Goal setting as a predictor of return to work in a population of chronic musculoskeletal pain patients

To assess prospectively the association between personal attributes, vocational factors, and the return to work outcome for patients with chronic, nonmalignant, musculoskeletal pain, we assessed return to work (RTW) motivation though an open-format listing of treatment goals in 59 chronic pain patients admitted to a university pain management program. Patients were then followed (average of 17.9 months) in the posttreatment period to determine whether they had in fact returned to employment. Results indicated that a number of pretreatment factors predicted future employment status in this patient population. Age, marital status, education and decreased length of unemployment were predictive of RTW outcome. Overall, RTW goal was the single best predictor of return to work outcome. In contrast, increased number of premorbid jobs, compensation status, patient's race and sex were not predictive. The present study suggests that the assessment of an individual's motivation as defined by goal-setting may be a key factor in predicting a favorable outcome in this typically refractory population of patients.

Aging and olfactory recognition memory: effect of encoding strategies and cognitive abilities

The effects of two encoding manipulations on recognition memory for odors were examined in 20 young and 20 elderly males. Subjects were instructed to use two different encoding strategies: (1) labeling-plus-definition (i.e., naming the odor and giving a short description) and, (2) life-episode association (i.e., associating a memory of a life-episode with each odor). Results revealed that elderly subjects performed significantly worse than young subjects in the labeling-plus-definition condition, but not in the life-episode task in which they achieved a level of performance not significantly different from the young. Encoding specificity or precision did not significantly impact recognition memory for the odors in either group. Analysis of response bias revealed that, in the label-plus-definition condition, young subjects were more conservative in responding style, while more liberal in their responding in the life-episode condition. In contrast, elderly subjects exhibited nearly identical response bias across both encoding conditions. The results suggest that age-related deficits in olfactory memory may be strategy dependent.

Olfactory identification deficits in schizophrenia: correlation with duration of illness

OBJECTIVE

The authors examined the relationship between deficits in olfactory identification and duration of illness in young and elderly patients with schizophrenia.

METHOD

Olfactory identification performance of 38 patients with schizophrenia and 40 normal subjects was compared by using the University of Pennsylvania Smell Identification Test.

RESULTS

The schizophrenic patients demonstrated olfactory deficits relative to the comparison group, and the elderly schizophrenic patients displayed a greater magnitude of olfactory deficit than the younger patients. Independent of normal aging effects and cognitive deficit, patients with schizophrenia showed a strong relationship between olfactory identification scores and duration of illness, which suggests that olfactory abilities decline progressively over the course of the disorder.

CONCLUSIONS

In contrast to other neuropsychological measures that have been reported to be stable over the course of illness, olfactory identification abilities deteriorate steadily in patients with schizophrenia, even for those with relatively recent onset.

Olfactory identification in elderly schizophrenia and Alzheimer's disease

In the present study we assessed olfactory identification ability using the University of Pennsylvania Smell Identification Test (UPSIT) in 16 elderly patients with schizophrenia (ES), 20 patients with a diagnosis of probable Alzheimer's disease (AD), and 20 healthy elderly controls (EC). Both patient groups exhibited marked deficits in UPSIT performance relative to controls. ES and AD patients with similar levels of general cognitive impairment did not differ on the UPSIT, suggesting that the two disorders may share a common dysfunction in olfactory brain regions. While there have been recent reports of greater olfactory impairment in males, neither patient group exhibited significant gender differences on the UPSIT.

Olfactory function in Huntington's disease patients and at-risk offspring

Odor identification ability and detection threshold sensitivity were measured in 25 probands with Huntington's disease, 12 at-risk offspring, and 37 unrelated controls. Relative to controls and at-risk offspring, HD patients exhibited significant impairment on both measures of olfactory function. By contrast, at-risk offspring did not evidence any olfactory impairment relative to controls. Thus, impaired olfactory function does not aggregate in the family members of HD patients, and does not serve as an indicator of genetic vulnerability to the disorder.

Proactive inhibition and semantic organization: relationship with verbal memory in patients with schizophrenia

Compared to other cognitive functions in schizophrenia, evidence suggests that verbal memory is particularly impaired. This study used the California Verbal Learning Test (CVLT) to examine proactive inhibition (PI) and semantic processing in verbal memory in 29 patients with schizophrenia and 29 healthy controls. Patients showed significantly less PI, but also did not organize (cluster) their recall according to semantic category. Controls and patients demonstrated small retroactive inhibition (RI) effects regardless of semantic content. Although both groups made similar types and numbers of free recall intrusion errors patients committed more phonemic and nonshared recognition errors. Results suggest that reduced semantic processing prevented build of PI, and contributes to defective memory in schizophrenia. The anatomic-physiologic abnormalities that underlie these findings may be particularly pronounced in prefrontal and temporal-parietal cortical areas.

Neuropsychiatry of 18q- syndrome

Our understanding of neuropsychiatric abnormalities in patients with deletions of the long arm of chromosome 18 (18q- syndrome) is based mainly on sporadic case reports. We characterized the neuropsychiatric phenotype in 27 patients across a wide age range (2-47 years) with breakpoints ranging from 18q22.3-18q21.2. Adaptive behavior scores (Vineland Composite) were significantly higher in females than in males (62 +/- 5 vs. 43 +/- 3). Intelligence ranged from borderline to severely deficient (IQ, 73- < 40), with academic achievement similarly impaired. Performance in specific neuropsychological functions, including attention, novel problem solving, memory, language, visuomotor integration, and fine motor dexterity, was consistently in the moderately-to-severely impaired range. Behavioral problems were common in both sexes, including aggressivity, hyperactivity, and temper tantrums. Contrary to the few previous reports, we found no evidence of psychosis in any patients. In a subset of patients selected on the basis of no prior knowledge of behavioral problems, 1 of 16 patients (6%) had autism, as defined by the Autistic Diagnostic Interview--Revised (ADI-R) [Lord et al., 1994: J Autism Dev Disord 24:659-685]. Thus, the prevalence of autism in 18q- syndrome is probably no greater than that in other developmental disabilities with a similar level of cognitive impairment. In contrast to what has been believed since 18q- was first described 30 years ago, we found no relationship between chromosome deletion size and any measure of cognition or behavior; nor were there any correlations between any of these measures with the presence or absence of abnormalities on MRI or somatosensory-evoked potentials.

Delay in diagnosis of epithelial ovarian cancer

OBJECTIVES

To investigate and analyze the process from first recognition of symptom(s) to final diagnosis at operation in patients with ovarian epithelial cancer.

METHOD

The medical records of 160 women with ovarian cancer were studied and traced back to the doctor first consulted, in order to obtain information on patient- and doctor-related delay.

RESULTS

Symptom duration was 12 weeks in patients with serous tumors and 7 weeks in patients with other histopathological classes; 56% were diagnosed within 4 weeks. Women in stages I and II were diagnosed faster than those in stages III and IV; 4% were diagnosed within 3 days because of an emergency operation; 30% were not diagnosed within 8 weeks.

CONCLUSION

Diagnosis of ovarian cancer is difficult due to the vagueness of the symptoms which mislead both patients and doctors. Methods to enable earlier diagnosis must be sought.

Glial fibrillary acidic protein-immunoreactive astrocytosis in elderly patients with schizophrenia and dementia

Clinical and neuropsychological studies of chronically institutionalized patients with schizophrenia indicate that severe cognitive impairment and functional disability in late life are very prevalent. The biological substrates for this dementia remain unknown. While subtle cytoarchitectural and morphometric abnormalities have been described in patients with schizophrenia and interpreted as reflecting aberrant neurodevelopment, postmaturational injury or neurodegeneration associated with gliosis remain as plausible explanations of at least some of the clinical manifestations of schizophrenia. We monitored astrocytosis and neurofibrillary tangle (NFT) formation in 21 elderly patients with schizophrenia (14 with concurrent dementia, 7 without), and in 12 normal and 5 Alzheimer's disease (AD) control cases. Astrocytes in ventromedial temporal, frontal, and calcarine cortices were immunohistochemically identified with monoclonal antibodies directed at glial fibrillary acidic protein (GFAP) and vimentin, and NFTs were labeled with an anti-tau antibody specific for paired helical filaments. There were no increases in GFAP- or vimentin-immunoreactive astrocyte counts, GFAP optical density, or NFT counts for the schizophrenic group as a whole compared to the non-neuropsychiatric group, while both groups differed from AD. When patients with schizophrenia were divided into demented and non-demented subtypes, those with dementia demonstrated significantly greater numbers of GFAP-positive astrocytes than those without dementia. These data may reflect an up-regulation of GFAP in normal astrocytes or the presence of reactive astrocytosis in a subgroup of schizophrenics. In the absence of any diagnostic neuropathological findings in this subgroup, the implications of these observations for the pathogenesis of schizophrenia remain to be determined.

Prospective clinicopathologic studies of schizophrenia: accrual and assessment of patients

OBJECTIVE

The purpose of this study was to characterize the neuropsychiatric profile of elderly patients with schizophrenia and establish a patient registry for prospective ante-mortem and post-mortem studies.

METHOD

Medical records of all chronically institutionalized patients in eight state hospitals who were over the age of 65 and had a chart diagnosis of schizophrenia (N = 528) were reviewed. Of the potential subjects, 192 were excluded because of clinical histories inconsistent with a diagnosis of schizophrenia, 56 because of insufficient information to establish a psychiatric diagnosis, and 122 because of family members' refusal to give consent for autopsy in the event of death. To date, 81 of the remaining 158 patients have undergone neuropsychiatric evaluation with standard assessment instruments.

RESULTS

Mini-Mental State scores of the 81 patients indicated severe dementia, and Functional Assessment Scale scores showed that patients required assistance with activities of daily living. All patients were rated as severely ill on the Brief Psychiatric Rating Scale. Ratings on the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms indicated a predominance of negative symptoms over positive. Of 30 patients who have died to date, research autopsies have been conducted on 26.

CONCLUSIONS

Establishing a well characterized, prospective patient registry for clinicopathologic studies of schizophrenia is feasible but labor intensive. Diagnosis of schizophrenia with a high degree of confidence can be achieved by means of detailed chart review and assessment of current neuropsychiatric functioning with standard rating instruments. These data provide a basis for correlations of clinicopathologic factors.

Smaller neuron size in schizophrenia in hippocampal subfields that mediate cortical-hippocampal interactions

OBJECTIVE

The goal of this study was to characterize the hippocampal formation in patients with schizophrenia by measuring neuron density, neuron size, and variability of neuronal axis orientation.

METHOD

Brain tissue was obtained at autopsy from 14 prospectively accrued elderly patients with chronic schizophrenia and 10 age-compatible individuals without psychiatric disorder. Eight hippocampal regions of interest and two internal control regions (primary motor and visual cortices) were identified on Nissl-stained sections. Morphometric measurements were made without knowledge of diagnosis by means of a computer-based image analysis system.

RESULTS

The patients exhibited smaller neuron size in the hippocampal regions relative to the control regions, which was significant only for the subiculum, CA1, and layer II of the entorhinal cortex. Neuron size in the control regions was nearly identical in the two groups. No significant differences in neuron density or in variability of neuronal axis orientation were identified for any region. There was no correlation between neuron size in any area and several potentially confounding variables (age, post-mortem interval, neuroleptic exposure, sex, brain hemisphere studied, duration of illness), with the exception of a negative correlation with age in layer II of the entorhinal cortex. Regression analyses indicated that the findings could not be attributed to these age effects.

CONCLUSIONS

The subiculum, entorhinal cortex, and CA1 are the major subfields of the hippocampal region that maintain the afferent and efferent connections of the hippocampus with widespread cortical and subcortical targets. The smaller size of neurons in these subfields may reflect the presence of structural or functional impairments that disrupt these connections, which in turn could have important behavioral sequelae.

MMPI characteristics in adults diagnosed with ADD: a preliminary report

Characterization of Attention Deficit Disorder (ADD) in adults has been hampered by an absence of well-defined clinical profiles on objective personality measures. A sample of 22 ADD adults completed personality testing (MMPI) in conjunction with cognitive assessment. A sample of 30 normal controls and 20 patients diagnosed with schizophrenia, who had completed the MMPI as part of a larger research protocol, were utilized as comparison groups. Validity and clinical scales revealed multiple elevations in the ADD group which were similar in nature but not to the same degree as elevations observed in the schizophrenia group. Harris-Lingoes subscales identified the sources of clinical scale elevations indicating a pattern of specific and nonspecific symptomatology which differentiated the three groups. The results may aid in identifying ADD in adults.

Methylphenidate and nortriptyline in the treatment of poststroke depression: a retrospective comparison

The hospital charts of elderly stroke patients with major depression, as determined by DSM-III-R criteria, who were treated with either methylphenidate (n = 28) or nortriptyline (n = 30) were retrospectively reviewed. Fifty-three percent of the methylphenidate patients experienced complete remission of depressive symptoms. Similarly, 43% of the patients in the nortriptyline group showed remission of depressive symptomatology. Whereas the response rates between the two treatment groups were not significantly different in the patients who did respond to treatment (chi 2 = .608, df = 1, p = NS), the speed of response was significantly better in the methylphenidate group (t[13] = 15.9, p < .001). The average peak response time for the methylphenidate patients was 2.4 days compared to 27 days for the nortriptyline group. This finding is consistent with previous reports suggesting a rapid response to methylphenidate and other psychostimulants, typically between 24 and 72 hours. Adverse side effects, such as cardiac changes, did not differ between groups, generally falling in the mild range of severity. These data suggest that the rapid effects of methylphenidate may be especially useful to speed recovery from depression so that patients can participate more fully in rehabilitation programs.

Symptoms and diagnostic difficulties in ovarian epithelial cancer

OBJECTIVE

To investigate and analyze symptoms in patients with different types of ovarian cancer.

METHOD

Records of 160 women with ovarian cancer were studied in detail following the patients from first consultation to operation and diagnosis at Sodersjukhuset, Stockholm.

RESULT

No specific group of symptoms could be linked to type or stage of ovarian cancer. Gastrointestinal symptoms were more common in patients with class 1C tumors. Only 21% complained of gynecological symptoms. Women with class 1C cancer had significantly more advanced disease than those with 2C-5C cancer as 77% had a stage III-IV tumor compared with 40% of class 2C-5C patients.

CONCLUSION

Diagnosis of ovarian cancer is difficult due to the multitude of symptoms often appearing late in the disease. The majority of women did not experience symptoms in the genital organs. Methods to encourage early consultation should be investigated.

Mechanism of age-related differences in frequency discrimination with backward masking: Speed of processing or stimulus persistence?

In Experiment 1, frequency-discrimination thresholds were estimated in a 2-interval, forced-choice, backward masking procedure with a masker acoustically dissimilar to the targets. Young subjects were more efficient in escaping the effects of masking than were their elderly counterparts. In Experiment 2, young and elderly subjects performed the same task, with a masker acoustically similar to the targets and with a target-dissimilar masker. Under target-similar masking and at short target-masker intervals, the elderly demonstrated significant improvement, reaching the level of performance of the young, whereas under the target-dissimilar masker, the age-related differences were restored. Both age-related slowing of information processing and increase in stimulus persistence can account for the results of Experiment 1, but only increased stimulus persistence explains the results of Experiment 2.

Structural brain CT changes and cognitive deficits in elderly depressives with and without reversible dementia ('pseudodementia')

Twenty-six elderly (greater than 60 yrs) patients with DSM-III major depression were compared to 13 patients with NINCDS/ADRDA probable Alzheimer's disease (AD), and to 31 screened normal controls. Subjects were matched on age and sex. Fifteen of the 26 depressed patients were cognitively impaired on the Mini-Mental State Examination (MMSE) upon admission, but after treatment returned to the normal range. These 15 patients were defined as having the dementia syndrome of depression (DOD). The remaining 11 depressed patients were termed depressed, cognitively normal (DCN). All subjects received standardized cranial CT scans for assessment of ventricular brain ratio (VBR) and CT attenuation numbers. Subjects also received neuropsychological evaluation. CT values for the 26 depressed patients lay between those of AD patients and normal controls. CT values for the DOD subgroup clustered near those of AD patients. Patterns of cognitive deficits and correlations of CT attenuation values with cognitive measures were also similar in AD and DOD. Most patients were reassessed at a mean of two years after initial testing; of the 11 of the 15 DOD re-examined, only one had undergone cognitive decline. By contrast, all AD patients retested had declined significantly. Episodes of DOD and DCN tended to 'breed true'. This study suggests that while patients with DOD may have underlying structural brain abnormalities, obvious short-term progression to AD does not commonly occur.

Ventricle-brain ratio, computed tomographic density, and brain area in 50 schizophrenics

A sample of 50 DSM-III-diagnosed schizophrenics (mean age, 34 years) intentionally biased to contain a relatively high proportion of persistently unemployed persons was compared with a sample of 87 normal volunteers on three computed tomographic measures. These were lateral ventricle-brain ratio, regional brain computed tomographic density values, and brain slice area. Images were made with the same computed tomographic scanner and identical scan parameters. Computed tomographic data were assessed blindly using a computer-linked image array processor and electronic planimeter. Ventricle-brain ratios were significantly higher in schizophrenics, with 28% of the patient sample exceeding 2 SDs of the control mean. Brain area measures were not associated with an enlarged ventricle-brain ratio. Contrary to our prediction, ventricular enlargement was unassociated with most negative symptom ratings, but was correlated with the absence of positive symptoms. A history of abnormal delivery and the presence of left-handedness were significant predictors of an enlarged ventricle-brain ratio on multiple regression analysis. Schizophrenics had a significantly smaller brain slice area compared with normal controls, a finding not attributable to height differences between groups. Brain slice area was inversely correlated with computed tomographic brain density across all subjects. After correction of computed tomographic density values for area using a linear regression model, no significant regional density differences were detectable between normal controls and schizophrenics. Within normal controls there was a significant relationship between social class and brain slice area, but not ventricle-brain ratio.

Auditory memory and age-related differences in two-tone frequency discrimination: trace decay and interference

We investigated age-related differences in the time course of two-tone frequency discrimination. Healthy young and elderly adults with normal hearing acuity in the 500-2000 Hz range performed a two-alternative forced choice frequency discrimination task. The stimuli were short tones separated by either a 250-ms (short), 850-ms (medium), or 3000-ms (long) silent inter-interstimulus interval (ISI). Frequency discrimination thresholds were estimated using an adaptive staircase procedure. Although young listeners performed better than the elderly at all ISIs, the latter showed a dramatic elevation of discrimination thresholds at 250 ms, while the thresholds of the young subjects increased significantly at 3000 ms. These results suggest that the elderly may be especially vulnerable to the effects of masking produced by the second tone at the short interval, whereas the young listeners tend to be differentially affected by the trace decay at long ISI. The results are discussed in the framework of stimulus persistence hypothesis.

Use of cefuroxime in preventing postcesarean infection in high-risk patients

Prophylactic antibiotic therapy is accepted for prevention of postceasarean infection in certain risk groups. Of the antibiotic regimens presented none appears superior. Patients having a cesarean section (CS) more than 6 h after membrane rupture were given three doses of cefuroxime (1.5 g every 8th hour) in a prospective study. This prophylaxis was as efficacious as a 7-day treatment with cefuroxime and cefadroxil. The infection rate was 21% which should be compared to approximately 50% when no prophylaxis was given. Patients with membrane rupture of less than 6 h and having a most urgent CS received the same 24-hour prophylaxis. No postoperative infection was recorded. Women having a CS with an ongoing uterine infection were treated with cefuroxime alone or combined with metronidazole. All but one (91%) had an uneventful recovery.

Olfactory recognition: differential impairments in early and late Huntington's and Alzheimer's diseases

Forty-two patients with senile dementia of the Alzheimer type (SDAT), 38 patients with Huntington's disease (HD) and matched normal controls were administered tests of olfactory, verbal, and visual recognition after being screened for normal olfactory discrimination. Early-affected Huntington's patients (EHD) with minimal chorea or cognitive deficit displayed marked deficits in olfactory recognition despite normal verbal and visual performance, even after correction for task difficulty, suggesting involvement of olfactory brain regions early in the disease process. In the early Alzheimer's group (EAD), marked deficits were seen on all recognition modalities indicating more global impairment. Both overall (early plus late) patient groups were impaired relative to controls on all recognition tasks, with the olfactory paradigm being most affected.

Prevention of postoperative infection in cesarean section after rupture of the membranes

Patients having a cesarean section more than 6 h after rupture of the membranes constitute a high risk group for postoperative infections. Two such groups were studied. Patients were given either cefuroxime 1.5 g every 8th hour for 24 h followed by cefadroxil 0.5 g twice daily for 6 days or received no medication. The infection rate was significantly reduced in the treatment group as compared to the control group (15% vs. 48%). Non-infected patients had a significantly shorter stay in hospital (8 days vs. 12 days). Combined use of these drugs for prevention of post-cesarean infection has not previously been reported. No side effects of the antibiotic prophylaxis were reported.

Adenocarcinoma of the uterine cervix

Between 1958 and 1969, 251 patients were treated at Radiumhemmet in Stockholm for adenocarcinoma of the uterine cervix. The histologic specimens were reevaluated. In the 211 cases of pure adenocarcinoma, the 5-year survival rate was compared with that in the total of cervical epithelial malignancies. The rate was lower in the adenocarcinoma cases, with respective crude 5-year survival rates of 84%, 50%, and 9% in Stages I, II, and III. Two modes of treatment, irradiation alone or irradiation plus radical surgery, were used in Stages IB and IIA. The combined treatment gave significantly improved 5-year survival rates.

Anaerobic bacteria in urine before and after prostatic massage of infertile men

In the present study 25 infertile men delivered urine before and after prostatic massage. Expressed prostatic secretion (EPS) was obtained from 11 men. Aerobic and anaerobic bacterial analyses showed that a total of 33 isolates was found in samples of urine voided before massage as compared to 59 isolates after massage of the prostate. There was an increase in the number of anaerobes whereas there was no change in the number of aerobes. The occurrence of EPS did not influence the number of aerobic and anaerobic isolates in urine voided after massage of the prostate. The most often isolated anaerobes in urine voided after prostatic massage were Eubacterium lentum, Peptococcus asaccharolyticus and Bacteroides species and the most common anaerobe in EPS was Peptostreptococcus micros.

Symptomatic, familial, perinatal, and social correlates of computerized axial tomography (CAT) changes in schizophrenics and bipolars

Computerized axial tomography (CAT) scans were blindly examined, and lateral ventricular-to-brain ratios calculated in 19 schizophrenic and 27 bipolar patients, and in an equal number of individually matched normal controls. Family history, early development, past psychiatric history, and current functioning and symptomatology were analyzed for all patients. Lateral ventricular enlargement on CAT was found in a significant proportion of both patient groups. Patients with such enlargement tended to have greater numbers of negative symptoms and poorer premorbid adjustment, but did not differ regarding family history of psychiatric illness. A subgroup of schizophrenics with presumed early brain damage was identified. This group had more marked ventricular enlargement, a greater number of negative symptoms, and an earlier onset of illness.

Analysis of prostatic acid phosphatase in urine voided before and after massage of the prostate in infertile men

Prostatic acid phosphatase (PAP) - a specific marker of prostatic secretion - has been analyzed by radioimmunoassay in samples of urine voided before and after massage of the prostate. In all patients there was an increase in urine PAP concentration after massage irrespective of the occurrence of expressed prostatic secretion. The mean PAP values increased from 4.9 to 45.8 micrograms/l. No significant change in urine creatinine concentration was observed. No lactoferrin was detected in the urine which should indicate that no secretion from the seminal vesicles was expressed into the urethra during massage of the prostate. Analysis of PAP in urine after massage of the prostate could increase the value of a urine sediment and microbial analysis in the investigation of male infertility.