting procedure developed for use in a school foodservice setting lowers the total fat and saturated fatty acid content of ground beef without substantially reducing its nutritional quality.

Prediction of response to methylphenidate among children with ADHD and mental retardation

OBJECTIVE

The primary purpose of this study was to predict stimulant medication response among children with attention-deficit hyperactivity disorder (ADHD) and mental retardation (MR).

METHOD

Forty-seven children with ADHD and MR (IQs of 48 to 77) served as subjects; ages ranged from 6.1 to 12.5 years. Subjects participated in a double-blind, placebo-controlled study of two doses of methylphenidate (0.3 and 0.6 mg/kg per dose) and a placebo. Data were collected in each child's weekday classroom and a Saturday laboratory classroom. Stepwise multiple regression analyses were used to predict drug responses in both settings.

RESULTS

Higher parent ratings of impulsivity and activity level at baseline were associated with greater gains in weekday classroom dependent measures. Similarly, higher weekday teacher measures of activity level, impulsivity, inattention, and conduct problems at baseline were related to improvement on Saturday laboratory classroom dependent measures. Finally, gender, race, and socioeconomic status (SES) were found to be important predictors, with males, Caucasian subjects, and subjects from families of higher SES more likely to evidence clinical gains on a number of variables than other subjects.

CONCLUSION

These results were generally consistent with research conducted among children with ADHD but without MR. However, factors such as race and conduct problems appear to have predictive utility specific to children with MR.

Classroom behavior and children with mental retardation: comparison of children with and without ADHD

Thirty-four children (ages 6-12 years) with moderate to borderline mental retardation were studied in a laboratory classroom setting to determine whether children identified as having attention deficit hyperactivity disorder on the basis of Conners Questionnaires differed in classroom behavior. Half of the children scored 15 or greater on both the Parent and Teacher Conners; the remaining children scored 11 or less. All were participants in a Saturday Education Program serving children with mental retardation. Direct observation of the laboratory classroom documented significant differences between groups on measures of on-task behavior and fidgetiness, especially during situations where little direct teacher feedback or supervision was available. Saturday Education Program staff, while blind as to group designation, rated the two groups as differing significantly on all scales of two standardized behavior problem checklists. Checklists by parents and teachers appear to be valid measures of classroom behavior of children with moderate to borderline mental retardation.

The distribution of root caries in community-dwelling elders in New England

An in-home examination of a probability sample of elders aged 70 and older living in the six New England states was conducted to estimate the prevalence and extent of root caries. Oral examinations were conducted by the visual-tactile method using a portable lamp, explorer, and a mouth mirror. Fifty-two percent of the study participants showed root caries experience and 22 percent had untreated root caries. In contrast to previous studies, this analysis showed that buccal root surfaces were no more likely than proximal surfaces to be affected by root caries. Logistic regression analysis showed that gingival recession and number of teeth were positively associated with root caries, while better oral hygiene maintenance and regular dental visits were negatively associated with root caries lesions (all factors: P < .05). The prevalence of root caries was found to increase with higher numbers of teeth except for a minority subgroup--i.e., those who retained 25 or more teeth. This study provides much-needed data on prevalence and extent of root caries in a probability sample of the oldest old in an entire region of the United States.

Validation of 24-hour recalls assisted by food records in third-grade children. The CATCH Collaborative Group

OBJECTIVE

The objective of the study was to validate the use of 24-hour recalls assisted by food records as a dietary assessment tool for use with third-grade children.

DESIGN

Trained staff observed children during mealtime at school, and parents observed and recorded what children ate in their presence. The following day children participated in a 24-hour recall interview. Children's ability to recall what they consumed during a 24-hour period was compared with observational data collected during the same period.

SETTING

All data were collected in elementary school settings at four sites involved in the Child and Adolescent Trial for Cardiovascular Health.

SUBJECTS

The sample of 49 children was self-selected, based on parents' willingness to observe and record their child's food intake.

MAIN OUTCOME MEASURES

Recalled and observed data for energy and nutrient levels were compared using mean energy and nutrient analysis and quartile classification. In addition, recalled and observed foods were compared by meal type and estimation of portion size.

STATISTICAL ANALYSIS PERFORMED

Paired t tests, Pearson and Spearman correlations, and classification analysis were used to compare recalled and observed data.

RESULTS

Comparison of observed and recalled food intakes showed no significant differences in percentage of energy from total fat, saturated fat, monounsaturated fat, and polyunsaturated fat or in the amount of sodium consumed, although there were differences in energy intakes. Spearman rank order correlations between recalled and observed nutrients ranged from .45 to .79. A 77.9% agreement was found across all meals in the food items children recalled having consumed compared with those adults actually observed them consuming.

CONCLUSIONS

We conclude that the 24-hour recall assisted by food records is a valid method for assessing the dietary intake of children as young as 8 years old for the purpose of group comparison.

Education and risk factors for coronary heart disease: results from a New England community

This article investigates the association of education with the estimated coronary heart disease (CHD) risk and the prevalence of CHD risk factors for men and women in a New England community over a period of 10 years. Educational differentials in knowledge of cardiovascular disease prevention, body mass index (BMI), total and high-density lipoprotein (HDL) cholesterol, cigarette smoking, and hypertension were examined for 3,765 respondents 25-64 years of age from five surveys of the Pawtucket Heart Health Program. We found a clear negative association between education and composite CHD risk. A stable separation in risk level was maintained across time between the least educated (< 12 years of education) and the other two educational groups (12, > or = 13 years of education) in both men and women. Educational differentials were observed in BMI and total and HDL cholesterol of the women 25-44 years of age. For men and women 25-44 years of age, smoking was negatively associated with education. Hypertension differed by education level among the women 45-64 years of age. These findings are highly comparable with the national data from aggregate vital statistics and the results of the National Health and Nutrition Examination Survey (NHANES) cohort follow-up.

Predicting physical activity change in men and women in two New England communities

We describe the predictors of change in physical activity in a population-derived sample of residents of two New England communities. In 1986-1987 and again in 1990-1991, we assessed the self-reported physical activity of 1,081 survey respondents using a single question concerning the frequency of exercise-induced sweating. We measured and analyzed sociodemographic variables, cardiovascular disease risk factors, health knowledge and beliefs, social support variables, and exercise performance variables at baseline as potential predictors of physical activity change. We defined physical activity change in subjects as follows: maintainers (12.2%) persisted with > or = 3 times per week of activity, adopters (16.0%) increased activity to > or = 3 times per week, quitters (11.9%) decreased activity to < 3 times per week, and sedentary (59.9%) individuals persisted with < 3 times per week of activity. Using polychotomous multiple logistic regression analysis, we found that short-term success with exercise and weight loss, school children's recommendation of exercise, and work outside the home predicted adoption or maintenance of increased physical activity in women. For men, short-term success with exercise and weight loss and health beliefs regarding the role of exercise in preventing heart attacks and stroke were the major determinants of maintaining or adopting increased physical activity. This identification of the predictors of physical activity change provides the rationale for future sex-specific strategies aimed at increasing regular physical activity and long-term adherence to an active lifestyle.

Electron Photodetachment Cross Sections of Small Carbon Clusters: Evidence for Nonlinear Isomers

Absolute cross sections for photodetachment of negative carbon clusters are reported for Cn (n = 3, ..., 8). The results indicate that various neutral isomers exist, some with electron affinities as low as 1 electron volt. The method of production plays an important role in the characteristics of carbon clusters.

High-risk profiles for nursing home admission

A statewide probability sample of 1,625 Massachusetts elderly was studied prospectively over a decade to identify risk profiles for long-term care (LTC) institutionalization. Previous admission to a LTC institution, age, basic ADL disability, and restricted outside mobility were the strongest individual predictors of institutionalization. Examining profiles of risk factors dramatically increased the ability to predict 10-year risk of admission.

Effects and noneffects of methylphenidate in children with mental retardation and ADHD

Stimulant medication efficacy was evaluated in 14 children with attention-deficit hyperactivity disorder and IQs of 48 to 74 in a double-blind crossover study of two methylphenidate doses and placebo. Dependent measures included behavioral ratings, work output, measures of learning, attention and impulsivity, and direct observation of peer social interactions. Nine children (64%) were methylphenidate-responders, based upon the Conners Hyperactivity Index. Significant gains in on-task behavior and attentional skills were noted with methylphenidate in comparison to placebo. No improvement on measures of learning or social interactions were observed. Results extend and replicate previous research conducted by the authors.

Microscopic vs. macroscopic deformation of the pulmonary alveolar duct

The stretch of the perimeters of alveolar ducts was measured at the surface of saline-filled specimens of human and dog lung parenchyma that were stretched biaxially. The microscopic stretch of these ducts was measured at several levels of isotropic biaxial macroscopic stretch of the parenchyma with stretch ratio (lambda x = lambda y) in the range of 1.20-1.40, which roughly corresponds to tidal breathing in humans and dogs. Alveolar walls were found to be load-carrying elements in the saline-filled lung, as seen by their straightness at all levels of stretch. Quantitatively, let l, A, L, and S denote, respectively, the duct perimeter length and area and the parenchymal target perimeter and area in the deformed state and lo, Ao, Lo, and So the corresponding variables in the undeformed state. The microscopic stretch ratio of the ducts (l/lo) was found to be approximately 4% larger than the macroscopic stretch ratio (L/Lo) in human lung and approximately 10% larger in dog lung. The microscopic area ratio of the ducts (A/Ao) was found to be approximately 10% larger than the macroscopic area ratio (S/So) in human lung and approximately 22% larger in dog lung. Ducts within human parenchyma were seen to be about twice as stiff as ducts within dog parenchyma over the range of macroscopic stretch studied. This correlates with the volume fractions of collagen and elastin being higher in the human lung than in dog lung. The observed nonuniformity in strain field at the microstructural level suggests the need to include a force balance between alveolar ducts and septal walls when modeling the mechanics of saline-filled parenchyma.

Drainage after thyroidectomy: a randomized clinical trial

A randomized clinical trial of surgical drainage in thyroid surgery was performed on 97 patients. Morbidity was not significantly different between both groups. The length of hospital stay was shorter in the undrained group. However, this RCT is not an indication of the value of drainage after thyroid surgery because the series is too small. Using a meta-analysis of the RCTs reported it is possible to show that to drain is not useful.