The prevalence of psychiatric morbidity and its associated factors in general health care in Taiwan

BACKGROUND

This paper reports the prevalence, disability, sociodemographic and clinical association of psychiatric morbidity among attenders in general health care in Taiwan where, as in the rest of non-Western countries, few studies have been carried out.

METHODS

A cross-sectional survey with a two-phase design was carried out at out-patient clinics of three health stations and a general hospital.

RESULTS

A total of 990 patients completed the brief screen in the first phase, 486 of whom completed the independent assessment in the second phase. The proportion of screening positives was 46.0% and the weighted prevalence of definite psychiatric disorder was 38.2%. Common mental disorders were associated with female gender and unemployment. Housewives, students and patients with higher educational attainment were at lower risk of having alcohol use disorders. Patients with common mental disorders were more likely to present with psychological complaints, to attribute their illness to psychosocial causes and to perceive their mental and physical health as poor. Psychiatric morbidity was associated with excess life events. Common mental disorders, particularly depressive disorders, were significantly associated with self-reported disability.

CONCLUSIONS

Psychiatric morbidity is a major health problem in general health care in Taiwan. Physicians should be aware of these health problems.

Measuring the built environment: validity of a site survey instrument for use in urban settings

There are few reliable measures of place with which to study the effects of socio-economic context on health. We report on the development and inter-rater reliability of a 27-item observer-rated built environment site survey checklist (BESSC). Across eleven 'housing areas' (defined as areas of homogeneity in housing form) and two raters, kappa coefficients were > or =0.5 for fifteen categorical items, and intra-class correlation coefficients exceeded 0.6 for a further three continuous measures. Ratings on several BESSC items were associated to a statistically significant degree with the prevalence of depression and residents' dissatisfaction with 'their area as a place to live'. BESSC items may prove to be valuable descriptors of the urban built environment in future studies.

Dementia in developing countries

The 10/66 Dementia Research Group (2000a) has drawn attention to the uneven distribution of research evidence worldwide; although two thirds (66%) of all persons with dementia live in developing countries, 10% or less of population-based research has been conducted in those regions. The study by Vas and colleagues on dementia in Mumbai, India, published in this issue of International Psychogeriatrics is therefore most welcome. Dementia has a very low profile in most developing countries. Families often view it as a normal part of aging, and few seek help despite experiencing significant strain (Pate1 & Prince, 2001; Shaji et al., in press). Unsurprisingly therefore it is accorded a low priority by policymakers in the developing world, and there is little sign of attention being given to the development of more responsive health care or social welfare services. Population-based research, well disseminated, can play an important role in increasing awareness at all levels of society.

Osteoporosis in primary biliary cirrhosis revisited

BACKGROUND

Primary biliary cirrhosis (PBC) is increasingly being diagnosed in the earlier non-cholestatic stages of disease. Accepted wisdom has been that PBC is frequently complicated by osteoporosis. Whether this association holds true for the broader spectrum of PBC patients now recognised has not as yet been studied.

AIMS

To examine the extent to which osteoporosis occurs more commonly in PBC patients than in normal individuals of the same age and sex.

DESIGN

Retrospective review of a large cohort of well characterised PBC patients.

PATIENTS

A total of 272 PBC patients with definite or probable PBC followed up for a mean of 10.1 years (total follow up 2726 patient years) who had at least one bone mineral density measurement (BMD).

RESULTS

In this unselected group of PBC patients, mean Z scores (number of SDs from age and sex matched normal mean values) at the neck of femur (NOF) and lumbar spine (LS) at first BMD measurement (7 (6) years after PBC diagnosis) were -0.1 (1.4) and 0.1 (1.4), respectively. At first BMD measurement, 18 PBC patients had Z scores less than -2.0 and 85 had T scores less than -2.5. No factors predictive of osteoporosis were found in affected patients. A total of 957 BMD measurements were performed (0.35 per patient year of follow up); 220 patients had two or more measurements. No patient went on to develop de novo osteoporosis during follow up. In the 51 patients (who were clinically representative of the whole group) who received no PBC or bone related treatment during follow up, %BMD changes per year at the NOF and LS were -1.6 (3.2) and 0.1 (2.2), respectively. No variance in this "natural" rate of BMD measurement was seen in patients receiving PBC modulating agents (including prednisolone and UDCA) or osteoporosis prophylaxis/therapy. Significant improvement at the LS was seen in patients undergoing liver transplantation.

CONCLUSIONS

Osteoporosis is not a specific complication of PBC.

Optimization of cytokine stability in stored amniotic fluid

OBJECTIVE

Many studies use stored amniotic fluid samples to assay cytokines and other proteins for outcome-based research; however, there is little information on the optimal methods of storage. The objective of our study was to evaluate cytokine stability in amniotic fluid stored at different temperatures both with and without a proteolytic enzyme inhibitor.

STUDY DESIGN

Patients undergoing midtrimester genetic amniocentesis for routine indications gave consent for the study. After the sample was centrifuged, the acellular portion of the sample was mixed to homogeneity and aliquoted in 0.5-mL increments and stored for 1 year at 4 degrees C, -20 degrees C, and -80 degrees C with and without the protease inhibitor aprotinin. Enzyme-linked immunoassays for angiogenin, interleukin-6, and vascular endothelial growth factor were performed simultaneously on each aliquot.

RESULTS

Thirty samples were assayed for each storage condition. Results were calculated as the percentage of its own sister aliquot stored at -80 degrees C without aprotinin. In all samples, there was a significant relation between storage temperature and cytokine levels, with the lowest levels found at 4 degrees C and the highest at -80 degrees C (angiogenin, P =.004; interleukin-6, P <.001; vascular endothelial growth factor, P =.02). The addition of aprotinin improved stability only for angiogenin at all temperatures (all P <.05).

CONCLUSIONS

Degradation of cytokines occurs when amniotic fluid samples are stored for prolonged periods at temperatures greater than -80 degrees C. The addition of a protease inhibitor helps stem the degradation of some cytokines.

Comparison of craniofacial skeletal characteristics of infants with bilateral choanal atresia and an age-matched normative population: computed tomography analysis

Choanal atresia (CA) results from the developmental failure of the posterior nasal cavity to communicate with the nasopharynx. Computed tomographic (CT) scanning is often used as a diagnostic tool for CA as it is able to provide information regarding the extent and type of atresia. Studies have used CT measurements to analyze the skeletal deformities of children with CA. Computed tomographic analysis of the complete craniofacial skeletal characteristics of children with CA has not been previously reported. This study analyzed the craniofacial skeletal characteristics of infants with bilateral choanal atresia (BCA) and compared them with age-matched standards. Eight patients with BCA under the age of 3 months were evaluated. Fourteen cranio-orbitozygomatic variables were used to represent the craniofacial skeletal configuration. The measurements from the control group were compared with the available values of age-matched normal controls. Statistically significant differences between the means of the sample group and control group were demonstrated in 10 of 14 variables. The sample group means were consistently smaller than the control group mean. Detailed knowledge of the underlying anatomy of infants with BCA will help in the development of treatment strategies and will provide data for evaluation of operative intervention on craniofacial growth.

Expression and regulation of Runx2/Cbfa1 and osteoblast phenotypic markers during the growth and differentiation of human osteoblasts

The runt family transcription factor (AML-3/PEBP2alphaA1/Cbfa1/RUNX2) plays a crucial role in formation of the mineralized skeleton during embryogenesis and regulates maturation of the osteoblast phenotype. Because steroid hormones and growth factors significantly influence growth and differentiation properties of osteoblasts, we addressed Cbfa1 as a target gene for regulation by dexamethasone (Dex), 1,25(OH)D(3) (vitamin D(3)), 17beta-estradiol, and transforming growth factor-beta1 (TGF-beta1). The representation of functional protein levels by Western blot analyses and gel mobility shift assays was examined during the growth and mineralization of several conditionally immortalized human osteoblast cell lines HOB 04-T8, 03-CE6, and 03-CE10, each representing different stages of maturation. In situ immunofluorescence demonstrates Cbfa1 is associated with nuclear matrix in punctate domains, some of which are transcriptionally active, colocalizing with phosphorylated RNA polymerase II. Although each of the cell lines exhibited different responses to the steroid hormones and to TGF-beta1, all cell lines showed a similar increase in Cbfa1 protein and DNA binding activity induced only by Dex. On the other hand, Cbfa1 mRNA levels were not altered by Dex treatment. This regulation of Cbfa1 by steroid hormones in human osteoblasts contrasts to modifications in Cbfa1 expression in primary rat calvarial osteoblasts and the mouse MC3T3-E1 osteoblast cell line. Thus, these results reveal multiple levels of regulation of Cbfa1 expression and activity in osteoblasts. Moreover, the data suggest that in committed human osteoblasts, constitutive expression of Cbfa1 may be required to sustain the osteoblast phenotype.

Isolated growth hormone (GH) deficiency due to compound heterozygosity for two new mutations in the GH-releasing hormone receptor gene

OBJECTIVE

Mutations in the GH releasing hormone receptor (GHRH-R) have recently been shown to cause autosomal recessive isolated GH deficiency (IGHD). Patients who are homozygous for GHRH-R mutations have a subnormal GH response to pharmacological agents that stimulate GH secretion and an appropriate response to exogenous GH therapy. We searched for mutations in the GHRH-R gene in a family in which two of three siblings were affected by IGHD.

DESIGN

We sequenced the 13 coding exons, the intron-exon boundaries and 327 bases of the promoter of the GHRH-R gene from peripheral blood cell genomic DNA of an index patient.

RESULTS

Both affected individuals were compound heterozygotes for two previously undescribed GHRH-R mutations: a change in codon 137 that replaces histidine with leucine (H137L), and a 5 bp deletion in exon 11 (Del 1140-1144). The patients' father was heterozygous for the H137L mutation, and the mother was heterozygous for the exon 11 deletion. We used site-directed mutagenesis to create the mutants in wild-type GHRH-R cDNA. Transient transfection of GHRH-R cDNAs in Chinese hamster ovary cells showed that cells transfected with both mutant receptors failed to increase cyclic AMP after treatment with GHRH.

CONCLUSIONS

We describe a family in which two siblings with IGHD were compound heterozygotes for two new mutations in the GHRH-R gene. These results suggest that mutant alleles for GHRH-R gene may be more common than previously suspected.

Association study of the 5-HT(2A) receptor gene polymorphism, T102C and essential hypertension

BACKGROUND

Serotonin dysfunction has been implicated in hypertension due to its ability to induce vasoconstriction via stimulation of 5-HT(2) receptors and due to the antihypertensive effect of ketanserin, an antagonist at the 5-HT(2A) receptor subtype, expressed both on arteries and the brain. The silent T102C polymorphism in the 5-HT(2A) gene is in absolute linkage disequilibrium with a polymorphism in the promoter and may contribute to genetic predisposition possibly by modifying the transcription of the gene.

OBJECTIVE

To examine the genetic contribution of the T102C 5-HT(2A)polymorphism in essential hypertension in a case-control sample of UK residents.

DESIGN

The hypertensive group consisted of 342 subjects over 75 years and the community-based control group consisted of 319 subjects. Subjects were genotyped for the T102C polymorphism by Mspl restriction enzyme digestion following PCR amplification.

RESULTS

Sex-specific association analysis revealed significant differences between hypertensive and normotensive subjects in the genotypes distribution (P = 0.016) and allelic frequencies (P = 0.007) in the female group. The direction of significance was increased frequency of the 102-C allele in the hypertensive subjects. There were no association between haplotype and age or body mass index, which suggest that the effect of the T102C variant is not influenced by these variables.

CONCLUSION

This data indicates that the T102C polymorphism in the 5-HT(2A) gene might be an independent risk factor for increased blood pressure in female individuals with essential hypertension.

Ageing and mental health in a developing country: who cares? Qualitative studies from Goa, India

BACKGROUND

While there is a growing body of epidemiological evidence on the prevalence of mental illnesses in late-life in developing countries, there is limited data on cultural perceptions of mental illnesses and care arrangement for older people.

METHOD

This qualitative study used focus group discussions with older people and key informants to investigate the status of older people and concepts of late-life mental health conditions, particularly dementia and depression, in Goa, India.

RESULTS

Vignettes of depression and dementia were widely recognized. However, neither condition was thought to constitute a health condition. Dementia was construed as a normal part of ageing and was not perceived as requiring medical care. Thus, primary health physicians rarely saw this condition in their clinical work, but community health workers frequently recognized individuals with dementia. Depression was a common presentation in primary care, but infrequently diagnosed. Both late-life mental disorders were attributed to abuse, neglect, or lack of love on the part of children towards a parent. There was evidence that the system of family care and support for older persons was less reliable than has been claimed. Care was often conditional upon the child's expectation of inheriting the parent's property. Care for those with dependency needs was almost entirely family-based with little or no formal services. Unsurprisingly, fear for the future, and in particular 'dependency anxiety' was commonplace among older Goans.

CONCLUSIONS

There is a need to raise awareness about mental disorders in late-life in the community and among health professionals, and to improve access to appropriate health care for the elderly with mental illness. The study suggests directions for the future development of locally appropriate support services, such as involving the comprehensive network of community health workers.

Stroke, vascular risk factors and depression: Cross-sectional study in a UK Caribbean-born population

BACKGROUND

Stroke, hypertension and diabetes are common in older Caribbean-born populations in the UK who may be at risk of depression secondary to vascular disease.

AIMS

We examined the association between stroke, vascular risk factors and depression in a community-based Caribbean-born population aged 55-75 years.

METHOD

Vascular risk factors were identified by interview, examination and blood tests. Depression was categorised using the Geriatric Depression Scale. Disablement was assessed as a potential mediating factor.

RESULTS

Physical illness and disablement were strongly associated with depression, independent of disablement. Previous stroke was associated with depression, independent of disablement. No vascular risk factors were associated with depression.

CONCLUSIONS

The risk of depression associated with stroke was not explained by disablement. However, the hypothesis that vascular risk factors are important in the genesis of depression was not supported.

Study on COgnition and Prognosis in the Elderly (SCOPE): baseline characteristics

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multi-centre, prospective, randomized, double-blind, parallel-group study. The primary objective of SCOPE is to assess the effect of the angiotensin II type 1 (AT1) receptor blocker, candesartan cilexetil 8-16 mg once daily, on major cardiovascular events in elderly patients (70-89 years of age) with mild hypertension (DBP 90-99 and/or SBP 160-179 mmHg). The secondary objectives of the study are to test the hypothesis that antihypertensive therapy can prevent cognitive decline (as measured by the Mini Mental State Examination, MMSE) and dementia, and to assess the effect of therapy on total mortality, myocardial infarction (MI), stroke, renal function, and hospitalization. A total of 4964 patients from 15 participating countries were recruited during the randomization phase of SCOPE, exceeding the target population of 4000. The mean age of the patients at enrolment was 76 years, the ratio of male to female patients was approximately 1:2, and 52% of patients were already being treated with an antihypertensive agent at enrolment. The majority of patients (88%) were educated to at least primary school level. At randomization, mean sitting blood pressure values were SBP 166 mmHg and DBP 90 mmHg, and the mean MMSE score was 28. Previous cardiovascular disease in the study population included myocardial infarction (4%), stroke (4%) and atrial fibrillation (4%). Men, more often than women, had a history of previous MI, stroke and atrial fibrillation. A greater percentage of men were smokers (13% vs 6% in women) and had attended university (11% vs 3% of women). Of the randomized patients, 21% were 80 years of age. In this age group smoking was less common (4% vs 10% for 70-79-year-olds) and fewer had attended university (4% vs 7% for 70-79-year-olds). The incidence of MI was similar in both age groups. However, stroke and atrial fibrillation had occurred approximately twice as frequently in the older patients. The patients' mean age at baseline was similar in the participating countries, and most countries showed the approximate 1:2 ratio for male to female patients. There was also little inter-country variation in terms of mean SBP, DBP or MMSE score. However, there was considerable regional variation in the percentage of patients on therapy prior to enrolment.

Does depression predict cognitive outcome 9 to 12 years later? Evidence from a prospective study of elderly hypertensives

BACKGROUND

Previous longitudinal studies of the association between depression and cognitive dysfunction have had relatively short follow-up periods. This report presents a long-term study of the association between baseline syndromal depression and cognitive outcome measured 9 to 12 years later.

METHODS

Self-CARE (D) depression, cognitive function and pre-morbid intelligence were recorded on 1083 subjects on entry to the Medical Research Council trial of treatment of hypertension in older adults in 1983-5. In 1994-5, we aimed to re-interview all survivors to assess cognitive function using the MMSE. We used multivariate analysis to explore whether baseline depression predicted cognitive outcome after this long follow-up period.

RESULTS

Baseline depression was crudely associated with poorer cognitive outcome at time 2. However, this long-term prospective association was no longer apparent after adjusting for baseline cognitive performance, which was associated with baseline depression and robustly predicted cognitive outcome at time 2. We found that gender modified the association between depression and poorer cognitive outcome, so that the association was statistically significant only among men.

CONCLUSION

Propensity for depression and failing cognition may have common determinants that still need to be established by future neurobiological investigations in conjunction with further long-term prospective epidemiological research.

Reconciling quantitative ultrasound of the calcaneus with X-ray-based measurements of the central skeleton

Osteoporosis is frequently undiagnosed before fracture because of the lack of availability of instruments to quantitate bone mass. To evaluate the utility of quantitative ultrasound (QUS) of the calcaneus to diagnose osteoporosis, we determined bone mineral density (BMD) of the posterior-arterior spine, total hip, and femoral neck by dual-energy X-ray absorptiometry (DXA) and QUS in 312 women aged 50 years and older. A risk factor assessment (simple calculated osteoporosis risk estimation [SCORE]) also was quantitated in all women. Ninety-four of the 312 women were diagnosed as osteoporotic based on T scores < or = -2.5 at the spine, total hip, and/or femoral neck. The sensitivity of the individual central sites for the diagnosis of osteoporosis was 49% at the spine (46 of 94 women), 32% at the total hip (30 of 94 women), and 81% at the femoral neck (76 of 94 women). At a QUS T score < or = -1, the peripheral technique had a sensitivity of 62% and a specificity of 72%. Combining a QUS T score of < or = -1 followed by a risk factor assessment of women with a QUS T score > or = -0.99 using a cut point of 11 increased sensitivity to 81% (comparable with femoral neck DXA) but decreased specificity to 58%. If peripheral QUS measurements and risk factor assessment are the only tools employed before initiation of therapy, the benefits of increased ease of diagnosis will need to be balanced against potentially unnecessary treatment in some normal patients and lack of treatment in some osteoporotic patients.

Long-term predictors of cognitive outcome in a cohort of older people with hypertension

BACKGROUND

Deteriorating cognitive function in late life substantially increases the risk for dementia, for other non-cognitive morbidity, for dependency, and early death.

AIMS

To identify early predictors of late-life cognitive outcome.

METHOD

Cognitive function, premorbid IQ, and cardiovascular risk exposure were recorded on 1083 subjects on entry to a hypertension treatment trial in 1983-1984. We followed up this cohort 9-12 years later to assess cognitive function with the Mini-Mental State Examination (MMSE), to update exposure status, and to obtain genomic material. Multivariate analysis was used to identify independent baseline predictors of cognitive outcome 9-12 years later.

RESULTS

We followed up 387 subjects (58.6% of survivors). After adjusting for baseline cognition, poorer cognitive outcome was found to be independently associated with a family history of dementia, increasing age, less decline in systolic blood-pressure, lower premorbid IQ (rather than limited education), and abstinence from alcohol.

CONCLUSIONS

Reduction in systolic blood pressure (among hypertensives) and moderate alcohol intake could protect against cognitive deterioration in late life.

Smoking, drinking, and incident cognitive impairment: a cohort community based study included in the Gospel Oak project

OBJECTIVES

Recent longitudinal studies have reported that smoking increases risk for cognitive impairment and that moderate alcohol intake could be preventive. The association between both cigarette smoking and alcohol drinking and incident cognitive impairment was studied in a representative population.

METHODS

This is a 1 year prospective population based cohort study of all residents aged 65 or over in the electoral ward of Gospel Oak in London, UK (n=889). Cognitive impairment was assessed at baseline and 1 year later using the organic brain syndrome (OBS) cognitive impairment scale from the short CARE structured assessment. Subjects who were cognitively impaired at baseline were excluded from this analysis.

RESULTS

The prevalence of OBS cognitive impairment was 10.4% at index assessment and the 1 year cumulative incidence of cognitive impairment was 5.7%. Cognitive impairment was not associated with use of alcohol, although there was a non-significant association in the direction of a protective effect against onset of cognitive impairment for moderate drinkers compared with non-drinkers and heavy drinkers. Current smoking status predicted cognitive impairment (risk ratio (RR) 3.7; (95% confidence interval (95% CI)=1.1-12.3) independently from sex, age, alcohol, occupational class, education, handicap, depression, and baseline cognitive function.

CONCLUSIONS

Smoking seems to be a prospective risk factor for incident cognitive impairment; thus encouragement of older people to stop smoking could be considered as part of a strategy to reduce the incidence of cognitive impairment.

Hypoglycaemic and other related actions of Tinospora cordifolia roots in alloxan-induced diabetic rats

Tinospora cordifolia is widely used in Indian Ayurvedic medicine for treating diabetes mellitus. Oral administration of an aqueous T. cordifolia root extract (TCREt) to alloxan diabetic rats caused a significant reduction in blood glucose and brain lipids. The extract caused an increase in body weight, total haemoglobin and hepatic hexokinase. The root extract also lowers hepatic glucose-6-phosphatase and serum acid phosphatase, alkaline phosphatase, and lactate dehydrogenase in diabetic rats. Thus TCREt has hypoglycaemic and hypolipidaemic effect.

Viral IL-10 gene transfer decreases inflammation and cell adhesion molecule expression in a rat model of venous thrombosis

Post-thrombotic inflammation probably contributes to chronic venous insufficiency, and little effective treatment exists. IL-10 is an anti-inflammatory cytokine that previously has been shown to decrease perithrombotic inflammation and thrombosis. We investigated in a rat model whether local expression of viral IL-10 (vIL-10) in a segment of vein that undergoes thrombosis would confer an anti-inflammatory effect and how this effect might be mediated. Rats underwent inferior vena cava isolation, cannulation, and instillation of saline or adenovirus encoding either beta-galactosidase or vIL-10. Two days after transfection, thrombosis was induced, 2 days after this the rats underwent gadolinium (Gd)-enhanced magnetic resonance venography exam, and the vein segments were harvested. Tissue transfection was confirmed by either RT-PCR of vIL-10 or positive 5-bromo-4-chloro-3-indolyl beta-d-galactopyranoside (X-Gal) staining. vIL-10 significantly decreased both leukocyte vein wall extravasation and area of Gd enhancement compared with those in controls, suggesting decreased inflammation. Immunohistochemistry demonstrated decreased endothelial border staining of P- and E-selectin, while ELISA of vein tissue homogenates revealed significantly decreased P- and E-selectin and ICAM-1 levels in the vIL-10 group compared with those in controls. Importantly, native cellular IL-10 was not significantly different between the groups. However, neither clot weight nor coagulation indexes, including tissue factor activity, tissue factor Ag, or von Willebrand factor levels, were significantly affected by local vIL-10 expression. These data suggest that local transfection of vIL-10 decreases venous thrombosis-associated inflammation and cell adhesion molecule expression, but does not directly affect local procoagulant activity.

A pilot study of sibling resemblance in later life

OBJECTIVE

Behavioural genetic studies of later life are strictly limited. We carried out a community-based pilot study of sibling resemblance with the primary aims of establishing the feasibility of such work in this population and estimating genetic influence on depression and its risk factors.

METHODOLOGY

Data were collected on surviving siblings of individuals interviewed in previous phases of an epidemiological study of the elderly (the Gospel Oak survey); scales relevant to the investigation of late life depression and its risk factors were utilized. Since families tend to be geographically scattered, the interview was conducted by telephone. Comparisons were made between data relating to the siblings and those obtained on the probands. Variability in phenotypic traits and environmental measures was partitioned into between- and within-family variation, in order to distinguish familial and non-familial sources of variation. Intraclass correlations were used to estimate the strength of genetic influences on continuous measures, while pairwise concordances were calculated for dichotomous traits.

RESULTS

Thirty-two siblings from 20 families were ultimately identified and interviewed. Intraclass correlations for the Depression and Dementia Diagnostic Scales and the Handicap Scale were 0, 0.27 and 0.22, respectively. Those for number of life events, number of friends in contact and number of neighbours in contact were 0.08, 0.03 and 0, respectively. Concordance for both depression caseness and dementia caseness was 0.

DISCUSSION

There were difficulties carrying out this study, which are discussed. The study is the first of its kind to examine familial resemblance for the common disorders of old age. Establishing ways of engaging elderly families with research will be a challenge that future research will need to meet.

The association between APOE and dementia does not seem to be mediated by vascular factors

OBJECTIVE

The effect of APOE on dementia may be mediated through dyslipidemia and atherogenesis through its effect on cholesterol metabolism. The authors investigated this possibility among aged survivors from the UK Medical Research Council Trial of the Treatment of Hypertension in Older Adults.

DESIGN

A total of 370 of 657 survivors from an initial cohort of 1,088 recruited into the trial between 1983 and 1985 were traced in 1994 and agreed to be screened for dementia. Blood samples were analyzed for APOE genotype and serum fibrinogen. Cholesterol level, smoking behavior, blood pressure, body mass index, and EKG recordings had been measured at recruitment 10 to 12 years earlier. Odds ratios (ORs) for the association between APOE epsilon4/* and both AD and dementia were estimated and adjusted incrementally for the effect of age and premorbid intelligence, cholesterol, other risk factors for vascular disease, and EKG evidence of cardiovascular disease.

RESULTS

The authors diagnosed 24 cases of National Institute of Neurological and Communicative Disorders and Stroke AD from 41 cases of dementia. The crude OR for the association between APOE epsilon4/* and AD was 3.40 (95% CI 1.30 to 8.91). APOE genotype was associated with serum cholesterol level, and there was a nonsignificant trend for an association with smoking behavior. After adjusting for these and all other vascular risk factors and vascular disease variables listed earlier, the OR for the association between APOE epsilon4/* and AD increased to 4.81 (1.60 to 14.4).

CONCLUSION

Presence of APOE epsilon4/* seems to increase the risk for dementia and AD independently of its effect on dyslipidemia and atherogenesis.

Dementia in developing countries. A consensus statement from the 10/66 Dementia Research Group

Less than one-tenth of all population-based research into dementia is directed towards the two-thirds or more of cases living in developing parts of the world. The 10/66 Dementia Research Group has been formed to redress this imbalance, encouraging active research collaboration between centres in different developing countries and between developed and developing countries. The 10/66 group consisted initially of researchers attending a symposium on dementia research in developing countries, held at the 1998 Alzheimer's Disease International conference. They noted a growing interest in this area, with many active researchers and others wishing to start new studies. There was felt to be an urgent need for more research: quantifying prevalence and incidence, exploring regional variations in international collaborations using harmonized methodologies, describing care arrangements for people with dementia, quantifying the impact on caregivers and evaluating the effectiveness of any newly implemented services. Methodological problems need to be addressed, particularly development of culture- and education-fair dementia diagnostic procedures. Good-quality research can generate awareness, pioneer service development and influence policy.

Methodological issues for population-based research into dementia in developing countries. A position paper from the 10/66 Dementia Research Group

The 10/66 Dementia Research Group has been formed to promote good-quality, internationally comparable research into dementia in developing countries through active research collaboration. In this position paper, we review existing research into dementia prevalence in developing regions of the world. Seven methodologically robust studies were identified. The prevalence of dementia, age-adjusted to the age structure of the Kerala population, ranged from 1.3% to 5.3% for all those aged 60 or over and from 1.7% to 5.2% for all those aged 65 and over. Two studies, from Ibadan, Nigeria and Ballabgarh, India, reported strikingly low prevalence figures. The reported prevalence for most studies was somewhat lower than the consistent figures for Europe reported by the EURODEM concerted action. Based on critical review of the literature, and on the practical research experience of members of the 10/66 group, recommendations have been made for procedure in the following areas: age limits for inclusion in dementia surveys, age ascertainment, sampling, scope for incidence studies, functional assessment and culture- and education-fair dementia diagnosis.

Vascular risk factors and Alzheimer's disease

OBJECTIVE

We aim to summarise the recent and accumulating epidemiological research which suggests that cardiovascular disease and vascular risk factors play an important role as risk factors for Alzheimer's disease (AD) in later life.

METHOD

The epidemiological literature is summarised in considering the evidence for such an association, focusing on optimally designed population-based studies. Potential mechanisms of association are considered, drawing on relevant findings from neuroscience.

RESULTS

Cardiovascular disease and vascular risk disorders appear to be important factors in the aetiology of AD. However, there is a paucity of prospective studies with an adequate duration of follow-up to investigate the apparent age- and time-dependent nature of these associations.

CONCLUSIONS

Vascular disorders represent potentially preventable risk factors with an important population impact due to their high prevalence in developed countries. The concept of AD and vascular dementia as clearly distinguishable disorders clinically or aetiologically is becoming increasingly tenuous. A better understanding of the relationship between AD and vascular disorders will depend on a more flexible diagnostic and conceptual framework.

Increasing rates of suicide in young men in England during the 1980s: the importance of social context

Attempts to explain rising rates of suicide among young men in Britain and elsewhere during the 1980's have identified the characteristics of those people who kill themselves. Little, however, is known about the impact that changes in social context may have had on changing rates of suicide during this time. Changes in aggregate levels of unemployment, poverty, marriage and the proportion of adults living alone during the 1980s were derived from data collected in the UK National Census of 1981 and 1991. In an ecological analysis these changes were compared with changes in age-adjusted rates of suicide in men aged 15 to 44, in 364 county districts of England between the beginning and end of the 1980s. Areas experiencing the lowest increase in rates of suicide were those that experienced the smallest rise in the proportion of people living alone, the greatest increase in unemployment and highest levels of social deprivation. In addition to investigating the effect that characteristics of people have in determining the risk of suicide in individuals who kill themselves, further attention needs to be paid to the impact that social context may have on mediating these risks.

Familial dwarfism due to a novel mutation of the growth hormone-releasing hormone receptor gene

Isolated growth hormone (GH) deficiency (IGHD) is a rare cause of short stature. The same mutation of the gene encoding the growth hormone-releasing hormone receptor (GHRHR) has been identified as the basis for IGHD in three families from the Indian subcontinent. The prevalence and heterogeneity of defects in the GHRHR gene are not known. Twenty-two dwarf members of a large, extended kindred containing at least 105 affected members with autosomal recessive short stature underwent extensive endocrine evaluation, which confirmed markedly reduced or undetectable serum concentrations of GH that did not increase in response to different stimuli. DNA sequences of the 13 exons and intron-exon boundaries of the GHRHR gene were determined in an index patient. A novel homozygous 5' splice site mutation (G-->A at position +1) in IVS1 was found. Thirty of the affected subjects tested were homozygous for this mutation, and 64 clinically unaffected patients were either heterozygous for the mutation (n = 41, including 9 obligate carriers) or homozygous for the wild-type sequence (n = 23). We describe a novel mutation in the GHRHR gene as cause of dwarfism in the largest kindred with familial IGHD described to date.

Morphometric analysis of the extramacular retina from postmortem eyes with retinitis pigmentosa

PURPOSE

To evaluate the degree of inner retinal preservation in the extramacular regions of postmortem retinitis pigmentosa (RP) eyes.

METHODS

Eighteen RP retinas and 11 age-matched healthy retinas were sectioned for morphometric analysis by light microscopy. The 18 RP retinas were classified by disease severity and mode of inheritance. Cell nuclei in the outer nuclear layer (ONL), inner nuclear layer (INL), and ganglion cell layer (GCL) were counted in adjacent 125-microm segments from an area spanning the region between 4 mm and 10 mm from the fovea.

RESULTS

A mixed-effects model showed a decrease in mean cell counts for each of the cell layers when the severity groups and inheritance types compared with those of control retinas. There was no statistically significant difference in the number of nuclei preserved in the INL and GCL in the moderate group compared with the severe group. Results from the INL counts for the different inheritance types of RP showed a higher overall mean percentage of cells was preserved for the autosomal dominant RP (ADRP) group when compared with the X-linked (XLRP) and simplex RP groups. Analysis of the GCL counts revealed significantly more counts only in the ADRP group compared with the XLRP group; the other group comparisons were not significant.

CONCLUSIONS

Retinitis pigmentosa results in cell loss in all retinal layers, with the most profound loss in the ONL, followed by the GCL and then the INL. The preservation of the INL and GCL in the extramacular region is less than that previously reported for the macular region of the same retinas.

Is chronic low-level lead exposure in early life an etiologic factor in Alzheimer's disease?

Few environmental risk factors for Alzheimer's disease have been identified. This lack of information may reflect the fact that salient factors affect most of the population in developed countries. Furthermore, the critical period of exposure may be earlier than hitherto suspected, during the first years of life, as the brain differentiates and develops. Exposure to lead at levels lower than those associated with evident toxicity causes mild intellectual impairment in childhood. I hypothesize that this may be one of the childhood exposures that also confers an additional risk for the onset of Alzheimer's disease.

Associations between diagnoses, impairments, disability and handicap in a population of elderly people

BACKGROUND

'Handicap' is the disadvantage for an individual that results from ill-health. It represents an important outcome in chronic disabling disease, but has proved difficult to measure until recently. The strength of association between handicap and other health status measures, and the relative contributions of health and socioeconomic variables to handicap have not been studied previously.

METHODS

We undertook a cross-sectional survey of all people > 65 years old in a defined geographical area of North London. The interview was based on the short-CARE psychiatric survey tool, and in addition included measures of physical health and disability, the London Handicap Scale, income, social support and housing. In all, 654 residents (74%) from a register of 889 were interviewed. A random sample of 225 had additional data collected which are reported in this analysis.

RESULTS

Strength of association with handicap scores increased progressively from diagnosis to impairment to disability. Variation in handicap with diagnosis was explained by impairment, and variation with impairment was mostly explained by disability. Age, housing quality, social support and income were associated with handicap score, but confounding by these did not explain the association between handicap and other aspects of disablement. Disease-associated variables explained quantitatively much more variation in handicap than socioeconomic variables.

CONCLUSIONS

The most potent influences on handicap are disease and disability, justifying the high priority given by health services to detection, treatment and rehabilitation. Where this is not possible handicap may be reduced to some extent through socioeconomic intervention.

Implementation of Groups for Creative Expression on a Psychiatric Inpatient Unit

Patients benefited from creativity group participation through expression of both positive and negative feelings, group acceptance, and acceptance of self in a non-competitive activity. Psychiatric nurses can lead creativity groups with a focus on creative expression, rather than psychotherapy. No specific training in the arts is required for these simple creative formats. It was found from using a variety of creative formats that, overall, patients received group projects better than individual projects done in a group setting.

The recognition and treatment of depression in older people in primary care

OBJECTIVES

To examine general practitioners' (GP) awareness of depression in their elderly patients (aged over 65) and to identify characteristics of those patients least likely to be recognized and treated.

DESIGN

A cross-sectional study comparing the clinical opinion of the GP with assessment of mental state using a validated interview schedule (the Short Comprehensive Assessment and Referral Evaluation).

SETTING AND SUBJECTS

510 elderly residents in the Gospel Oak area of Camden in North London registered with 28 GPs at 13 practices.

MAIN OUTCOME MEASURES

Agreement between GP view and patients interview. Evidence of active management measured by examining GP records for appointments, referrals and prescription of psychotropic mediation.

RESULTS

GPs were aware of depression in 36 (51%) of 70 depressed patients. Those least likely to be recognized were men, the married, those with high levels of physical handicap, those suffering from visual impairment and those who were least well educated. Of the 32 patients believed to be depressed, 12 (38%) were prescribed antidepressant medication and/or referred to mental health/social services.

CONCLUSIONS

Levels of recognition of depression were lower than other recent reports. These findings may reflect the continued debate about the most suitable management of the elderly depressed in primary care and stress the need for further evaluation of appropriate treatment strategies for this group.

Do antiarthritic drugs decrease the risk for cognitive decline? An analysis based on data from the MRC treatment trial of hypertension in older adults

We ascertained nonsteroidal anti-inflammatory drug (NSAID) use in 2,651 participants in the UK MRC treatment trial of hypertension in older adults and measured change in cognitive function over the subsequent 54 months. There was a significant, although modest, association between change in the Paired Associate Learning Test score over time and NSAID use, which was modified by age. NSAID users showed less decline, with younger subjects seeming to benefit more than older. We found no relationship between NSAID use and time taken to complete the Trail Making Test and also no relationship between anti-indigestion drug use and either cognitive outcome. These analyses highlight the need for larger studies with prospective classification of NSAID use and adequate control of confounding, including exposure to other medications. A randomized controlled trial of NSAIDs, in those known to be at risk of cognitive decline or dementia, may be indicated in the future.

Concurrent validity of a telephone-administered version of the Gospel Oak instrument (including the SHORT-CARE)

OBJECTIVE

The aim of the study was to establish the concurrent validity of a telephone-administered version of the survey measures utilized in the Gospel Oak studies, the core of which was the SHORT-CARE.

DESIGN

Comparisons were made between data obtained by administering the interview in its conventional, face-to-face form with those generated by conducting it by telephone.

SETTING

A UK teaching hospital.

PATIENTS

Elderly subjects of both sexes, recruited from geriatric and psychogeriatric day hospitals.

MEASURES

The Depression Diagnostic Scale, Dementia Diagnostic Scale and Organic Brain Syndrome scale (all taken from the SHORT-CARE) and the London Handicap Scale.

RESULTS

For depressive symptomatology, cognitive impairment, subjective memory impairment and handicap, intraclass correlations were 0.86, 0.89, 0.83 and 0.70, respectively. The kappa coefficient for agreement on case-level diagnosis of pervasive depression was 0.79.

CONCLUSIONS

These results indicate that the instrument is broadly reliable when administered by telephone.

The need for research on dementia in developing countries

Dementia is one of the commonest and most disabling late-life mental disorders. Its prevalence and incidence have been assessed in developed countries, and show little geographical variation between countries and regions. Although most older people live in developing countries, little research has been carried out in those settings. There is some evidence that age-specific prevalence rates for dementia in developing countries may be relatively low. More research is needed to allow developing countries to estimate the current extent, type and cost of medical and social service provision, and to make confident predictions of future need. Research in different cultures with different levels of economic and industrial development will also increase the variance of environmental exposure, facilitating the identification of environmental risk factors and gene-environment interactions for dementia. Research methodologies need to be adapted to the different circumstances of developing countries, with implications for sampling, cognitive screening and definitive dementia diagnosis.

Effects of FSH on serum immunoreactive inhibin levels in the luteal phase of the menstrual cycle

OBJECTIVE

FSH causes a dose-related increase in circulating immunoreactive inhibin (INH) in the follicular phase of the menstrual cycle, while LH is the major stimulus to INH secretion by the corpus luteum. The present study was undertaken to assess whether FSH can also stimulate INH production during the luteal phase.

DESIGN

Normal volunteers were treated with a single injection of LH-free FSH (Metrodin, 150 units) or saline as control, during the early, mid- or late luteal phase of the cycle, with subsequent hormone measurements.

PATIENTS

The 21 volunteers were aged 19-29. Seven subjects given FSH and 8 controls were studied in the early luteal phase, 1-4 days post ovulation. Eight FSH treated subjects and 10 controls were studied in the midluteal phase, 5-9 days post ovulation, and 6 each, respectively, were studied in the late luteal phase.

MEASUREMENTS

Oestradiol (E2), progesterone (P), and INH were measured by previously described radio-immunoassays.

RESULTS

In both the early and mid-luteal phases, FSH caused a significant rise in INH (early, from 778 to 922 U/l, mid-luteal 1553 to 2090 U/l) and E2 (early 371 to 545 pmol/l, mid-luteal 528 to 636) while there was no significant change in P. No significant changes occurred in the saline treated subjects. In the late luteal phase FSH prevented the significant fall in INH seen in the controls, whilst there was no effect on E2 or P.

CONCLUSIONS

It was concluded that both FSH and LH are capable of modulating inhibin production during the luteal phase of the menstrual cycle. FSH may exert its actions on the corpus luteum or alternatively on developing follicles. The present study cannot clearly distinguish between these possibilities.

A longitudinal study of factors predicting change in cognitive test scores over time, in an older hypertensive population

This study aims to describe factors associated with cognitive decline among 2584 subjects, aged 65-74, who were followed up for 54 months in the Medical Research Council Elderly Hypertension Trial (1982-1989). The subjects completed a cognitive test, the Paired Associate Learning Test (PALT), five times over this period. Decline on the PALT was associated with advanced age, male sex, rural residence, depression and low intelligence. These effects were modified by gender and level of pre-morbid intelligence. Advanced age, rural residence and number of cigarettes smoked daily were only associated with PALT decline among women of below median intelligence. The association between depression and PALT decline was only apparent in women of below median intelligence and men of above median intelligence. While these findings are consistent with other research into cognitive decline, they differ in some ways from reported risk factors for dementia, suggesting aetiological separateness. That women were more vulnerable than men to the effects of age and smoking raises the question of the impact on cognition of accelerated atherosclerosis after the menopause.

Approaches for assessing the efficacy of occupational health and safety standards

The regulation of hazards is one of the most dramatic forms of intervention in occupational safety and health (OSH). Despite their high degree of potential social and economic impact, relatively little research has been conducted to specifically evaluate the effectiveness of OSH standards with regard to preventing occupational diseases and injuries. This paper reviews the basic scientific approaches that may be used to evaluate the efficacy of OSH standards. These approaches encompass the following research areas: (1) exposure surveillance, (2) disease surveillance, and (3) prospective studies following the introduction of the standard. Research on asbestos and asbestosis, respirable crystalline silica (quartz) and silicosis, and respirable coal mine dust and coal workers' pneumoconiosis (CWP) are used to illustrate these approaches and the type of information that is currently available. The examples (quartz, coal dust, asbestos) reveal substantial limitations in the types of information currently available for evaluating the efficacy of these OSH standards. Ideally, plans for evaluating the efficacy of OSH standards should be developed for existing and future standards. These plans should include programs for the surveillance of exposures and adverse health effects and, when possible, for prospective studies designed to evaluate how the risk of disease (or injury) is modified by the introduction of the standard.

Practice guidelines for the prediction and prevention of pressure ulcers: evaluating the evidence

Clinical practice guidelines for the prediction and prevention of pressure ulcer (Agency for Health Care Policy and Research [AHCPR], 1992) were evaluated in a Canadian, university-affiliated, acute care hospital. Through a prospective study, the prevalence of pressure ulcers was determined, and pressure ulcer incidence was tracked to evaluate the accuracy of the Braden Scale for risk assessment. The prevalence rate for stage II or greater pressure ulcers was 13.6%; the rate was 29.7% when stage I (persistent redness) was included. In evaluating the Braden Scale's accuracy in predicting risk, the findings from this study were less favorable than previous reports. The total Braden score that appeared to have the best balance of sensitivity (67%) and specificity (66%) was 19. Several factors should be considered: The scale was implemented and tested hospitalwide with a wide range of patient diagnoses, age, and severity; the study was a cross-section of an existing population; and the levels of nursing care and type of staff vary between units ranging from critical to long-term care. This study highlights the need for individual settings to evaluate the AHCPR Guidelines for the Prediction and Prevention of Pressure Ulcers.

Outcome of extensive evaluation before adjuvant therapy in women with breast cancer and 10 or more positive axillary lymph nodes

PURPOSE

To evaluate the effect of extensive screening of women with high-risk, node-positive breast cancer on the detection of occult metastatic disease and patient eligibility for a randomized trial of the addition of high-dose chemotherapy and autologous bone marrow support (ABMT) to standard adjuvant therapy.

PATIENTS AND METHODS

Women with resected T1-3N1,2 primary breast cancer and > or = 10 positive axillary lymph nodes referred for possible trial participation were evaluated for this report. All had normal chest x-ray, bone scan, and liver ultrasound performed by the referring physician. Those who provided informed consent for the randomized trial were further evaluated according to protocol with computed tomographic (CT) scans of the head, chest, abdomen, and pelvis and bilateral bone marrow biopsies; those with metastatic disease detected by any of these tests were excluded from study registration.

RESULTS

Forty-four women were evaluated between February 1993 and April 1995. Fourteen did not undergo further protocol staging because of refusal to participate or the presence of metastatic disease on clinical assessment or review of outside radiologic studies. The remaining 30 underwent additional investigations, and seven (23%; 95% confidence interval [CI], 12% to 41%) had metastases detected by CT scanning (four patients) or bone marrow biopsy (three patients) not detected by routine screening.

CONCLUSION

Although the number of patients evaluated is small, these data suggest that some of the improvement in outcome of women with > or = 10 positive axillary lymph nodes who receive ABMT as part of adjuvant chemotherapy in phase II trials may be from the exclusion of patients with occult metastatic disease. The importance of these exclusions can only be determined by ongoing, randomized controlled trials.

A recurring dominant negative mutation causes autosomal dominant growth hormone deficiency--a clinical research center study

Familial isolated GH deficiency type II (IGHD-II) is an autosomal dominant disorder that has been previously shown in some patients to be caused by heterogeneous GH gene defects that affect GH messenger RNA (mRNA) splicing. We report here our finding of multiple G-->A transitions of the first base of the donor splice site of IVS 3 (+ 1G-->A) in IGHD II subjects from three nonrelated kindreds from Sweden, North America, and South Africa. This + 1G-->A substitution creates an NlaIII site that was used to demonstrate that all affected individuals in all three families were heterozygous for the mutation. To determine the effect of this mutation on GH mRNA processing, HeLa cells were transfected with expression plasmids containing normal or mutant + 1G-->A alleles, and complementary DNAs from the resulting GH mRNAs were sequenced. The mutation was found to destroy the GH IVS 3 donor splice site, causing skipping of exon 3 and loss of the codons for amino acids 32-71 of the mature GH peptide from the mutant GH mRNA. Our finding of exon 3 skipping in transcripts of the + 1G-->A mutant allele is identical to our previous report of a different sixth base transition (+6T-->C) mutation of the IVS 3 donor splice site that also causes IGHD II. Microsatellite analysis of an affected subjects' DNA from each of the three nonrelated kindreds indicates that the + 1G-->A mutation arose independently in each family. Finding that neither grandparent has the mutation in the first family suggests that it arose de novo in that family. Our data indicate that 1) + 1G-->A IVS 3 mutations perturb GH mRNA splicing and cause IGHD II; and 2) these mutations can present as de novo GHD cases.

The effect of epidermal growth factor mouthwash on cytotoxic-induced oral ulceration. A phase I clinical trial

A double-blind clinical trial was performed to study the effect of epidermal growth factor (EGF) mouthwash on the healing and recurrence of oral ulceration in 12 patients undergoing cancer chemotherapy. The oral distribution or cytotoxic-induced ulcers corresponded to the salivary gutters. There was no difference in the rate of healing of established ulcers between the experimental and placebo groups. However, there was a small delay in the onset and severity of recurrent ulceration. It was concluded that EGF mouthwash does not accelerate ulcer healing, but it may have the potential to protect the oral epithelium from cytotoxic damage.

Screening women for high risk of postnatal depression

A ten-item screening questionnaire was constructed from previous reports on risk factors for postnatal depression, and its ability to predict antenatally the development of postnatal depression was tested. Women attending an antenatal clinic at 36 wk gestation completed the questionnaire and, at 8 wk postpartum, were assessed for the presence of depression using the Edinburgh Postnatal Depression Scale (EPDS). Although antenatal questionnaire scores correlated significantly with postnatal EPDS scores, this was largely because the questionnaire was able to identify correctly those who would not become depressed. Neither the questionnaire as a whole, nor groups of items, was able to discriminate well between women who later did or did not become depressed. However, women who reported previous or current treatment for depression were at a threefold greater risk of becoming or remaining depressed postnatally. Possible reasons for the negative results are discussed, including the heterogeneity of depression occurring in the postnatal period.

Effects of vitamin D on insulin and glucagon secretion in non-insulin-dependent diabetes mellitus

Vitamin D has been shown to increase insulin release from pancreatic islet cells in vitro, and to improve insulin secretion in vitamin D-deficient animals. Few attempts have been made to evaluate this issue directly in humans. We studied 35 otherwise healthy diabetic subjects in the early spring at the seasonal nadir of 25-hydroxyvitamin D [25(OH)D] concentrations (mean 35 +/- 7 nmol/L). Fasting glucose, insulin, C-peptide, and glucagon concentrations, and their responses to Sustacal stimulation were not related to indexes of mineral metabolism. In 20 subjects, a double-blinded, placebo-controlled, crossover trials of 1,25-dihydroxyvitamin D[1,25](OH)2D] treatment (1 micrograms/d for 4 d) had no effect on fasting or stimulated glucose, insulin, C-peptide, or glucagon concentrations. However, insulin and C-peptide responses to Sustacal after 1,25(OH)2D treatment were related to duration of diabetes (r2 = 0.28, P = 0.052 and r2 = 0.25, P = 0.002, respectively) in that short duration correlated with improvement after 1,25(OH)2D treatment. Hence, vitamin D nutrition, or 1,25(OH)2D therapy, had no major effect on glucose homeostasis in non-insulin-dependent diabetes mellitus.

Neuropsychological patterns of adolescents and young adults with spina bifida

The purpose of this study was to examine neuropsychological profiles for patients with spina bifida. The sample consisted of 37 subjects with spina bifida between the ages of 14 and 23. Each of the subjects was seen individually and administered the Halstead-Reitan Neuropsychological Test Battery as well as the appropriate Wechsler Intelligence Scale. Scores from the Halstead-Reitan were subjected to cluster analysis to formulate clinical subtypes. The results indicated a three group solution was most appropriate, which appeared to reflect a continuum of dysfunction. Implications for rehabilitation programming are discussed.

Raphe pallidus stimulation increases gastric contractility via TRH projections to the dorsal vagal complex in rats

The role of thyrotropin releasing hormone (TRH) in the dorsal vagal complex (DVC) in mediating the enhanced gastric contractility induced by glutamate (100 pmol) microinjected into the raphe pallidus (Rpa) was investigated in urethane-anesthetized rats acutely implanted with miniature strain gauge force transducers on the corpus of the stomach. Glutamate-induced stimulation of gastric contractility was dose-dependently inhibited by bilateral microinjection into the DVC of TRH antibody (0.17, 0.85 or 1.7 micrograms/100 nl/site) but not by vehicle. TRH antibody microinjected into the dorsal medullary reticular field had no effect. These data indicate that activation of Rpa neurons by glutamate increases gastric motor function through TRH release in the DVC.

Risk factors for Alzheimer's disease and dementia: a case-control study based on the MRC elderly hypertension trial

We surveyed 1,545 subjects--recruited into the UK Medical Research Council elderly hypertension treatment trial between 1982 and 1987--to detect incident cases of dementia, identifying 50 cases of dementia, including 31 cases of probable or possible Alzheimer's disease (AD). These we compared with 223 unimpaired, unmatched controls from the same population for exposure to familial, cardiovascular, educational, and geographic risk factors for dementia. Our study confirms the association of family history of dementia with dementia (odds ratio [OR] = 4.36) and AD (OR = 4.69), and of advanced age with dementia (OR = 2.81). Rural residence exerted a protective effect for dementia (OR = 0.21) and AD (OR = 0.28). We report near-significant associations between AD and dementia and several cardiovascular risk factors (ECG ischemia, systolic hypertension, and smoking) among subjects lacking a family history of dementia. We postulate the existence of a nonfamilial form of dementia transcending traditional categories of multi-infarct dementia and AD, more common among urban residents, and mediated through vascular pathology. Risk factors reported elsewhere but not confirmed in this study were advanced maternal age and winter season of birth.