Screening for cognitive impairment, Alzheimer's disease and other dementias: opinions of European caregivers, payors, physicians and the general public

The IMPACT survey queried physicians, caregivers, payors and members of the general public from 5 European countries (France, Germany, Italy, Spain and the United Kingdom) regarding their opinions towards screening for Alzheimer's disease (AD) as part of a 30-minute Web-based questionnaire conducted between April and May 2009. A larger proportion of caregivers (84%) and members of the general public (80%) than of physicians (56%) or payors (40%) viewed routine screening for AD as extremely or very important (P < 0.001 for caregivers or general public vs physicians or payors). When asked if everyone should be routinely screened for AD at age 65, a smaller proportion of physicians (42%) and payors (44%) than members of the general public (81%) or caregivers (80%) agreed (P < 0.001 for caregivers or general public vs physicians or payors). These opinions were generally consistent across the 5 countries for each respondent group. A notable exception was physician respondents from Italy, where most generalists and specialists actually favoured screening. Overall, generalists had a more positive attitude towards screening than specialists. The most frequently cited reason given by those who did not favour routine screening at age 65 was screening inaccuracy. This article discusses these results in relation to what screening is, when to screen and the barriers to screening. Despite the majority of IMPACT respondents being in favour of screening for AD, the evidence to support the introduction of population screening for cognitive impairment is not available; however, the importance of optimal identification of AD and other dementias in primary care should be a priority for community health professionals and payors. In order to do this effectively, further work is required to identify good assessment guidelines for use during opportunistic screening for cognitive impairment in primary care.

The carer/key worker relationship cycle: a theory of the reciprocal process

This study focused on the relationship that develops between professional key workers and dementia carers operating within the home environment. Some research has been directed towards those caring for a relative/friend with dementia and how their role might be made less burdensome; however, the relationship that exists and develops between a carer and their key professional is limited. The aim of this study was to examine this relationship in greater detail and generate a theoretical explanation of this psychosocial process. The grounded theory methodology has particular applicability for this aim. Carer/key worker dyads within Lanarkshire were interviewed in tandem and all interviews recorded. The transcripts were then analysed and initial data categories identified progressing through to the final core category that explained all subordinate data. This study provided a clearer insight into the interpersonal processes associated with this relationship and how it may more effectively be initiated, managed and strengthened. It created the potential to produce a more positive care outcome for the person with dementia. It also has implications for future research into similar aspects of care giving, particularly for health care education and management, as well as carer advisory services.

Duplication of 7q34 is specific to juvenile pilocytic astrocytomas and a hallmark of cerebellar and optic pathway tumours

Background:

Juvenile pilocytic astrocytomas (JPA), a subgroup of low-grade astrocytomas (LGA), are common, heterogeneous and poorly understood subset of brain tumours in children. Chromosomal 7q34 duplication leading to fusion genes formed between KIAA1549 and BRAF and subsequent constitutive activation of BRAF was recently identified in a proportion of LGA, and may be involved in their pathogenesis. Our aim was to investigate additional chromosomal unbalances in LGA and whether incidence of 7q34 duplication is associated with tumour type or location.

Methods and results:

Using Illumina-Human-Hap300-Duo and 610-Quad high-resolution-SNP-based arrays and quantitative PCR on genes of interest, we investigated 84 paediatric LGA. We demonstrate that 7q34 duplication is specific to sporadic JPA (35 of 53 – 66%) and does not occur in other LGA subtypes (0 of 27) or NF1-associated-JPA (0 of 4). We also establish that it is site specific as it occurs in the majority of cerebellar JPA (24 of 30 – 80%) followed by brainstem, hypothalamic/optic pathway JPA (10 of 16 – 62.5%) and is rare in hemispheric JPA (1 of 7 – 14%). The MAP-kinase pathway, assessed through ERK phosphorylation, was active in all tumours regardless of 7q34 duplication. Gain of function studies performed on hTERT-immortalised astrocytes show that overexpression of wild-type BRAF does not increase cell proliferation or baseline MAPK signalling even if it sensitises cells to EGFR stimulation.

Conclusions and interpretation:

Our results suggest that variants of JPA might arise from a unique site-restricted progenitor cell where 7q34 duplication, a hallmark of this tumour-type in association to MAPK-kinase pathway activation, potentially plays a site-specific role in their pathogenesis. Importantly, gain of function abnormalities in components of MAP-Kinase signalling are potentially present in all JPA making this tumour amenable to therapeutic targeting of this pathway.

Silent subtype 3 pituitary adenoma: a clinicopathologic analysis of the Mayo Clinic experience

BACKGROUND

Macroadenomas represent 50% of pituitary tumours and are often (30%) nonfunctioning. Their immunophenotype suggests differentiation toward a specific pituitary cell line. A substantial proportion of tumours with particularly aggressive behaviour are so called 'silent subtype 3 adenoma'. Its diagnosis requires ultrastructural confirmation. Although once included among silent corticotroph adenomas, this aggressive, morphologically distinctive tumour is now recognized as a major form of plurihormonal adenoma and, in fact, some patients might present with clinical hormonal excess. The cytogenesis and pathobiology of silent subtype 3 adenomas is unsettled.

OBJECTIVE

We undertook a systematic clinicopathologic examination of the Mayo Clinic experience with this poorly understood tumour.

DESIGN

This retrospective, single institution study found 27 confirmed examples of silent subtype 3 adenoma, a frequency of 0.9% of adenomas. Despite histologic and immunophenotypic variation, their ultrastructural features were diagnostic and the sole basis for case inclusion.

RESULTS

The study group was comprised of 16 men (59%) and 11 women (41%); two patients (7%) had definitive diagnosis of multiple endocrine neoplasia type 1 (MEN1). Three tumours (11%) were discovered incidentally. Nine patients each (38%) presented with headaches or visual field loss. Endocrine hyperfunction was noted in eight cases (30%), including GH excess in five (19%) and clinically significant PRL elevation in three (11%). Hypogonadism was noted in 17 cases (63%) and growth arrest in one (4%). All tumours were macroadenomas; 16 (60%) showed radiographic evidence of invasion. Most tumours were plurihormonal, featuring immunoreactivity for PRL (17), GH (15), TSH (16) or ACTH (3); only one lesion was immunonegative. Although a gross total resection was achieved in 19 cases (70%), re-operation for recurrence(s) was required in seven of these (37%). Follow-up (mean, 69 months) showed a high (59%) rate of persistent or recurrent of tumour. Overall, 14 patients (54%) underwent radiotherapy after surgical treatment: three patients (12%) for substantial residual tumour, eight (31%) as adjuvant therapy and three (12%) for tumour regrowth.

CONCLUSION

Silent subtype 3 adenoma, a plurihormonal tumour, is rare and aggressive in nature. This adenoma must be considered in the differential of often clinically nonfunctioning but plurihormonal adenomas featuring variable cytologic atypia. Electron microscopy is required for confirmation of the diagnosis. The cytogenesis of silent subtype 3 adenoma remains unsettled.

The development of binocular function in infancy

Binocular function in infancy can be assessed by means of the visual evoked potential (VEP) induced by a dynamic random dot pattern which alternates between a binocularly correlated and an anticorrelated state. A VEP time-locked to the alternation can only be produced by binocular interaction in the cortex. This interaction becomes detectable at around three months of age. Optokinetic nystagmus (OKN) in monocular viewing becomes symmetrical in nasal and temporal directions around the same age. Animal analogues and clinical cases suggest that this may also be an indicator of cortical binocularity. These techniques may be applicable to clinical assessment of binocular function in young infants.

Assessment of visual acuity in infancy and early childhood

The forced-choice preferential looking method (FPL) shows the development of acuity during the first year of life, and is applicable to clinical assessment. A tracking test using a narrow strip of grating yields a more sensitive measure for the later part of this age range, however. The development of acuity is dominated by neural rather than optical or accommodative factors. By age 3 years resolution acuity is very close to adult performance, but at 5 years 'crowding' effects may still impair performance on practical acuity tasks more than for the adult.

The use of isotropic photorefraction for vision screening in infants

Isotropic photorefraction is a technique which makes possible the rapid, economic, large scale screening of infants and young children for refractive errors. The relative size of blur circles reflected from the fundus in 3 flash photographs with different camera settings allows the size and direction of refractive errors to be estimated. The method has been validated against retinoscopic measures on a large group of infants. Findings of a high incidence of astigmatism in the first year are confirmed. Detection of hypermetropia in early infancy by this screening procedure may allow preventive treatment for accommodative strabismus.

Factors associated with depressive symptoms in African American crack cocaine smokers

Few studies have examined factors associated with depressive symptoms in crack cocaine smokers, although cocaine use has been linked to depression. The purpose of this study was to identify correlates of depressive symptoms in a sample of 799 HIV-positive and HIV-seronegative African-American crack cocaine smokers. Multiple regression modelling revealed that anxiety was strongly and positively associated with depressive symptoms. In addition, being female and more frequent crack smoking were also found to be associated. Higher self-esteem and decision-making confidence were found to be associated with less often experiencing depressive symptoms. The model accounted for 64% of the variance in the data. It was noteworthy that HIV infection, as such, was not associated with depressive symptoms. The study has important implication for mental health and health promotion interventions targeting crack cocaine smokers.

Mood and smoking in schizophrenia

There have been few investigations into the relationship of smoking to the presentation of anxiety and depression in clients with a primary diagnosis of schizophrenia. Using a survey design, the current study sought to determine if there was a significant difference between smoking and non-smoking clients in this clinical group on self-report measures of anxiety and depression. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression. One hundred clients (male = 74) with a primary diagnosis of schizophrenia completed the HADS. No significant difference was observed in anxiety and depression scores as a function of smoking status. A logistic regression analysis revealed that gender was a significant predictor of smoking status. The notion that smoking behaviour and mood state are associated with schizophrenia was not supported. However, a high proportion of the cohort were smokers (69%), and male gender was a significant predictive factor in smoking status. Further research in this area is recommended in order to develop strategies which reduce this current level of smoking in clients with a primary diagnosis of schizophrenia.

Cortical vision, MRI and developmental outcome in preterm infants

OBJECTIVES

To test two measures of visual cortical function in the first year of life as early markers of functionally significant brain damage in infants born preterm: orientation-reversal visual event-related potentials (OR-VERP) and a behavioural test of cortically controlled visual attention-fixation shifts under competition (FS). Also to examine how these measures relate to (1) perinatal brain insults identified by MRI, and (2) later neurodevelopmental status.

PATIENTS AND METHODS

After neonatal and term-age-equivalent MRI, 26 preterm infants (<32 weeks of gestational age, mean 28.1 weeks) were given the OR-VERP and FS tests before 12 months post-term age and a neurodevelopmental assessment (Griffiths Scales) at 2 years. MRI scans examined for parenchymal lesions, intraventricular haemorrhage, ventricular dilatation and diffuse excessive high signal intensity were classified into three categories of severity. Cortical visual test results were compared across these categories and examined as predictors of developmental status at 2 years.

RESULTS

26 infants were studied. 13/25 infants showed significant OR-VERP responses. 12/26 showed normal FS performance. On both tests, the proportion of infants meeting these criteria decreased significantly with MRI severity. As predictors of Griffiths developmental quotient < or =80, the FS test had a sensitivity of 100%, a specificity of 61%, and positive and negative predictive values of 50% and 100%, respectively; corresponding values for OR-VERP were 86%, 65%, 50% and 92% .

CONCLUSIONS

Visual cortical tests can provide early indicators of the functional impact of perinatal brain damage in the preterm infant.

A prospective 6-month analysis of the naturalistic use of aripiprazole - factors predicting favourable outcome

OBJECTIVE

To evaluate the effectiveness of aripiprazole in clinical practice.

METHOD

Prospective follow-up of patients consecutively prescribed aripiprazole in an acute mental health unit. Retrospective analysis of outcome from casenotes.

RESULTS

Data were available on 228 patients. Fifty-one per cent discontinued aripiprazole over 6-month follow-up. Continuation with treatment was more likely in out-patients [relative risk (RR) 1.50; 95% CI: 1.13-2.00], those never before considered for clozapine treatment (RR 1.61, 95% CI: 1.06-2.44) and older patients [RR 1.05, 95% CI: 1.01-1.09 (per 5-year increase)]. The main reason for early discontinuation was the occurrence of minor adverse effects.

CONCLUSION

Aripiprazole is effective in practice. Outcome is likely to be improved by careful patient selection and by attending to adverse effects experienced early in treatment.

Grounded theory research: literature reviewing and reflexivity

AIM

This paper is a report of a discussion of the arguments surrounding the role of the initial literature review in grounded theory.

BACKGROUND

Researchers new to grounded theory may find themselves confused about the literature review, something we ourselves experienced, pointing to the need for clarity about use of the literature in grounded theory to help guide others about to embark on similar research journeys.

DISCUSSION

The arguments for and against the use of a substantial topic-related initial literature review in a grounded theory study are discussed, giving examples from our own studies. The use of theoretically sampled literature and the necessity for reflexivity are also discussed. Reflexivity is viewed as the explicit quest to limit researcher effects on the data by awareness of self, something seen as integral both to the process of data collection and the constant comparison method essential to grounded theory.

CONCLUSION

A researcher who is close to the field may already be theoretically sensitized and familiar with the literature on the study topic. Use of literature or any other preknowledge should not prevent a grounded theory arising from the inductive-deductive interplay which is at the heart of this method. Reflexivity is needed to prevent prior knowledge distorting the researcher's perceptions of the data.

[Renin-angiotensin-aldosterone system: an old system offering new drug targets for the cerebral circulation]

In a rat model of human essential hypertension (SHR), the chronic increase in cerebral arteriolar blood pressure is accompanied by remodelling with wall hypertrophy and a fall in diameter. The latter produces an increase in cerebrovascular resistance which maintains cerebral blood flow autoregulation at high systemic blood pressure levels, but accentuates hypoperfusion at low arterial pressures such as those observed during and following cerebral ischemia. Using ACE inhibitors and AT1 blockers we have shown that the normalisation of wall thickness is pressure-dependent but that the normalisation of arteriolar diameter relates to a pressure-independent mechanism involving aldosterone. This raises the possibility of new drug targets for arteriolar remodelling involving intracellular sodium-dependent modulation of protein metabolism.

Importance de l’activation des PPARgamma dans la pharmacologie de la rigidité artérielle

Specific treatment of age-related aortic wall arteriosclerosis and stiffening is lacking. As anti-inflammatory ligands for peroxisome proliferator-activated receptor-gamma have beneficial effects on the arterial wall in atherosclerosis, we investigated whether chronic pioglitazone treatment protects against another form of vascular wall disease, arteriosclerosis. In a rat model of elastocalcinotic arteriosclerosis (hypervitaminosis D and nicotine, VDN), we evaluated whether pioglitazone attenuated arteriosclerosis and its consequences, aortic wall rigidity, increased aortic pulse pressure and left ventricular hypertrophy. In VDN rats, medial calcification was associated with monocyte/macrophage infiltration and induction of TNF-alpha and IL-1B. Pioglitazone decreased TNF-alpha and IL-1B mRNA expression, blunted aortic wall calcification and prevented fragmentation of elastic fibers. Pioglitazone reduced aortic wall stiffness, aortic pulse pressure and left ventricular hypertrophy. Our results may be clinically relevant in elderly patients suffering from aortic wall stiffening and isolated systolic hypertension.

The prevalence of suicidal behaviours in a group of HIV-positive men

We studied a convenience sample of 54 HIV-positive men, recruited from HIV/AIDS community based service organizations. Data were collected on HIV risk factors and suicidal behaviours. Fifty-nine percent of the sample reported ever thinking about suicide, and 50% of those individuals reported attempting suicide at some point in their lives. Suicide ideation and attempts were more common among white participants. Suicidal behaviours were prevalent in this sample suggesting a need for mental health and suicide interventions targeted for this population.

Illicit tranquilliser use and dependence among female opiate users

This study determined the predictors of 12-month dependence on illicit tranquillisers among female opiate users attending three services in Glasgow, Scotland, UK. Twelve-month drug dependence was measured using the Diagnostic Interview Schedule. The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms. 60% (159/266) had used illicit tranquillisers in the past 30 days, and 50% (132/266) met criteria for 12-month dependence on illicit tranquillisers. Polydrug use, injecting drug use, childhood and adulthood abuse, adverse life experiences and current and previous mental health problems were associated with 12-month dependence on illicit tranquillisers. Using multiple logistic regression, polydrug use in last 30 days (OR 3.2, 95% CI 1.5 - 7.0), history of deliberate self-harm (OR 2.5, 95% CI 1.4 - 4.4), history of injecting drug use (OR 2.5, 1.2 - 5.2) and likely to need treatment for current neurotic symptoms (CIS-R > or = 18) (OR 2.4, 95% CI 1.3 - 4.4) predicted 12-month dependence on illicit tranquillisers. Drug users in general and female drug users in particular who are using illicit tranquillisers are also particularly likely to have psychiatric symptoms requiring treatment. Mental health problems should be assessed and monitored among this client group and counselling and psychosocial support should be provided when indicated.

Complement activation in very early Alzheimer disease

The activation of the classical complement (C)-system in early-stage Alzheimer disease (AD) and nondemented aging was examined with immunohistochemistry in subjects assessed by the Clinical Dementia Rating (CDR). Activation (staining for C3 and C4 fragments) was found in all brains with amyloid deposits, including all nondemented (CDR 0) cases, with either small numbers of diffuse plaques or with sufficient plaques and tangles to indicate preclinical AD. Staining for C3 and C4 increased in parallel with plaque density in very mild to severe clinical AD. A subset of very mild AD (CDR 0.5) cases also showed C1q (on plaques) and C5b-9 (on neuritic plaques and tangles), whereas these C-fragments were consistently found in severe AD (CDR 3). Mirror section (split-face) analysis showed that C1q, C3, and apoJ (clusterin) occurred on the same plaques. However, C-system regulators CD59, CR1, DAF, and MCP were not detected on plaques or tangles at any stage, indicating that C-activation related to AD is incompletely controlled.

The prevalence of partner violence in a group of HIV-infected men

There is a paucity of literature regarding partner violence among males that identifies the sex and relationship of their partner(s). We studied a convenience sample of 54 HIV-infected men, recruited from HIV/AIDS service organizations. Using a standard questionnaire, we collected data on HIV risk behaviours and self-reports of acts of partner violence and forced sex. Physical violence perpetrated by a primary or a casual partner was reported by 39% and 17% of the sample, respectively. Life-time forced sex by a primary or casual partner was reported by 32% and 15% of the sample, respectively. Forced sex was more commonly reported by participants who were non-white and reported a higher number of primary partners in the previous 12 months. We recommend that health care providers be aware of the high rates of intimate partner violence among men infected or at risk of infection with HIV.

Asymmetric deterioration of spatial awareness with diminishing levels of alertness in normal children and children with ADHD

BACKGROUND

There is growing literature suggesting that some children diagnosed with attention deficit hyperactivity disorder (ADHD) can show a significant bias in attention away from left space. Here we examine mechanisms that may underpin these effects in both clinical and non-clinical child populations. Unilateral spatial inattention (unilateral neglect) is a commonly reported consequence of stroke in adults. Although for most patients the problem is relatively transient, persistent forms of neglect are almost exclusively associated with right hemisphere lesions. It has been suggested that this chronicity may result from co-existing disruption to right hemisphere dominant systems that mediate alertness. Here we present two studies examining the relationship between sustained attention and left spatial awareness in childhood.

METHOD

In the first, normal children without the ADHD diagnosis were administered a non-spatial test of sustained attention/alertness. Children who performed poorly at this task, relative to their more attentive peers, showed a modest but reliable delay in awareness of left-sided visual information. Furthermore, attention towards the left declined for both groups as a function of time-on-task, suggesting a significant within-subject modulatory effect of alertness on spatial awareness. The second study examines this relationship in children referred to clinical services for attention problems. Irrespective of their final diagnosis, children were divided into two groups according to their performance in sustained attention/alertness tasks.

RESULTS

The results suggest that, regardless of the children's clinical diagnosis, diminished sustained attention/alertness levels formed the strongest predictor of relatively delayed awareness of information presented within left visual space. Two children within this group exhibited signs of hitherto undetected spatial neglect as severe as that observed in some brain-injured adults.

CONCLUSIONS

Clinical and theoretical implications are discussed.

Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses

BACKGROUND

Social disorganisation, fragmentation and isolation have long been posited as influencing the rate of psychoses at area level. Measuring such societal constructs is difficult. A census-based index measuring social fragmentation has been proposed.

AIMS

To investigate the association between first-admission rates for psychosis and area-based measures of social fragmentation, deprivation and urban/rural index.

METHOD

We used indirect standardisation methods and logistic regression models to examine associations of social fragmentation, deprivation and urban/rural categories with first admissions for psychoses in Scotland for the 5-year period 1989-1993.

RESULTS

Areas characterised by high social fragmentation had higher first-ever admission rates for psychosis independent of deprivation and urban/rural status. There was a dose-response relationship between social fragmentation category and first-ever admission rates for psychosis. There was no statistically significant interaction between social fragmentation, deprivation and urban/rural index.

CONCLUSIONS

First-admission rates are strongly associated with measures of social fragmentation, independent of material deprivation and urban/rural category.

Three cases of disputed paternity in dogs resolved by the use of DNA fingerprinting

DNA fingerprinting with the probes 33.15 and alpha-globin 3'HVR has been used to resolve three cases of disputed paternity in dogs. For each pedigree it was necessary to establish which bands in the DNA fingerprints of the offspring were of paternal origin, and then establish which putative sire carried all these bands. In the first case, a litter of Rhodesian Ridgebacks, twelve DNA bands were informative in establishing paternity. In the second case, a litter of Afghan hounds, five DNA bands established paternity, Lastly, in a litter of Border collies, five DNA bands established paternity. In each case a single dog only sired the entire litter.

Structure-function relationship in the tocopherol transfer protein

The role of specific amino acid residues in mediating the biochemical functions of tocopherol transfer protein (TTP) was investigated using site-directed mutagenesis and functional assays. These findings further current understanding of TTP mechanism of action and its role in human health.

Comparison of drug use and psychiatric morbidity between prostitute and non-prostitute female drug users in Glasgow, Scotland

AIMS

To compare psychiatric morbidity between 176 female drug users with lifetime involvement in prostitution (prostitutes) and 89 female drug users with no involvement (non-prostitutes) in Glasgow, Scotland.

METHOD

The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms.

RESULTS

Prostitutes were more likely to report adult physical (OR 1.8) or sexual abuse (OR 2.4), to have attempted suicide (OR 1.7) and to meet criteria for current depressive ideas (OR 1.8) than non-prostitutes. Seventy-two percent of prostitutes and sixty-seven percent of non-prostitutes met criteria for a level of current neurotic symptoms likely to need treatment (CIS-R > or = 18). Being in foster care (OR 8.9), being prescribed medication for emotional problems in the last 30 days (OR 7.7), adult sexual abuse (OR 4.5), poly drug use in the last 30 days (OR 3.6) and adult physical abuse (OR 2.6) were significantly associated with a CIS-R score of > or = 18 for prostitutes using multiple logistic regression.

CONCLUSIONS

Higher rates of adulthood abuse among prostitutes may explain the greater proportion of prostitutes than non-prostitutes meeting criteria for current depressive ideas and lifetime suicide attempts.

Recommendations for a technical quality control program for diagnostic X-ray equipment

This position paper was produced by a working party set up by the Radiology Special Interest Group of the ACPSEM in 2001. It is designed to give the consensus view of College members in Australia and New Zealand on the nature and frequency of tests which should be performed on diagnostic x-ray equipment to maintain adequate quality control of imaging performance and radiation safety. Tests on mammographic equipment have been excluded having been covered in a previous ACPSEM position paper (Australas Phys Eng Sci Med, 24(3):107-131, 2001). Detailed descriptions of test procedures are not given but it is intended that a series of workbooks should be produced giving College recommended test methods for each imaging modality. The recommendations are produced here in an easy-to-read, tabular form giving the nature and purpose of each test and the implications of non-compliance with regard to image quality and radiation safety.

Non-cycloplegic refractive screening can identify infants whose visual outcome at 4 years is improved by spectacle correction

The Second Cambridge Population Infant Vision Screening Programme using the VPR-1 videorefractor without cycloplegia was undertaken in order to identify those infants with refractive errors who were potentially amblyogenic or strabismogenic. Infants identified at eight months were entered into a control trial of treatment with partial spectacle correction and underwent a long-term follow-up that monitored a wide range of visual, visuoperceptual, visuocognitive, visuomotor, linguistic and social development. In the present paper, the authors report on the outcome measures of visual acuity and strabismus. Poor acuity was defined as a best-corrected acuity of 6/12 or worse on crowded letters or 6/9 or worse on single letters, at age 4 years. Acuity was measured in 79 infants who were significantly hyperopic and/or anisometropic at 11-12 months of age, 23 who showed hyperopia of +3D but less than +3.5D, 196 control subjects, 14 controls with refractive errors, and 126 others who showed an accommodative lag on screening but were not significantly hyperopic on first retinoscopy. There was a poorer acuity outcome in the untreated group of hyperopes compared to controls (p < 0.0001) and to the children who were compliant in spectacle wear (p < 0.001) or who were prescribed spectacles (p < 0.05). Children who were significantly hyperopic at eight months were also more likely to be strabismic by 5.5 years compared to the emmetropic control group (p < 0.001). However, the present study did not find a significant difference in the incidence of strabismus between corrected and uncorrected hyperopic infants. Children who were not refractively corrected for significant hyperopia were four times more likely to have poor acuity at 5.5 years than infants who wore their hyperopic correction, supporting the findings of the First Cambridge Population Infant Vision Screening Programme.

Visual function at school age in children with neonatal encephalopathy and low Apgar scores

OBJECTIVE

To assess different aspects of visual function at school age in children who suffered from neonatal encephalopathy.

METHOD

Thirty nine full term infants with neonatal encephalopathy, low Apgar scores, and early neonatal imaging were studied using a battery of tests assessing different aspects of visual function (crowding acuity, stereopsis, visual fields) at school age. The results were compared with brain magnetic resonance imaging (MRI) findings and, when possible, with the results of the assessment of visual function performed at 5 and 12 months, available in 24 of the 39 children examined at school age.

RESULTS

Sixteen of the 39 children (41%) had abnormal results at school age in at least one of the visual tests used. Seven of these 16 were untestable on all tests. The remaining 23 children (59%) had normal results.

CONCLUSIONS

The presence and severity of visual impairment was related to the severity of brain lesions. Moderate or severe basal ganglia lesions and severe white matter changes were always associated with abnormal visual function. Infants with normal MRI, minimal basal ganglia lesions, and minimal or moderate white matter involvement tended to have normal vision. It was also found that the assessment of visual function performed in the first year was a reliable indicator of visual function at school age. With two exceptions, the results on the 5 month visual assessment were predictive of visual outcome at school age. In the remaining two cases, a normal visual outcome at 5 years was associated with visual abnormalities at 5 months but these had already normalised by the age of 1 year.