Epidemiological studies of cognitive impairment and dementia across Eastern and Middle European countries (epidemiology of dementia in Eastern and Middle European Countries)

OBJECTIVE

To determine the availability and the consistency of prevalence findings of epidemiological studies on cognitive impairment and dementia conducted in Eastern and Middle Europe.

METHODS

We adopted a stepwise multimethod study approach consisting of iterative literature searches for epidemiological articles published between 1990 and 2006 and subsequent data analyses of published material, reanalyses of existing accessible epidemiological data sets and expert inquiries in Eastern and Middle European countries. Systematic computer-assisted searches used the keywords: "dementia", "Alzheimer", "cognitive impairment", "incidence", "prevalence", "epidemiology" in combination with the name of the relevant countries or "Europe" in English and Polish language. We supplemented the literature search with a review of the references in the articles that were identified during the initial search.

RESULTS

We were able to find few regional and country-specific epidemiological studies of various kinds (population-based, cohort, cross-sectional studies) and conducted on different restricted population groups of patients (from neurological units, out-patients units, residential homes). No studies were identified from most of the countries taken under consideration and the ones we found were characterized by an immense diversity with a considerable degree of clinical and methodological variations. The few studies that there are suggest prevalence rates of dementia in Eastern Europe similar to those in Western Europe.

CONCLUSIONS

There is strong need for epidemiological studies in Eastern and Middle Europe, as well as for greater coordination and standardization of methods to improve the quality and comparability of epidemiological data to determine the prevalences' rates of dementia in all the EU countries.

Impairment, disability, social support and depression among older parents in rural Thailand

BACKGROUND

It is not known whether social support modifies the association between depression and impairment or disability in older people from developing countries in Asia.

METHOD

We used a Thai version of the EURO-D scale to measure depression in 1104 Thai rural community-dwelling parents aged 60 years. These were all those providing data on depression who were recruited as part of a study of older adults with at least one living child (biological, stepchild or adopted child). Logistic regression modelling was used to determine: (a) whether impairment, disability and social support deficits were associated with depression; (b) whether social support modified this association.

RESULTS

There were strong graded relationships between impairment, disability, social support deficits and EURO-D caseness. Level of impairment, but not disability, interacted with poor social support in that depression was especially likely in those who had more physical impairments as well as one or more social support deficits (p value for interaction=0.018), even after full adjustment.

CONCLUSIONS

Social support is important in reducing the association between physical impairment and depression in Thai older adults, especially for those with a large number of impairments. Enhancing social support as well as improving healthcare and disability facilities should be emphasized in interventions to prevent depression in older adults.

Appraising the mitogenicity of insulin analogues relative to human insulin-response to: Weinstein D, Simon M, Yehezkel E, Laron Z, Werner H. Insulin analogues display IGF-I-like mitogenic and anti-apoptotic activity in cultured cancer cells. Diabetes Metab Res Rev 2009; 25(1): 41-9

Interest in mitogenic and potentially carcinogenic effects of insulin and insulin analogues has been renewed by several recent publications that have examined the relationship between cancer and insulin analogues. Actions mediated through the insulin-like growth factor-I receptor in a hyperinsulinaemic state have been implicated mechanistically. Both type 2 diabetes and endogenously elevated insulin-like growth factor-I have been epidemiologically linked to malignancies. Therefore, in vitro mitogenic effects and binding affinities of the various analogues have been analysed. A recent publication by Weinstein et al. studied the in vitro mitogenic and anti-apoptotic activities of insulin analogues, and their conclusion asserts that insulins glargine, detemir, and lispro displayed proliferative and anti-apoptotic effects in a number of malignant cell lines. However, their conclusions are not supported by the data which are not complete and lack clear statistical significance. This data should be interpreted cautiously in light of all other presently available scientific evidence. Prospective, randomized clinical trials will best address any direct relationship between insulin analogues and cancer. Until those studies are designed and completed, clinicians should consider the demonstrated strong benefit of glycaemic control in balance with any alleged risk.

Mental health in the tropics

Although problems in mental health constitute 14% of the global burden of disease, mental health has been largely missing from the international health agenda. The burden from mental illness is largely attributable to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. The last decade has seen some progress in addressing this gap. In 2001, the World Health Report, Mental Health: New Understanding, New Hope, drew attention to the situation, with an appeal from the World Health Organization's Director General that 'mental health - neglected for far too long - is crucial to the overall well-being of individuals, societies and countries and must be universally regarded in a new light.' In September 2007, the journal Lancet launched the global mental health series, which highlighted the public-health dimension of mental health, identified barriers to receiving treatment, and gave a call for action to the nations of the world, to make a major commitment to upgrade the quality of mental-health services, to develop evidence-based treatment and preventive measures, to provide support for research in mental health, and to develop indicators to monitor progress. In October 2008, the World Health Organization launched the Mental Health Gap Action Programme, with the aim of scaling up the services for mental, neurological and substance-use disorders in all countries but especially those with low and middle incomes. The programme aims to develop evidence-based packages of care, psycho-social interventions and pharmacotherapy for tens of millions who could be treated for depression, schizophrenia and epilepsy, prevented from suicide, and begin to lead normal lives - even in very poor countries. While there is cause for optimism, much remains to be done. Most of all, there needs to be awareness amongst health providers and planners that mental health is an integral part of general health concerns, and that there can be no health without mental health.

Utility of adiponectin as a biomarker predictive of glycemic efficacy is demonstrated by collaborative pooling of data from clinical trials conducted by multiple sponsors

This study, conducted under the Metabolic Disorders Steering Committee of the Biomarkers Consortium (a public-private partnership managed by the Foundation for the National Institutes of Health (FNIH)), analyzed blinded data on 2,688 type 2 diabetes (T2D) patients from randomized clinical trials conducted by four pharmaceutical companies. An increase in the levels of adiponectin was observed after peroxisome proliferator-activated receptor (PPAR)-agonist treatment (P < 0.0001), but not after treatment with non-PPAR drugs. This increase correlated with decreases in levels of glucose, hemoglobin A(1c) (Hb(A1c)), hematocrit, and triglycerides, and increases in levels of blood urea nitrogen, creatinine, and high-density lipoprotein cholesterol (HDL-C). Early (6-8 weeks) increases in levels of adiponectin after treatment with PPAR agonists showed a negative correlation (r = -0.21, P < 0.0001) with subsequent changes in levels of Hb(A1c). Changes in adiponectin level did not appear to be associated with baseline level of Hb(A1c). Logistic regression demonstrated that an increase in the level of adiponectin predicts a decrease in the level of Hb(A1c). These analyses confirm previously demonstrated relationships between adiponectin levels and metabolic parameters and support the robust predictive utility of adiponectin across the spectrum of glucose tolerance. Cross-company precompetitive collaboration is a feasible and powerful approach to biomarker qualification.

Association of tobacco (T) use with risk of distant metastases (DM), tumor recurrence, and death in patients (pts) with HPV-positive (+) squamous cell cancer of the oropharynx (SCCOP)

6001

Background: Chemoradiation (CRT) for HPV (+) SCCOP is associated with a more favorable prognosis than HPV-negative (-) SCCOP. However, the interaction of HPV and T in terms of etiology and disease progression remains unclear. HPV (+) SCCOP pts were prospectively studied to determine if T use was a key variable in discriminating which pts would develop DM, locoregional recurrences (LR), or second primaries (SP). Methods: From 1999–2007, 124 pts with stage III/IV SCCOP were enrolled in one of two CRT trials. Tumor specimens were analyzed for HPV presence and type. Use of T, determined via self-reporting and chart review, was recorded as both continuous (number of pack-yrs) and categorical (never, former, and current) variables. Former T users were subdivided into an early cessation group (quit ≥ 20 yrs prior to diagnosis) and a late cessation group (quit < 20 yrs prior to diagnosis). T use and HPV status were analyzed with respect to survival & the development of DM, LR, or SP. Results: Of the 124 pts, 100 (81%) were HPV (+), 22 of which developed disease progression (22%). Twenty-four were HPV (-), 12 of which had disease progression (50%). Seventeen of 124 pts (14%) developed DM [12 HPV (+), 5 HPV (-)]. Nine of 124 (7%) developed LR [5 HPV (+), 4 HPV (-)], and 8 of 124 (7%) developed SP [5 HPV (+), 3 HPV (-)]. Thirty-two HPV (+) pts were never-T users, 88% (28/32) of which remain alive with no evidence of disease; 3 died from other causes and 1 died of lung metastases from SCCOP. Sixty-eight were HPV (+) and had T exposure. Of 46 former T users, 37/46 (80%) are living. Twenty were HPV (+) and in the early cessation group, 35% (7/20) of which had disease progression [3 LR, 3 DM, 1 SP]. Twenty-six HPV (+) pts were former T users in the late cessation group, 11% (3/26) of which had disease progression [2 DM, 1 SP]. Of 22 HPV (+) current T users, 68% (15/22) are alive and 36% (8/22) have developed disease progression. Seventeen of the 24 HPV (-) pts were current T users, 47% (8/17) of which developed disease progression. Conclusions: Never-T users with HPV-positive SCCOP have improved survival & reduced risk of disease progression compared to HPV (+) & HPV (-) former & current T users.

No significant financial relationships to disclose.

Pooled analyses of two international, multicenter clinical studies of romidepsin in 167 patients with cutaneous T-cell lymphoma (CTCL)

8546

Background: Romidepsin is a novel pan-HDAC inhibitor with demonstrated single-agent activity in 2 open-label clinical studies of 167 patients (pts) with CTCL [mycosis fungoides or Sézary Syndrome (SS)]. Data for these 2 studies were pooled for more accurate estimates of endpoints and investigation of subpopulations. Methods: GPI-04–0001 (pivotal study) enrolled 96 pts with confirmed CTCL who had recieved ≥1 prior systemic therapy. NCI 1312 (supportive study) enrolled 71 pts with CTCL. Pts recieved romidepsin, 14mg/m2 as a 4-hr infusion on days 1, 8, and 15 every 28 days until disease progression (≥25% increase). The primary efficacy endpoint for both studies was overall response rate (ORR) using a composite endpoint that included skin assessment, lymph node and visceral involvement and abnormal circulating T-cells/Sézary cells. Results: 167 pts received romidepsin (as-treated); 135 pts (81%) were in the efficacy evaluable population. Mean age was 57±12 yrs, 67% men, 87% white. 103 pts (76%) had stage ≥IIB disease. Median number of prior systemic therapies was 2 (range 1–8). ORR in the table. Responses were noted in: 42% of pts with stage ≥IIB; 11 (58%) of 19 pts with SS (erythroderma + Sézary cells, >1000/ml or >20% ); and 20 (38%) of 52 pts who received prior bexarotene and 8 (40%) of 20 pts who had received denileukin diftitox. Most common drug-related adverse events (AE), all grades, included: nausea (67%), fatigue (49%), anorexia (37%), ECG T-wave changes (29%), anemia (26%), dysgeusia (23%), neutropenia (22%), leucopenia (20%). Related serious AEs in 2% of pts: supraventicular arrhythmia, ventricular arrhythmia, infection, neutropenia, WBC decreased, hyperuricemia, hypotension; all other serious AEs in ≤1 pt. 3 deaths reported as possibly related. Conclusions: Romidepsin is a valuable new therapy for pts with CTCL based on the ORR, CR, durability of response, improvement in all disease compartments and responses at all stages and in all subpopulations analyzed.

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Differentiating human NT2/D1 neurospheres as a versatile in vitro 3D model system for developmental neurotoxicity testing

Developmental neurotoxicity is a major issue in human health and may have lasting neurological implications. In this preliminary study we exposed differentiating Ntera2/clone D1 (NT2/D1) cell neurospheres to known human teratogens classed as non-embryotoxic (acrylamide), weakly embryotoxic (lithium, valproic acid) and strongly embryotoxic (hydroxyurea) as listed by European Centre for the Validation of Alternative Methods (ECVAM) and examined endpoints of cell viability and neuronal protein marker expression specific to the central nervous system, to identify developmental neurotoxins. Following induction of neuronal differentiation, valproic acid had the most significant effect on neurogenesis, in terms of reduced viability and decreased neuronal markers. Lithium had least effect on viability and did not significantly alter the expression of neuronal markers. Hydroxyurea significantly reduced cell viability but did not affect neuronal protein marker expression. Acrylamide reduced neurosphere viability but did not affect neuronal protein marker expression. Overall, this NT2/D1-based neurosphere model of neurogenesis, may provide the basis for a model of developmental neurotoxicity in vitro.

Cognitive-behavioural therapy v. structured care for medically unexplained symptoms: randomised controlled trial

BACKGROUND

A pilot trial in Sri Lanka among patients with medically unexplained symptoms revealed that cognitive-behavioural therapy (CBT) administered by a psychiatrist was efficacious.

AIMS

To evaluate CBT provided by primary care physicians in a comparison with structured care.

METHOD

A randomised control trial (n=75 in each arm) offered six 30 min sessions of structured care or therapy. The outcomes of the two interventions were compared at 3 months, 6 months, 9 months and 12 months.

RESULTS

In each arm, 64 patients (85%) completed the three mandatory sessions. No difference was observed between groups in mean scores on the General Health Questionnaire or the Bradford Somatic Inventory, or in number of complaints or patient-initiated consultations at 3 months. For both groups, all outcome measures improved at 3 months, and remained constant in the follow-up assessments.

CONCLUSIONS

Cognitive-behavioural therapy given by primary care physicians after a short course of training is no more efficacious than structured care. Natural remission is an unlikely explanation for improvements in people with chronic medically unexplained symptoms, but lack of a 'treatment as usual' arm limits further conclusions. Further research on enhanced structured care, medical assessment and structured care incorporating simple elements of CBT principles is worthy of consideration.

Characterization of Sclerotinia and mycoparasite Coniothyrium minitans interaction by microscale co-culture

AIMS

To characterize the interaction of Sclerotinia sclerotiorum and S. minor with strains of the mycoparasite and commercial biocontrol agent Coniothyrium minitans using novel perfusion chamber gasket co-culture.

METHODS AND RESULTS

Sclerotinia were cultured in perfusion chamber gaskets and then flooded with Coniothyrium conidia. After germination, Coniothyrium failed to show any form of directed growth, making contact with Sclerotinia hyphae in a random manner. In turn, some Coniothyrium hyphae coiled round Sclerotinia counterparts and although no intracellular growth was observed, Coniothyrium proliferated, while the hyphae of Sclerotinia became vacuolated and lost the cytoplasm. When co-cultures of Sclerotinia with Coniothyrium were flooded with FITC-lectins, small difference in fluorescence between the fungi was found with FITC-Con A suggesting that cell walls of both the species exposed mannose. In contrast, Coniothyrium fluoresced poorly in comparison with Sclerotinia when FITC-wheat germ agglutinin was used, indicating a marked paucity of N-acetylglucosamine exposure by cell walls of Coniothyrium, hence reduced exposure to chitinolytic enzyme action.

CONCLUSIONS, SIGNIFICANCE AND IMPACT OF THE STUDY

The approach employed supported direct sequential microscopic observation of Coniothyrium and Sclerotinia as well as the utilization of representative fluorescent moieties to characterize relative carbohydrate cell wall exposure.

Prevalence of depressive symptoms and syndromes in later life in ten European countries: the SHARE study

BACKGROUND

The EURO-D, a12-item self-report questionnaire for depression, was developed with the aim of facilitating cross-cultural research into late-life depression in Europe.

AIMS

To describe the national variation in depression symptoms and syndrome prevalence across ten European countries.

METHOD

The EURO-D was administered to cross-sectional nationally representative samples of non-institutionalised persons aged > or =50 years (n=22 777). The effects of age, gender, education and cognitive functioning on individual symptoms and EURO-D factor scores were estimated. Country-specific depression prevalence rates and mean factor scores were re-estimated, adjusted for these compositional effects.

RESULTS

The prevalence of all symptoms was higher in the Latin ethno-lingual group of countries, especially symptoms related to motivation. Women scored higher on affective suffering; older people and those with impaired verbal fluency scored higher on motivation.

CONCLUSIONS

The prevalence of individual EURO-D symptoms and of probable depression (cut-off score > or =4) varied consistently between countries. Standardising for effects of age, gender, education and cognitive function suggested that these compositional factors did not account for the observed variation.

Chemo-selection as a strategy for organ preservation in patients with T4 laryngeal squamous cell carcinoma

6005

Background: We previously reported high rates of overall survival (OS) and laryngeal preservation in two sequential phase II trials with stage III/IV laryngeal squamous cell carcinoma patients (pts), who attained a >50% response after 1 cycle of induction chemotherapy, and who were treated with chemoradiation. Since then, all pts were re-staged to correspond with the most recent American Joint Committee on Cancer staging guidelines. Here we report the outcomes of the T4 pts from both studies. Methods: Pts received 1 cycle of cisplatin 100 mg/m2 & 5-FU 1,000 mg/m2/day × 5 days (P+5FU). Pts with > 50% response received chemoradiation with 70 Gy & P 100 mg/m2, days 1, 22, & 43. Pts with ≤ 50% response underwent laryngectomy. Final planned tumor assessment by direct laryngoscopy with biopsy was performed 8 wks after chemoradiation. Pts who were histologic complete responders, received 2 cycles of P+5FU. Pts with residual disease had planned salvage surgery. Results: Thirty-two T4 eligible (cartilage invasion 31, base of tongue involvement 1) pts were enrolled, 23 M; 9 F; median age 56; stage: IVA 31, IVB 1; site: 19 supraglottic, 13 glottic. After 1 cycle induction chemotherapy, 26 pts (81%) had > 50% response & received chemoradiation; 5 (16%) had surgery; & 1 refused surgery. After chemoradiation, 22 pts had a complete histologic response, & 4 pts required immediate salvage larngectomy for residual disease. Of those responding to chemoradiation, 2 pts eventually required salvage laryngectomy. Currently, 17/32 (53%) are alive (15 without disease), 10 are dead of disease, & 5 are dead from other causes. Toxicity: grade 3/4 granulocytopenia 19%, grade 3/4 mucositis 49%. Median time to follow-up is 45 months. The 3 yr overall survival (OS) is 75% (95% CI=55%, 86%), & the 4 yr OS is 70% (95% CI = 50%, 83%). The 3 yr disease-free survival (DFS) is 77% (CI=58%, 88%), & the 4 yr DFS is 72% (CI=52%, 85%). Conclusions: Our results suggest that chemo-selection is an alternative, organ preservation strategy to total laryngectomy for pts with T4 laryngeal squamous cell carcinoma.

No significant financial relationships to disclose.

Efficacy and safety of denileukin diftitox (Dd) in a phase III, double-blind, placebo-controlled study of CD25+ patients with cutaneous T-cell lymphoma (CTCL)

8026

Background: ONTAK®(Dd), a genetically engineered fusion protein combines the enzymatically active domain of diphtheria toxin with the sequence of interleukin-2 (IL-2), designed to target IL-2 receptor expressing malignancies. Dd received FDA accelerated approval for the treatment of CTCL in patients with the CD25 component of the IL-2 receptor. Methods: The confirmatory placebo- controlled L4389–11 phase III trial evaluated 9 and 18μg/kg/d Dd in 144 patients with CD25(+) CTCL. Patients (=3 prior treatments, stages Ia - III) received Dd or placebo IV for up to 8 cycles, consisting of Dd once daily for 5 days every 3 weeks. Tumor burden in skin, blood and lymph nodes and a physician's global (PGA) were assessed relative to baseline and before every treatment cycle beginning with cycle 2. Confirmation of tumor response required two more consecutive cycles (3 observations). Investigator assessments were ratified by an independent Drug Evaluation Review Committee. Results: Initial analysis of activity and benefit shown below. Both Dd treatment arms were greatly superior to placebo in a dose dependent fashion. Population demographics were the same across treatment arms (median age 59 years, 55% male). Randomization was stratified by disease status at baseline, 67% were = stage IIa, 33% were =stage IIb. Response between stage groups within each arm did not differ significantly. Many responses were confirmed after 5 or more cycles. AEs were similar to those in previous Dd studies. The only significantly different Grade 3/4 adverse event was nausea (2% in Placebo and 15% in 18μg/kg/d). No differences in serious adverse events among treatment arms were observed. The frequency of AEs and SAEs markedly decrease after the first two cycles of treatment. Conclusions: This is the largest randomized, placebo controlled trial conducted in CTCL, providing clear evidence for efficacy and clinical benefit for Dd.

No significant financial relationships to disclose.

[Table: see text]

Development of a new measure of health-related quality of life for people with dementia: DEMQOL

BACKGROUND

We identified the need to develop a scientifically rigorous measure of health-related quality of life (HRQL) in dementia that would be appropriate for use at all stages of dementia severity and would be available in both self- and proxy-report versions.

METHOD

We used standard psychometric methods to eliminate items with poor psychometric properties (item-reduction field test) and to assess the acceptability, reliability and validity of the item-reduced instruments (psychometric evaluation field test). We developed and validated two versions of DEMQOL: a 28-item interviewer-administered questionnaire that is self-reported by the person with dementia (DEMQOL) and a 31-item interviewer-administered questionnaire that is proxy-reported by a caregiver (DEMQOL-Proxy).

RESULTS

DEMQOL shows high reliability (internal consistency and test-retest) and moderate validity in people with mild/moderate dementia. DEMQOL-Proxy shows good acceptability and internal consistency and moderate evidence of validity in people with mild/moderate and severe dementia. Test-retest reliability and performance in people with severe dementia need further testing.

CONCLUSIONS

DEMQOL and DEMQOL-Proxy show psychometric properties that are comparable with the best available dementia-specific measures of HRQL. We recommend that DEMQOL and DEMQOL-Proxy are used together. Reliability and validity need to be confirmed in independent samples and responsiveness needs to be evaluated.

The development of a novel Bio-MEMS filtration chip for the separation of specific cells in fluid suspension

In the clinical/microbiological laboratory there are currently several ways of separating specific cells from a fluid suspension. Conventionally cells can be separated based on size, density, electrical charge, light-scattering properties, and antigenic surface properties. Separating cells using these parameters can require complex technologies and specialist equipment. This paper proposes new Bio-MEMS (microelectromechanical systems) filtration chips manufactured using deep reactive ion etching (DRIE) technology that, when used in conjunction with an optical microscope and a syringe, can filter and grade cells for size without the requirement for additional expensive equipment. These chips also offer great versatility in terms of design and their low cost allows them to be disposable, eliminating sample contamination. The pumping mechanism, unlike many other current filtration techniques, leaves samples mechanically and chemically undamaged.

In this paper the principles behind harnessing passive pumping are explored, modelled, and validated against empirical data, and their integration into a microfluidic device to separate cells from a mixed population suspension is described. The design, means of manufacture, and results from preliminary tests are also presented.

Chemo-selection of patients (pts) for organ preservation in advanced laryngeal cancer: Failure of chemotherapy (CT) as the sole treatment for complete histologic responders (CHR) to neoadjuvant chemotherapy

5560

Background: We conducted a phase II organ preservation trial for stage III/IV laryngeal cancer pts in an attempt to identify pts, who were CHR after 1 cycle of induction CT, who might be curable with CT alone. Methods: Pts received 1 cycle of cisplatin 100 mg/m2 & 5-FU 1000 mg/m2/day x 5 days (P+5FU). CHR received 1 cycle of P+5FU, followed by weekly docetaxel (D) 35 mg/m2 x 3 wks, followed by 1 cycle of P+5FU, & no radiotherapy (RT). Pts with >50% (but < 100%) response (PR) received chemoradiation (CRT) with 70 Gy & P 100 mg/m2 days 1, 22, & 43. Pts with < 50% response underwent laryngectomy. Final planned tumor assessment with direct laryngoscopy with biopsy was done 8 wks after CRT or 3 wks after the last cycle of P+5FU (CT alone arm). CHR after CT alone received 2 cycles of P+5FU alternating with 2 cycles of D. CHR after CRT received 2 cycles of P+5FU, & pts with residual disease had planned salvage surgery. Results: 32 eligible pts were enrolled, 24 M; 8 F; median age 56, stage III/IV- 7/25. After 1 cycle CT, 4 pts (13%) had CHR & received CT alone; 24 (75%) had PR & received CRT; 3 had surgery; & 1 refused surgery. Of pts who had CT alone, 4/4 had regional failures; 3/4 underwent neck dissection & 1/4 had laryngectomy & neck dissection; all had adjuvant RT because of multiple nodes or extracapsular spread; 3/4 are alive without disease & 1/4 is dead of complications. 5/24 who received CRT failed; 2/24 had surgery & 3/24 were unresectable. Toxicity: Gr 3/4 granulocytopenia 19%, Gr 3/4 mucositis with CT alone 12.5%. Median follow-up is 16.5 months. 2 yr overall survival is 88.2% (95% CI = 75.3%, 100%). 1 yr disease-free survival (DFS) is 81.8% (CI=67.2%, 96.5%). 2 yr DFS is 76% (CI=58.4%, 93.5%). The proportion of pts alive & free of cancer with intact larynx at 1 yr is 69.1% (CI = 51.9%, 86.3%) & at 2 yrs is 63.8% (CI=45%, 82.5%). 1 pt developed distant metastases. Larynx preservation was achieved in 24 pts (75%). Conclusions: CT alone is not an effective strategy for advanced laryngeal cancer pts, even in CHR after 1 cycle of induction CT, due to high nodal failure rate. Planned integration of early regional control by surgery or lower-dose RT may be necessary to allow treatment approaches that spare selected pts high-dose RT.

No significant financial relationships to disclose.

Four year follow up of fatigue in a geographically defined primary biliary cirrhosis patient cohort

BACKGROUND AND AIMS

Fatigue is the commonest symptom described by patients in most populations with the autoimmune liver disease primary biliary cirrhosis (PBC), and appears to be unrelated to liver disease severity. At present, it is unclear how the fatigue experienced by patients (only characterised to date in cross sectional studies) evolves over time. In this study, we set out to address how fatigue had changed over four years of follow up in a geographically defined cohort of PBC patients who participated in an earlier cross sectional study of fatigue impact.

METHODS

Participants in the original 2000 study who were still alive in 2004 were asked to complete the same fatigue assessment tool (fatigue impact score, FIS). In those who had died between 2000 and 2004, medical notes, death certificates, and primary care records were reviewed.

RESULTS

A total of 108 of the original cohort of 136 patients were alive at the time of the follow up study, 99 of whom (92%) participated in the follow up study. With the exception of four patients who underwent transplantation between 2000 and 2004, all of whom showed significant improvement in fatigue severity as assessed by FIS, fatigue severity was unchanged over four years of follow up. Among the 28 patients who died during the follow up period, survival was significantly lower in patients who were fatigued at the 2000 baseline (FIS above the median for the whole PBC population (40/160); log rank test, p = 0.006 v non-fatigued patients at baseline). Increased fatigue severity was independently associated with decreased survival on multivariate analysis. Fatigued PBC subjects were significantly more likely to have suffered a cardiac death than non-fatigued patients.

CONCLUSIONS

The fatigue phenotype appears to be highly stable in PBC. The presence of fatigue in PBC is independently associated with a significantly increased risk of death in general, and cardiac death in particular. Factors underpinning fatigue in PBC, and the mechanisms whereby fatigue is associated with increased mortality, warrant further study.

Quality of life in dementia: more than just cognition. An analysis of associations with quality of life in dementia

OBJECTIVES

To explore the extent to which commonly used measures of specific outcomes in dementia are an appropriate proxy for quality of life in dementia.

METHODS

This was a cross sectional study set in communities in London and Nottingham, comprising 101 people with dementia and their 99 main family caregivers. The main outcome measures were health related quality of life in dementia (measured by the DEMQOL-Proxy), cognition (Mini Mental State Examination), functional impairment (Barthel Index), behavioural and psychological symptoms in dementia (Neuropsychiatric Inventory; NPI), and carer mental health (General Health Questionnaire).

RESULTS

On univariate analysis, decreased quality of life was statistically significantly correlated with higher levels of behavioural and psychological disturbance (NPI total score and its agitation, depression, anxiety, disinhibition, and irritability subscales); younger age of the person with dementia; and poorer mental health of the carer. Quality of life was not statistically significantly associated with cognition or carer age. In a multivariate model, psychological and behavioural disturbance and patient age remained statistically significantly associated with quality of life. Carer mental health was no longer statistically significantly associated, and cognition and functional limitation remained statistically insignificant.

CONCLUSIONS

These data suggest that quality of life in dementia is complex, and that simple proxy substitutions of discrete measures such as cognition or function are likely to miss important factors.

Measurement of health-related quality of life for people with dementia: development of a new instrument (DEMQOL) and an evaluation of current methodology

OBJECTIVES

To develop and validate a psychometrically rigorous measure of health-related quality of life (HRQoL) for people with dementia: DEMQOL.

DATA SOURCES

Literature review. Expert opinion. Interviews and questionnaires.

REVIEW METHODS

Gold standard psychometric techniques were used to develop DEMQOL and DEMQOL-Proxy. A conceptual framework was generated from a review of the literature, qualitative interviews with people with dementia and their carers, expert opinion and team discussion. Items for each component of the conceptual framework were drafted and piloted to produce questionnaires for the person with dementia (DEMQOL) and carer (DEMQOL-Proxy). An extensive two-stage field-testing was then undertaken of both measures in large samples of people with dementia (n = 130) and their carers (n = 126) representing a range of severity and care arrangements. In the first field test, items with poor psychometric performance were eliminated separately for DEMQOL and DEMQOL-Proxy to produce two shorter, more scientifically robust instruments. In the second field test, the item-reduced questionnaires were evaluated along with other validating measures (n = 101 people with dementia, n = 99 carers) to assess acceptability, reliability and validity.

RESULTS

Rigorous evaluation in two-stage field testing with 241 people with dementia and 225 carers demonstrated that in psychometric terms: (1) DEMQOL is comparable to the best available dementia-specific HRQoL measures in mild to moderate dementia, but is not appropriate for use in severe dementia [Mini Mental State Examination (MMSE) <10]; and (2) DEMQOL-Proxy is comparable to the best available proxy measure in mild to moderate dementia, and shows promise in severe dementia. In addition, the DEMQOL system has been validated in the UK in a large sample of people with dementia and their carers, and it provides separate measures for self-report and proxy report, which allows outcomes assessment across a wide range of severity in dementia.

CONCLUSIONS

The 28-item DEMQOL and 31-item DEMQOL-Proxy provide a method for evaluating HRQoL in dementia. The new measures show comparable psychometric properties to the best available dementia-specific measures, provide both self- and proxy-report versions for people with dementia and their carers, are appropriate for use in mild/moderate dementia (MMSE >/= 10) and are suitable for use in the UK. DEMQOL-Proxy also shows promise in severe dementia. As DEMQOL and DEMQOL-Proxy give different but complementary perspectives on quality of life in dementia, the use of both measures together is recommended. In severe dementia, only DEMQOL-Proxy should be used. Further research with DEMQOL is needed to confirm these findings in an independent sample, evaluate responsiveness, investigate the feasibility of use in specific subgroups and in economic evaluation, and develop population norms. Additional research is needed to address the psychometric challenges of self-report in dementia and validating new dementia-specific HRQoL measures.

Glucocorticosteroids for primary biliary cirrhosis

BACKGROUND

Primary biliary cirrhosis is a chronic progressive cholestatic liver disease of presumed autoimmune etiology, characterised by the destruction of small intrahepatic bile ducts and the eventual development of cirrhosis and liver failure. Its progression may be influenced by immunosuppression. Glucocorticosteroids are potent immunosuppressive agents, but they are associated with significant adverse effects, including osteoporosis.

OBJECTIVES

To systematically evaluate the beneficial and harmful effects of glucocorticosteroids versus placebo or no intervention for patients with primary biliary cirrhosis.

SEARCH STRATEGY

The Cochrane Hepato-Biliary Controlled Trials Register,The Cochrane Library, MEDLINE, EMBASE, and the full text of the identified studies were searched until June 2004. The search strategy included terms for primary biliary cirrhosis and glucocorticosteroids (including the names of frequently used preparations). Previous research groups and manufacturers were contacted for additional references. No language restrictions were applied.

SELECTION CRITERIA

Double-blind, single-blind, or unblinded randomised clinical trials evaluating any preparation of glucocorticosteroids versus placebo or no intervention in patients with primary biliary cirrhosis diagnosed by abnormal liver function tests and either anti-mitochondrial antibodies or histology were included. Additional agents were allowed if they were administered to both groups equally.

DATA COLLECTION AND ANALYSIS

The quality of the randomised clinical trials was evaluated by methodology components (generation of allocation sequence; allocation concealment; blinding; follow up). Analyses were performed according to the intention-to-treat method with missing data being accounted for by imputation.

MAIN RESULTS

Only two underpowered trials (reporting 36 and 40 patients) were identified. These differed markedly in their inclusion criteria and treatment protocols. Both stated that they used placebo. However, allocation concealment was unclear. Only one trial reported any patient deaths. No significant improvement in mortality was identified (odds ratio (OR) 0.42, 95% confidence interval (CI) 0.10 to 1.76). Improvements in serum markers of liver inflammation and liver histology were identified. Potentially prognostically linked markers such as bilirubin and albumin were incompletely reported. Bone mineral density (weighted mean difference -2.84%, 95% CI -4.16 to -1.53) and the number of patients with any adverse event (OR 8.99, 95% CI 2.15 to 37.58) were significantly increased in the glucocorticosteroid group.

AUTHORS' CONCLUSIONS

There is insufficient data to support or reject the use of glucocorticosteroids for patients with primary biliary cirrhosis. It may be appropriate to consider a large prospective randomised clinical trial on this topic.

Insight in people with psychosis: the influence of culture

The assessment of insight is a part of the routine clinical examination for people with mental illness. Such assessment, by psychiatrists, is based on the current definitions of insight, which rely on western notions of health and illness. This paper discusses the recent findings of explanatory models of people with a variety of physical diseases in Vellore, India. It also summaries the results of studies on insight in schizophrenia, which examined explanatory models of illness among patients, relatives, and the general population, in Vellore. The findings argue for the fact that the assessment of insight should be against the local cultural standards rather than universal yardsticks.

Behavioral and psychological symptoms of dementia in developing countries

BACKGROUND

Little is known about the prevalence of, or associations with behavioral and psychological symptoms of dementia (BPSD) in developing countries.

METHODS

Individuals diagnosed as having dementia according to DSM-IV criteria (mild and moderate cases as defined by the Clinical Dementia Rating scale only), together with their main caregiver, were recruited from 21 centers in 17 developing countries. People with dementia were directly assessed with the Community Screening Interview for Dementia and the Geriatric Mental State Schedule (GMS); GMS data were processed by the AGECAT computer program to yield diagnostic information on 8 psychiatric syndromes. Caregivers answered direct questions about behavioral symptoms of dementia (BSD) and completed the Zarit Burden Inventory.

RESULTS

At least one BSD was reported in 70.9% of the 555 participants. At least one case-level AGECAT psychiatric syndrome (not including the organic syndrome) was exhibited by 49.5% of people with dementia. Depression syndromes (43.8%) were most common followed by anxiety neurosis (14.2%) and schizophreniform/paranoid psychosis (10.9%). Caregivers were more likely to report BSD in people with dementia who were married, younger and better educated. More advanced dementia, poorer functioning and the presence of depression or anxiety were each associated with BSD. BSD, and psychiatric syndromes (anxiety neurosis and schizophreniform/paranoid psychosis) predicted caregiver strain after controlling for cognitive impairment. BPSD are poorly understood, leading to shame and blame.

CONCLUSIONS

BPSD are common among people with dementia in developing countries, though we found marked regional variations. Representative population studies are needed to clarify prevalence and impact, but our research suggests considerable unmet need, with much scope for intervention. Raising awareness of the problem should be the first step.

Premorbid cognitive testing predicts the onset of dementia and Alzheimer's disease better than and independently of APOE genotype

OBJECTIVE

To determine whether a cognitive test package can predict the onset of dementia up to 11 years later, and the extent to which this prediction is independent of that provided by APOE genotype.

METHODS

Prospective cohort study based on 54 general practices in the UK; 657 survivors of the 1088 participants in the MRC treatment trial of hypertension in older adults were followed for up to 11 years; 370 participants (57% of survivors) were traced, screened for dementia, and genotyped for APOE in 1994. Baseline assessments included trail making test A, paired associated learning test, Raven's progressive matrices, and national adult reading test. At follow up, both mini-mental state examination and CAMCOG were used. Outcome measures were DSM-IIIR dementia and NINCDS-ADRDA possible and probable Alzheimer's disease.

RESULTS

All the cognitive tests completed in 1983 predicted onset of dementia and Alzheimer's disease up to 11 years later, as did APOE genotype. Cognitive test performance was not associated with APOE genotype. Addition of cognitive tests increased the area under the ROC curve for the prediction of Alzheimer's disease provided by age, family history, and APOE genotype (0.81 v 0.69, p = 0.048); addition of APOE genotype did not increase the area under the ROC curve for the prediction provided by age, family history, and cognitive tests (0.81 v 0.77, p = 0.28).

CONCLUSIONS

Simple tests of cognitive ability provide useful predictive information up to a decade before the onset of dementia. The predictive information provided is independent of, but not enhanced by, the addition of APOE genotype.

Validation of two survey diagnostic interviews among primary care attendees: a comparison of CIS-R and CIDI with SCAN ICD-10 diagnostic categories

BACKGROUND

The most widely used survey measures in psychiatry, the Composite International Diagnostic Interview (CIDI) and the Clinical Interview Schedule-Revised (CIS-R) have generated estimates of psychiatric morbidity that show considerable variation. Doubts have been raised regarding the validity of these structured lay interviewer assessments. There have been no direct comparisons of the performances of these instruments against a common, established criterion.

METHOD

A total of 105 unselected primary care attendees were each interviewed with CIDI, CIS-R and SCAN in a single sitting with random order of administration. SCAN was administered by a SCAN trained psychiatrist, and CIDI and CIS-R by a public health doctor. Concordance was estimated for all ICD-10 neurotic disorders. We assessed the overall discriminability of the CIS-R morbidity scale using a receiver operating characteristic (ROC) analysis.

RESULTS

The concordance for CIDI for ICD-10 diagnoses was moderate to excellent (kappa= 0.58-0.97). Concordance for CIS-R ranged between poor and moderate (kappa = 0.10-0.65). The area under the ROC curve for the CIS-R morbidity scale with respect to any ICD-10 disorder [0.87 (95% CI 0.79-0-95)] indicated good overall discriminability, but poor sensitivity (44%) and high specificity (97%) at the usual CIS-R cut-point of 11/12.

CONCLUSION

Among primary care attendees the CIDI is a highly valid assessment of common mental disorders, and the CIS-R is moderately valid. Previous studies may have underestimated validity. Against the criteria of all ICD-10 diagnoses (including less severe depressive and anxiety disorders) a much lower CIS-R cut-point is required than that which is usually advocated.

Polymorph count for predicting non-gonococcal urethral infection: a model using Chlamydia trachomatis diagnosed by ligase chain reaction

BACKGROUND/OBJECTIVES

The criteria for the diagnosis of non-gonococcal urethritis (NGU) on a Gram stained urethral smear are derived from previous studies which used culture as a diagnostic test for Chlamydia trachomatis. Our objectives were (1). to re-assess the relation between urethral polymorph count and C trachomatis infection, using ligase chain reaction (LCR) as the diagnostic test; and (2). to assess other possible predictors of C trachomatis infection such as symptoms, signs, demographic and behavioural variables.

METHODS

We collected data from 363 men consecutively attending a genitourinary medicine clinic (excluding those with gonorrhoea and follow up visits) who had a urethral smear and a urethral LCR test for C trachomatis. The sensitivity and specificity of a discrete cut off in urethral polymorphonuclear leucocyte (PMNL) count as a diagnostic test for chlamydia urethritis were calculated. The associations between other variables, such as age and symptoms, and this infection were also estimated.

RESULTS

8% of men had C trachomatis infection and 26% of men had a PMNL count of 5 or more. Of those men with chlamydia 37% did not have NGU; 20% of men with NGU had chlamydia. Adjusted odds ratios for risk of chlamydial infection were significant for age less than 30 relative to 40 years and over (adj OR 13.6; 95% confidence interval 1.69 to 110), a PMNL count of 20 or more (6.56; 2.15 to 20.0), a PMNL count of 5-19 (3.59; 1.41 to 9.15), and the symptom of dysuria (3.27; 1.32 to 8.08). However a PMNL count of 5 or more was only 63% sensitive and 77% specific for C trachomatis infection. No association between sexual behaviour and chlamydial infection was found in this setting.

CONCLUSIONS

The PMNL count is associated with presence of chlamydial infection but a large proportion of men with chlamydia have PMNL counts below the recommended cut off for a diagnosis of NSU. Lower age and the presence of symptoms may be as predictive as the urethral polymorph count for chlamydial urethritis and possibly for other urethral infections.

Tamoxifen: a novel treatment for primary biliary cirrhosis?

Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease, which predominantly affects women. It is characterised histologically by necroinflammation of small intrahepatic bile ducts and biochemically by elevated serum alkaline phosphatase, levels of which at diagnosis predict survival. Ursodeoxycholic acid (UDCA) is the only treatment shown to improve liver biochemistry and survival. We report two patients with PBC who show a fall in serum alkaline phosphates levels whilst receiving tamoxifen therapy. Tamoxifen may exert this effect, which warrants further study, either via cholangiocyte estrogen receptors, inhibiting cholangiocyte proliferation and inducing apoptosis or by activating pregnane X receptor, analogous to the mode of action of UDCA.

Vascular disease risk factors as determinants of incident depressive symptoms: a prospective community-based study

BACKGROUND

The potential association between vascular disease and depression have been the focus for much clinical psychiatric research, although few epidemiological prospective studies have looked into this association.

AIMS

This study explores the a priori hypothesis of a prospective association between cardiovascular disease or its risk factors and incident depressive symptoms.

METHOD

A prospective primary care based study derived from a multi-centre randomized controlled trial of moderate hypertension. 2584 moderately-hypertensive volunteers were followed-up for 54 months when five assessments of depressive symptoms, vascular disease and its risk factors were made.

RESULTS

We found an association between the dependent variable (incident depressive symptoms measured with the Self-CARE-D) and baseline smoker status, low serum cholesterol levels, poorer cognitive function (particularly executive dysfunction), female gender and increasing age. These associations were independent of all other cardiovascular risk factors (ECG evidence of ischaemia or arrhythmia, systolic or diastolic blood pressure, blood pressure decline along the trial and body mass index).

CONCLUSIONS

Our results do not support the hypothesis of a specific association between vascular disease or its risk factors and incident depressive symptoms.

Fatigue and primary biliary cirrhosis: association of globus pallidus magnetisation transfer ratio measurements with fatigue severity and blood manganese levels

BACKGROUND AND AIM

Fatigue is the commonest symptom in primary biliary cirrhosis (PBC), affecting individuals at all stages of disease. The pathogenesis of fatigue in PBC is unknown although rat models suggest a central nervous system (CNS) cause. We examined the hypothesis that a CNS abnormality related to cholestasis, rather than cirrhosis per se, underlies this symptom.

PATIENTS AND METHODS

Fourteen patients with precirrhotic PBC (stage I-II disease), four patients with stage III-IV PBC, and 11 healthy women were studied using cerebral magnetisation contrast imaging and proton magnetic resonance spectroscopy (MRS).

RESULTS

The globus pallidus magnetisation transfer ratio (MTR), a quantifiable tissue characteristic that may be abnormal in the presence of normal magnetic resonance imaging, was significantly reduced in precirrhotic PBC patients compared with healthy controls. These measurements correlated with blood manganese levels and were more abnormal in the more fatigued subjects. There were no differences in MRS measurements between the three study groups, suggesting that the abnormal MTR was not related to hepatic encephalopathy.

CONCLUSION

This study suggests that impairments in liver function in PBC may adversely affect the brain long before the development of cirrhosis and hepatic encephalopathy, possibly as a result of altered manganese homeostasis within the CNS.

Poor sensitivity and consistency of microscopy in the diagnosis of low grade non-gonococcal urethritis

OBJECTIVES

To determine the reliability of the diagnosis of non-gonococcal urethritis (NGU), and the variation between and within microscopists, from urethral smears at a large London genitourinary medicine clinic.

METHODS

A senior microscopist (SM) preselected 60 Gram stained urethral smear slides, 20 negative (<5 polymorphs/hpf), 20 low grade NGU (5-20 p/hpf), and 20 high grade NGU (>20 p/hpf). Ten experienced microscopists, blinded to these initial grades, examined all slides giving each a polymorph score. After relabelling and randomly changing their order, the slides were re-examined by the same microscopists. Finally, the SM determined whether the study had resulted in loss of cells from any of the slides. The SM's initial grading and the consensus among microscopists provide two gold standards for analysis.

RESULTS

Nine low grade and five high grade slides were removed from analysis because of loss of cells. By SM standard, considering microscopists' readings as simply non-NGU (<5 p/hpf) or NGU (>or=5 p/hpf), 97% from negative slides were correct (variation 93-100 across microscopists), 68% from low grade slides (45-95), and 94% from high grade slides (83-100). Consistency between repeat readings by the same microscopist was 96% for negatives, 75% for low grade and 89% for high grade slides. Results were similar by consensus standard.

CONCLUSIONS

There was considerable variation between and within microscopists in the diagnosis of NGU. Sensitivity was strongly related to grade of urethritis, with an appreciable proportion of low grade urethritis falsely diagnosed as negative. With increasing attendances for sexual health screening, a false positive rate of only 3% may lead to many false diagnoses.

[Epidemiological research on dementia in developing countries]

As the world population is ageing, dementia becomes an important public health problem, particularly in developing countries. Epidemiological research in these settings is scarce and present additional methodological difficulties, mainly regarding the socio-cultural adequacy of instruments used to identify cases of dementia. As a result of these concerns the 10/66 Dementia Research Group was founded to fill this gap. This is an international network of investigators, mostly from developing countries, and the group's name was based on the paradox that less than 10% of the population-based studies on dementia are directed to 2/3 or more cases of people with dementia living in developing countries. The aim of the paper is to update data in the literature regarding the differences in dementia prevalence and incidence seen in developed and developing countries.

The Geriatric Mental State Examination in the 21st century

The Geriatric Mental State Examination (GMS) is now established as one of the most commonly used mental health assessments for older people. Its strengths lie in extensive validity studies, high inter-rater reliability, accessibility to trained raters, irrespective of professional background and its continual evolution and adaptation. Its computerisation, association with supplementary instruments and support by a diagnostic algorithm provides a comprehensive diagnostic system and syndrome profile for each subject. The instrument has been validated against most major diagnostic systems and has been used as outcome measures in intervention studies. It has been translated into numerous languages and validated as a diagnostic instrument in various cultures. Such studies have exposed weaknesses, including the over diagnoses of organic states in populations with poorly developed education. On-going studies continue to address these issues, providing a culture sensitive instrument enabling unique trans-cultural research in a relatively under-researched field.