Coping with dementia: evaluation of four nonpharmacologic interventions

To evaluate nonpharmacologic interventions, caregivers (65 women, 38 men) and their dementia-diagnosed spouses (patients) were randomized to one of four treatment programs (cognitive stimulation, dyadic counseling, dual supportive seminar, and early-stage day care) or to a wait-list control group. Assessments occurred initially and at postintervention (3 months). Patients were evaluated on memory, verbal fluency, and problem-solving ability, and caregivers were assessed on marital interaction, emotional status, and physical health, along with stress, coping, and social support. Caregivers also completed a program evaluation. Repeated measures procedures showed that patients in the cognitive stimulation group demonstrated more improvement over time in cognitive outcomes, and caregivers decreased in depressive symptoms. Early-stage day-care and dual supportive seminar group caregivers reported a decrease in hostility and a decrease in use of negative coping strategies, respectively. Although qualitatively derived benefits differed across groups, similarities in program content reduced the potential for quantitative differentiation among the groups.

Trans-anastomotic porto-portal varices in patients with gastrointestinal haemorrhage

AIM

Porto-portal varices are commonly seen in patients with segmental extra-hepatic portal hypertension and develop to provide a collateral circulation around an area of portal venous obstruction. It is not well recognized that such communications may also develop across surgical anastomoses and be the source of gastrointestinal haemorrhage. The possible mode of development of such communications has not been previously discussed.

MATERIALS AND METHODS

Over a 3-year period between 1995 and 1998, porto-portal varices were demonstrated across surgical anastomoses in four patients who were referred for the investigation of acute (two), acute-on-chronic (one) and chronic gastrointestinal bleeding (one). Their medical notes and the findings at angiography were reviewed.

RESULTS

Three patients had segmental portal hypertension due to extra-hepatic portal vein (one) or superior mesenteric vein (two) stenosis/occlusion. One patient had mild portal hypertension due to hepatic fibrosis secondary to congenital biliary atresia. At angiography all patients were shown to have varices crossing previous surgical anastomoses. These varices were presumed to be the cause of bleeding in three of the four patients; the site of bleeding in the fourth individual was not determined.

CONCLUSIONS

Trans-anastomotic porto-portal varices are rare. They develop in the presence of extra-hepatic portal hypertension and presumably arise within peri-anastomotic inflammatory tissue. Such varices may be difficult to manage and their prognosis is poor when bleeding occurs.

Trans rectal ultrasound guided radioactive seed implant: the Sumter experience

108 patients were treated between 1/06/97 and 7/19/99. Ages ranged from 53 years to 82 years. Pretreatment PSA ranged from 4.0 to 34.6 and post treatment PSA from 0 to 7.3. Given the fact that carcinoma of the prostate is a relatively slow growing tumor and that long survival times are not uncommon even in the face of relatively advanced disease, our treatment team believes that the preferred method of treatment in otherwise healthy patients who have a 20 year life expectancy is radical surgery. We do believe that brachytherapy has a role in the treatment of organ-confined disease and may possibly be proven to be as effective as surgery; however, until there is at least 15-year data, it cannot be considered as the primary treatment of choice in young men. The senior author has stressed the term "treatment team" in this paper for a reason. We sincerely believe that the best results for our patients are obtained when we approach the treatment of the patient as a unified team that makes use of our individual talents and training for the good of the patient as a whole. Each member of the team performs the procedures that he is best trained to do, and we are consistent in our approach and advice to our patients regardless of our disciplines.

Clinical criteria for the diagnosis of vascular dementia: a multicenter study of comparability and interrater reliability

BACKGROUND

Several clinical criteria have been developed to standardize the diagnosis of vascular dementia (VaD). Significant differences in patient classification have been reported, depending on the criteria used. Few studies have examined interrater reliability.

OBJECTIVE

To assess the concordance in classification and interrater reliability for the following 4 clinical definitions of VaD: the Hachinski Ischemic Score (HIS), the Alzheimer Disease Diagnostic and Treatment Centers (ADDTC), National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN), and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

METHODS

Structured diagnostic checklists were developed for 4 criteria for VaD, 2 criteria for Alzheimer disease (AD), and 4 criteria for dementia. Twenty-five case vignettes, representing a spectrum of cognitive impairment and subtypes of dementia, were prepared in a standardized clinical format. Concordance in case classification using different criteria and interrater reliability among 7 ADDTCs given a specific set of criteria was assessed using the kappa statistic.

RESULTS

The frequency of a diagnosis of VaD was highest using the modified HIS or DSM-IV criteria, intermediate using the original HIS and ADDTC criteria, and lowest using the NINDS-AIREN criteria. Scores for interrater reliability ranged from kappa = 0.30 (ADDTC) to kappa = 0.61 (original HIS).

CONCLUSIONS

Clinical criteria for VaD are not interchangeable. Depending on the criteria selected, the reported prevalence of VaD will vary significantly. The traditional HIS has higher interrater reliability than the newer criteria for VaD. Prospective longitudinal studies with clinical-pathological correlation are needed to compare validity.

Superior mesenteric vein stenosis complicating Crohn's disease

BACKGROUND

Superior mesenteric vein stenosis as a consequence of mesenteric fibrosis, causing the development of small bowel varices, is an unrecognised association of Crohn's disease.

CASE REPORTS

Two cases of gastrointestinal bleeding occurring in patients with Crohn's disease, and a third case, presenting with pain and diarrhoea, are described. In all three patients, visceral angiography showed superior mesenteric vein stenosis with dilatation of draining collateral veins in the small bowel. Overt gastrointestinal bleeding or iron deficiency anaemia resulting from mucosal ulceration is common in Crohn's disease, but acute or chronic bleeding from small bowel varices as a result of superior mesenteric vein stenosis due to fibrosis has not previously been reported.

The investigation of iron deficiency anemia--a hospital based audit

BACKGROUND/AIMS

Iron deficiency anemia (IDA) is associated with an increased incidence of malignancy. Our aim was to audit the management of patients with IDA seen in a teaching hospital gastroenterology unit, and to assess the role of upper and lower gastrointestinal endoscopy as well as mesenteric angiography in improving the diagnostic yield.

METHODOLOGY

A retrospective review of all outpatient letters and in-patient discharge summaries in an 11 month period in 1996 was used to identify anemic patients. All endoscopic and radiological procedures were documented on these patients.

RESULTS

98 cases (46 male) of IDA were identified. Of these, 94% had upper GI endoscopy with a yield for potential bleeding sources of 54% (including 4 malignancies) and 84% had lower GI investigation by colonoscopy or barium enema with a diagnostic yield of 37% (including 3 malignancies and 10 adenomatous polyps). Combined endoscopic and barium examinations provided a positive diagnosis in 69%, and 12.2% had significant co-existent upper and lower GI pathology. Thirty-three patients underwent visceral angiography (27 of who had no positive endoscopic diagnosis). Twenty-seven studies revealed a bleeding source (yield 82%). Overall an underlying diagnosis was made in 92% of patients.

CONCLUSIONS

The incidence of significant dual pathology in patients with IDA was high. Investigation of the lower GI tract should be performed in all patients unless a malignancy is found on upper GI endoscopy. Mesenteric angiography has a high diagnostic yield, and is a useful investigation in patients with resistant or transfusion dependent anemia in whom endoscopic or barium studies are normal.

Immunohistochemistry to identify Leishmania parasites in fixed tissues

The definitive diagnosis of leishmaniasis currently depends on the identification of characteristic amastigote morphology in tissue, or isolation of promastigotes by culture. Histopathological identification can be difficult, and is variably sensitive; culture is considered "the gold standard", but is not uniformly diagnostic or available. In this study, we compared light microscopic immunohistochemistry (IHC) using a monoclonal anti-Leishmania antibody (G2D10) to standard hematoxylin and eosin (H&E) stain in the diagnosis of Leishmania on skin. Sixty-one archived specimens from patients suspected of being infected with Leishmania were used; 41 of these had leishmaniasis confirmed by culture. Although not statistically significant, both sensitivity and specificity were higher for IHC compared to H&E: 51% (95% CI: 35-67%) compared to 42% (CI: 26-58%; 2p=0.29) for sensitivity, and 100% (CI: 83-100%) compared to 85% (CI: 62-97%, 2p=0.25) for specificity, respectively. Furthermore, because organisms could be diagnosed by IHC at low power (x20-40), this assay was more rapid than H&E, in which parasite morphology could best be identified at oil immersion power. The G2D10 antibody has broad Leishmania species recognition, and offers promise as a simple, rapid diagnostic screen for leishmaniasis. Further study is underway to better characterize this antibody.

Safety and efficacy of intravenous sodium stibogluconate in the treatment of leishmaniasis: recent U.S. military experience

The efficacy and toxicity of sodium stibogluconate (SSG) at a dosage of 20 mg/(kg.d) for either 20 days (for cutaneous disease) or 28 days (for visceral, mucosal, or viscerotropic disease) in the treatment of leishmaniasis is reported. Ninety-six U.S. Department of Defense health care beneficiaries with parasitologically confirmed leishmaniasis were prospectively followed for 1 year. One patient was infected with human immunodeficiency virus; otherwise, comorbidity was absent. Clinical cure occurred in 91% of 83 cases of cutaneous disease and 93% of 13 cases of visceral/viscerotropic disease. Adverse effects were common and necessitated interruption of treatment in 28% of cases, but they were generally reversible. These included arthralgias and myalgias (58%), pancreatitis (97%), transaminitis (67%), headache (22%), hematologic suppression (44%), and rash (9%). No subsequent mucosal leishmaniasis was identified, and there were no deaths attributable to SSG or leishmaniasis.

Endovascular occlusion with a new mechanical detachable coil

OBJECTIVE

Metallic coils have been used for vascular embolization for many years but controlled-release coils have only recently become commercially available. Most of these devices are microcoils that were manufactured primarily for the packing of intracerebral aneurysms; therefore, they lack radial force and are not ideal agents for the occlusion of high-flow lesions such as pulmonary arteriovenous malformations (PAVMs). The objective of this study was to review our experience with a new detachable coil based on the conventional Gianturco-Wallace coil.

SUBJECTS AND METHODS

The new detachable coil was initially used for the treatment of varicocele in 20 patients. Subsequently, the coil was used in 48 patients during 90 procedures for the treatment of PAVMs.

RESULTS

A total of 548 coils were used. Complete occlusion of the testicular vein was achieved in all patients with varicocele. Successful occlusion of the PAVM being treated was achieved in all patients, and no instances of recanalization were documented in any of the patients who returned for follow-up angiography. Forty-one coils had to be removed completely from the catheter before detachment because of inappropriate size or position. Eight coils failed to detach easily, and six of these had to be removed. Most of these device failures were associated with kinking of the screw thread mechanism between the coil and the delivery wire.

CONCLUSION

The Jackson detachable coil allows safer, more accurate, and more distal embolization of PAVMs than is possible with nondetachable coils. Complications associated with its use have been few.

Pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVMs) are uncommon lesions, but are the cause of considerable morbidity and occasional mortality. They most commonly occur in association with hereditary haemorrhagic telangectasia and screening of families with this condition is therefore important. Embolization of PAVMs by coils is a well tolerated effective procedure with a low complication rate in skilled hands. Treatment results in both symptomatic and physiological improvement, and evidence for a reduction in stroke and cerebral abscess is accumulating. Radiological techniques now represent the primary treatment of choice, with surgical resection rarely required.

Meckel's diverticulum: angiographic findings in 16 patients

OBJECTIVE

The purpose of this study was to assess the sensitivity of angiography in revealing the vitellointestinal artery or other arteriographic abnormalities in patients in whom surgery subsequently proved Meckel's diverticulum.

MATERIALS AND METHODS

From the 36 patients who had undergone a Meckel's diverticulectomy between 1980 and 1997 at Hammersmith Hospital or a referring hospital, we selected 18 who had undergone preoperative angiography at our institution. Case notes and angiograms of these 18 patients were reviewed for the presence of a persistent vitellointestinal artery or other angiographic evidence of a Meckel's diverticulum.

RESULTS

Angiograms of 16 of 18 patients were available for review. A striking male preponderance existed (male:female = 13:3). Mean age was 28 years (range, 12-65 years). In 11 (69%) of the 16 patients, a persistent vitellointestinal artery was seen that had been noted at the time of the study and reported before surgery for nine patients. Other angiographic abnormalities at the site of the Meckel's diverticulum were present in four patients and included a vascular blush, early venous return, and arterial irregularity.

CONCLUSION

Angiography will show a persistent vitellointestinal artery in most individuals with a Meckel's diverticulum who present with chronic gastrointestinal bleeding. However, the recognition of a persistent vitellointestinal artery may be difficult because of overlying vessels, and superselective catheterization of distal ileal arteries may be necessary.

A survey of a Canadian on-line substance abuse prevention initiative for adolescents and young adults

Electronic Zoot is a Canadian youth-oriented, computer bulletin board system based in Edmonton. The system is designed to teach its users about the risks associated with substance use and abuse. More than 600 of Electronic Zoot's users were surveyed to obtain demographic data and information about attitudes. The majority of the users of the system were male. Most users were between 11 and 25 years of age and a disproportionately high number were from rural communities. It was found that peer support was a primary component of this telehealth service. Statistically significant age differences revealed that the system's younger users were more likely than its older users to be influenced by the drug education message of the bulletin board system. In addition, it was noted that on-line surveys are easy to conduct and greatly facilitate the collection of longitudinal telehealth data.

Neuron-like cells on the apical surface of the developing rat olfactory epithelium

Using scanning electron microscopy (SEM), we encountered a new phenomenon in developing olfactory structures. A few cells with single slender processes that sprout from their cell bodies were found lying on the surface of the developing olfactory epithelium in 15 and 16 day old rat embryos. These slender processes resemble leading processes as they often have filopodia or filopodium-like structures at their distal ends. This finding suggests a presence of a small population of olfactory epithelial cells that resemble, but need not be, neurons. Their location may reflect cell shedding, but the fact that they extend processes over the epithelial surface may also mean that the cells were caught while they were migrating.

Cells resembling hair cells in developing rat olfactory and nasal respiratory epithelia

A hitherto ignored microvillous cell type, distinct from microvillous supporting cells and other microvillous cell types, was encountered in olfactory and respiratory epithelia of nasal turbinates of rat fetuses, near the transition between these two epithelia. The apex of the cell resembles the apices of vestibular hair cells. The cell has a cone-shaped bundle of microvilli, resembling the complex bundle of hair-cell stereocilia, accompanied by a cilium. Therefore we called this cell type the nasal hair cell. Cilium and microvilli seemed adhered. Cell numbers were very low, up to about 5 per turbinate. The cell's appearance is precocious compared to that of olfactory receptor and supporting cells. Also, while the apices of olfactory receptor and supporting cells and of ciliated respiratory cells underwent major morphological maturation during the developmental period from embryonic day 16 to day 21, the apical structures of the nasal hair cell only changed marginally from embryonic day 16, when they were first seen, through to at least embryonic day 21. The cell's location and precociously mature appearance suggests that it plays a special role in the development of nasal epithelia.

A banded topography in the developing rat's olfactory epithelial surface

In situ hybridization studies from various laboratories have shown that the rat's olfactory epithelium has four distinct regions in which most putative odor receptors are located. To determine whether morphological features accompany this biochemical patterning, olfactory epithelial surfaces of rat nasal endoturbinates and septa were examined with scanning electron microscopy, placing particular emphasis on endoturbinate IIb. There was some morphological patterning at embryonic day 15 (E15), but distinct regions were not yet discernible. Regionalization became distinct at E16 and E18. Posterior regions (Regions 1 and 2) had much higher receptor cell knob densities than more anterior regions closer to the respiratory epithelium (Regions 3 and 4). Supporting cell microvilli were longer in Region 1 than in Region 2. Apices of cells surrounding the receptor cells were flatter in Regions 1 and 2 than in Regions 3 and, especially, Region 4. In Regions 1-3, these surrounding cells were made up mainly of supporting cells; in Region 4 they included respiratory cells. Regions 3 and 4 also had glandular openings and scattered microvillous cells that resemble hair cells of the ear. Older fetuses and adults showed similar evidence of patterning, but detailed examination was precluded by the increased length and entanglement of receptor cell cilia and supporting cell microvilli. In conclusion, a distinct topographic pattern, involving both receptor and surrounding cells, emerges during development of the rat olfactory epithelial surface. Location of the bands roughly matches the zones seen by in situ hybridization.

Vascular intervention in the thorax: bronchial artery embolization for haemoptysis

Massive haemoptysis is defined as the expectoration of more than 600 mls of blood in 48 h. Many patients are not surgical candidates because of the presence of severe bilateral pulmonary disease and these individuals are best managed by bronchial artery embolization. Occlusion of both the bronchial arteries and hypertrophied non-bronchial systemic arteries is essential if bleeding is to be controlled. A pulmonary arterial source of haemorrhage is uncommon but should always be considered in a patient who has further haemoptyses shortly after a technically successful embolization of bronchial and non-bronchial systemic arteries. The immediate control of haemorrhage is achieved in the majority of patients although subsequent rebleeding on longterm follow-up is not uncommon.

Olestra affects serum concentrations of alpha-tocopherol and carotenoids but not vitamin D or vitamin K status in free-living subjects

Normal, healthy, free-living adults ingested either 18 g/d olestra, with or without 1.1 mg tocopheryl acetate/g olestra, or 18 g/d triglyceride placebo, for 16 wk in a double-blind, placebo-controlled study. Serum concentrations of alpha-tocopherol, alpha-carotene, beta-carotene, lycopene, lutein/zeaxanthin, retinol and cholesterol were measured biweekly. Serum 25-hydroxyvitamin D concentration, prothrombin time, partial thromboplastin time and plasma concentration of functional prothrombin (Simplastin-Ecarin assay) were measured at wk 0, 8 and 16. Relative to the placebo group, serum alpha-tocopherol concentration was reduced 6% for the group given 18 g/d olestra. Addition of tocopheryl acetate to olestra partially offset the effect of olestra. For the group given 18 g/d olestra plus 1.1 mg tocopheryl acetate/g olestra, serum alpha-tocopherol concentration was 4% less than the placebo value. Olestra reduced serum concentration of beta-carotene by 27%; the other carotenoids were similarly affected. Serum cholesterol concentration was reduced approximately 4.5% in the olestra groups, relative to placebo, but the differences were not significant. Serum triglycerides, serum 25-hydroxyvitamin D, prothrombin time, partial thromboplastin time or the plasma concentration of under-gamma-carboxylated prothrombin were unaffected by olestra. Clinical observations and laboratory measures indicated no health-related effects of olestra; mild-to-moderate transient gastrointestinal symptoms such as bloating, cramping, loose stools and diarrhea were reported by all groups.

Persistence of immunity of Nematodirus battus infection in lambs

Fifty-four Greyface Suffolk lambs aged 3 months were allocated to six groups of seven and one group of 12. Three groups were infected continuously with Nematodirus battus larvae (L3) over a 7-week period and three groups remained worm-free. One week after the last larval dose all six groups were treated with anthelmintic and challenged with a single dose of 30,000 N. battus L3 either 1, 6 or 12 weeks post-treatment (PT) and killed 10 days later. A seventh continuously infected and treated group (n = 12) was segregated into four sub-groups of three lambs which were used as tissue cell count controls and provided data on local cellular responses prior to challenge. Lambs in the first sub-group were killed immediately after anthelmintic treatment and those in the other sub-groups were killed on the same day that the lambs in the other main groups were challenged. Overall post-challenge worm burdens did not differ significantly between previously infected and challenge control groups although they were significantly reduced in both treatment groups by Week 12 PT. The principal manifestation of acquired immunity that was maintained throughout 12 weeks without further infection was retardation in larval development. There was also evidence of preferential rejection of male worms from immune lambs. Local mast cell, but not eosinophil, responses were significantly enhanced by previous infection and persisted up to Week 12 PT. The numbers of bone marrow eosinophils were significantly increased as a result of previous infection and this response persisted up to Week 12 PT. During primary infection anti-L4 and anti-adult worm IgG responses were significantly increased in the previously infected lambs by Day 42 post-infection. Eosinophil responses during this period did not differ between groups. The inflammatory cell responses, coupled with the parasitological observations, suggest that immunity to previous infection is maintained for up to 12 weeks PT without further antigenic stimulation. This 'immunological memory' may have waned partially after 6 weeks PT although the superimposition of age resistance may have masked the effect.

Behavioural effects in mice of subchronic chlordiazepoxide, maprotiline, and fluvoxamine. I. Social interactions

The present study compares the effects of subchronic administration (daily. 21 days) of chlordiazepoxide (CD), maprotiline and fluvoxamine on the behavior of male mice during dyadic social interactions. Maprotiline like chlordiazepoxide, stimulated aggression at 4 mg/kg and 2 mg/kg respectively (intermediate dose levels), whereas effects of fluvoxamine (3-8 mg/kg) were mainly sedative. Non-social activity was reduced by CD at 4 and 8 mg/kg and by maprotiline at 0.5 mg/kg. At the highest dose tested (10 mg/kg), maprotiline increased immobility, resembling the effects of fluvoxamine, while at 2 mg/kg, it reduced social investigation. Thus, despite some commonalities, there were several differences in behavioral profile of the compounds tested. Data are discussed in relation to the efficacy of each of these compounds in treating anxiety and depressive disorders.